Wound Dressings

Covering the wound with an occlusive dressing prevents drying and allows the wound to be moist, promoting healing with collagen synthesis and angiogenesis (Field, 1994). Using a topical antibiotic reduces infection only in wound laceration repairs (Dire et al., 1995), not in elective hospital or office surgical procedures (Smack et al., 1996). Studies show no dressing preference for burn wound care (American Burn Association, 2001), although it should be based on wound origin, depth, size, location, exudate, and degree of contamination (Singer et al., 2008a). Wounds closed with tissue adhesives provide their own protection and require no additional dressing. Review warning signs of infection with the patient, and advise on standard postoperative wound care and timing of suture removal.

Closure techniques should minimize skin trauma, result in good skin-edge approximation without undue tension, and result in a cosmetically pleasing appearance (Fig. 28-8). The best cosmetic results can be achieved by using the finest suture possible, depending on skin thickness and tension. Generally a 3-0 (000) or 4-0 (0000) suture is appropriate on the trunk, 4-0 or 5-0 on the extremities and scalp, and 5-0 or 6-0 on the face. Forceps with teeth and skin hooks should be used to reduce crush injury to wound edges. Use the least amount of sutures to close the skin with good approximation and without deep, open space. Sutures on the face should be removed about day 3 to day 5, wounds not under tension on day 7 to 10, and wounds under tension, on the hands, or over joints on day 10 to 14. If you remove a suture and the wound opens up, cease removing the other sutures and place a sterile strip while asking the patient to return in 2 days.

Sutures are an option along with staples, tissue adhesives, and use of hair to tie edges together on some scalp wounds. Avoid staples in the scalp if computed tomography (CT) or magnetic resonance imaging (MRI) is planned. Expedient cleaning, debridement, and closure with the least trauma to the wound and patient should be the goal.

Figure 28-8 Wound repair: skin closure. A, Too few stitches used. Note gaping between sutures. B, Too many stitches used. C, Correct number of stitches used for a wound under an average amount of tension.

(From Lammers RL. Methods of wound closure. In Roberts JR, Hedges JR [eds]. Clinical Procedures In Emergency Medicine, 5th ed. Elsevier, Philadelphia, 2010.)

Figure 28-8 Wound repair: skin closure. A, Too few stitches used. Note gaping between sutures. B, Too many stitches used. C, Correct number of stitches used for a wound under an average amount of tension.

(From Lammers RL. Methods of wound closure. In Roberts JR, Hedges JR [eds]. Clinical Procedures In Emergency Medicine, 5th ed. Elsevier, Philadelphia, 2010.)

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