Postoperative care begins immediately after laceration repair in the ED with gentle cleansing using normal saline or clean (tap) water to remove any residual blood products or contamination. Additional considerations include dressings, topical antibiotics, edema reduction techniques, prophylactic antibiotics, tetanus prophylaxis, and wound drains. Before ED release, give the patient instructions regarding wound care and cleansing, pain control, signs of infection, follow-up dates, and short-term and long-term cosmetic expectations.

Postoperative wound dressing should be tailored to both the type of wound and method of wound closure. Most sutured or stapled lacerations should be covered with a protective, nonadherent dressing for 24 to 48 hours. Maintaining a moist environment increases the rate of re-epithelialization, and occluded wounds heal faster than those exposed to air.^1,2,3 Conversely, leaving lacerations exposed to air may result in a slightly lower healing rate but does not result in an increased rate of infection.⁴

Useful dressings are semipermeable films manufactured from transparent polyurethane or similar synthetic films coated on one surface with a water-resistant hypoallergenic adhesive. They are highly elastic, conform easily to body parts, and are generally resistant to shear and tear. They are permeable to moisture vapor and oxygen but impermeable to water and bacteria. Common brands of semipermeable wound dressings are OpSite Post-Op^® (Smith & Nephew PLC, London, UK), Bioclusive^® (Johnson & Johnson, New Brunswick, NJ), and Tegaderm^® (3M, St. Paul, MN). The disadvantages of these products are that they cannot absorb large amounts of fluid and exudate, and they do not adhere well to very moist wounds.

Topical antibiotic creams and ointments are an alternative to the use of commercial dressings to maintain a moist environment. As an added benefit, topical antibiotics may help reduce infection rates and may also prevent scab formation.^5,6,7 However, patients whose lacerations are closed with tissue adhesives should not use topical ointments or creams because they will loosen the adhesive and may result in dehiscence. Tissue adhesives serve as their own antimicrobial barrier and occlusive dressing; wounds closed with tissue adhesives do not require supplementary dressings.

Wounds with associated soft tissue contusion should have the injury site elevated above the patient’s heart for 24 to 48 hours to limit accumulation of fluid in the wound interstitial spaces. Wounds with little edema heal more rapidly than those with marked edema. Pressure dressings can be used to minimize the accumulation of intercellular fluid in the subcutaneous space. Pressure dressings are useful for ear and scalp lacerations (see chapter 42, “Face and Scalp Lacerations”). Pressure dressing applied to the ear can prevent auricular hematoma formation and reduce the subsequent likelihood of a cauliflower deformity. Vaseline gauze or Xeroform^® (Kendall Healthcare, Mansfield, MA) dressings are easy to mold around the ear. For large scalp lacerations that have a tendency to bleed, short-term use of a pressure dressing will limit subcutaneous hematoma formation. However, excessive pressure should be avoided in all pressure dressings, especially in the extremities where they may compromise circulation. Consider a short period of splinting with large lacerations over joints to reduce pain, limit tension on the wound, minimize swelling, and promote healing.

Prophylactic oral antibiotics are not recommended except for select circumstances^8,9,10,11 based on guiding principles: the degree of bacterial contamination, the presence of infection-potentiating factors (e.g., soil), the mechanism of injury, and the presence or absence of host predisposition to infection.^12,13,14 Compulsive wound cleansing is far more important than antibiotics to reduce postrepair wound infection.^15,16

Prophylactic antibiotics are recommended for human bites, cat bites, deep dog bite puncture wounds, bite wounds to the hand, open fractures, and wounds with exposed joints or tendon.^{12,13,14,15,16,17} Also, consider prophylactic antibiotics after wound closure in a lymphedematous area.^18,19

The risk of bacteremia during care of grossly contaminated lacerations in the ED is unknown, but is likely to be small.²⁰ However, some patients who have structural heart disease, arteriovenous hemodialysis fistulas, prosthetic joints, cerebrospinal fluid shunts, vascular grafts, or other permanent indwelling “hardware” may trap bacteria from the blood stream and develop infections in the above-mentioned organs or devices. There is no evidence for preprocedure antibiotic prophylaxis to prevent bacteremic spread of infection from manipulation of a contaminated site. If the physician chooses to use antibiotic prophylaxis for the management of a heavily contaminated wound in a patient with these conditions or devices, give a single dose of an IV antibiotic before the wound is manipulated.

Antibiotics used for postrepair prophylaxis are similar to those used for treatment of established infections (Table 47-1).⁸ For most patients, a first-generation cephalosporin or antistaphylococcal penicillin (e.g., dicloxacillin) is reasonable. Although methicillin-resistant Staphylococcus aureus has become a common cause of skin and soft tissue infections, postinjury antibiotic prophylaxis to cover this pathogen does not appear necessary.⁸ Amoxicillin-clavulanate is the preferred prophylactic treatment for high-risk mammalian bite wounds.^12,13 For open fractures or joints, a parenteral antistaphylococcal agent and an aminoglycoside should be used.¹⁷ There is no evidence that patients who receive antibiotic prophylaxis benefit from an initial IV dose. Antibiotic prophylaxis continues for 3 to 5 days for nonbite injuries and 5 to 7 days for bite wounds. Patients at high risk for infection should be told to return for a wound check in 24 to 48 hours.

Two thirds of the recent tetanus cases in the United States follow lacerations, puncture wounds, and crush injuries (see chapter 156, “Tetanus”),²¹ so, as part of wound care, ask about previous tetanus immunizations. Recommendations for tetanus prophylaxis are based on the condition of the wound and the patient’s immunization history (Table 47-2). Consider passive immunization with tetanus immune globulin for those without a history of a primary series of three tetanus immunizations. Because of the emergence of pertussis infections, Tdap (containing the acellular pertussis vaccine) should replace a single dose of tetanus and diphtheria toxoids for adults who have not previously received a dose of Tdap (either in the primary series, as a booster, or for wound management).²² The 2013 Advisory Committee on Immunization practices recommend either Tdap or Boostrix^® for those >65 years old.

The only contraindication to tetanus toxoid is a history of neurologic or severe systemic reaction after a previous dose. Local self-limited reactions, such as erythema, induration, and pain at the injection site, are common after tetanus vaccination. These local side effects do not preclude future tetanus immunization. Exaggerated local reactions occur occasionally after tetanus toxoid and involve extensive pain and swelling of the entire extremity. Exaggerated local reactions occur most often in adults with high serum tetanus antitoxin levels who have received frequent doses of tetanus toxoid. Such patients should not receive tetanus toxoid more frequently than every 10 years. Severe systemic reactions to tetanus immunization include generalized urticaria, anaphylaxis, or neurologic complications, including peripheral neuropathy and Guillain-Barré syndrome. A severe allergic reaction, including acute respiratory distress or cardiovascular collapse after a dose of tetanus toxoid, is a contraindication to further immunization. A moderate or severe acute illness is also a reason to defer routine immunization, although a minor illness is not. If the use of a tetanus toxoid is contraindicated, consider passive immunization with tetanus immune globulin in a tetanus-prone wound.