By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Here I will review some basic elements of the ongoing management of wound care. This presupposes an initial workup has been done, with basic initial steps already being done such as placement of sutures and antibiotic and tetanus prophylaxis, when indicated. Oftentimes, as a family doctor, patients will come to me after surgery for followup wound management, or after emergency room initial management of wounds, and it will be my role to provide appropriate advice and followup assessment.
Whether I am the one to provide initial wound care or not, wounds should generally be dressed with a nonadhesive dressing. This means using an ointment such as petroleum jelly followed by something like a piece of gauze (sometimes antibiotic ointments are used here, which is generally unnecessary unless the patient has risk factors for infection). If the wound produces discharge, another layer of absorbable gauze can be placed to absorb some of the ooze. Beyond this layer, either tape or a bandage can be used to wrap the dressing and secure it to the body (the latter can be applied with slight tension to act to compress the wound as well in the setting of mild swelling or bleeding). If the wound is overlaying a joint or in an area at high risk of reinjury, the area may be splinted. Elevating the affected area can also help to reduce swelling and decrease associated pain.
Patients should be instructed to keep the dressing clean, dry, and intact (dirty and wet dressings increase risk of infection), and they should not remove the initial dressing until at least 24-48 hours after placement. In the first 48 hours, the skin re-epithelializes to form a new barrier layer, and removing the dressing can hinder the progress of this important step. Once re-epithelialized, the risk of infection is much lower. At approximately 48 hours, the patient should be instructed to remove the dressing and inspect the wound for signs of infection, although in high risk wounds or patients, it is best if the patient returns for medical inspection. Signs to look for would be redness extending greater than 2 cm from the border of the wound, very firm and tense skin surrounding the wound, red streaking in the nearby skin tracking away from the wound, ongoing bleeding or discharge from the wound, or pain that is uncontrolled or worsening while taking mild analgesics, or signs of systemic infection such as fever/chills or nausea. Signs of infection would be indications for antibiotic treatment.
Once the 48 hour period has passed, patients can gently clean the wound with soap and water if needed, but they should still avoid immersing it in water for 7 days, while the wound develops increased integrity. They can continue to dress the wound with a moist dressing to promote improved healing and decrease scar formation for those 7 days.
Suture removal general guidelines are as follows, with the basic understanding that the longer sutures are in for, the greater the chances of durable healing, while at the same time it increases the risk for worsening scar formation:
To decrease scar widening after suture removal, which can happen in the first 3-5 weeks after suture removal, consider using wound closure strips for added support in cosmetically sensitive areas. As well, patients can be instructed to avoid exposing the scar to sunlight in the first 4 months after the wound begins healing as sunlight can worsen the appearance of scars in this time period.