Special Considerations

Face and Scalp

- These wounds rarely become infected because of the high blood flow of the face and scalp.
- Most face and scalp wounds can be closed after irrigation. Debridement should be minimized to reduce cosmetic deformity. If the patient will arrive at a surgical facility within 24 hours, it is better to defer wound closure.
- The clinician should take into consideration the low probability of infection when planning closure of a facial wound because of the poor cosmetic outcomes associated with delayed primary closure.
- When primary closure is acceptable, sutures should only remain in place for 4–5 days for the face and 7 days for the scalp.

Open Globe Injury

- Apply an eye shield to prevent further damage.
- Do not place any type of dressing in contact with the globe or underneath the eye shield.
- Moxifloxacin 400mg PO daily to prevent endophthalmitis
- Ondansetron 4mg PO/IV every 4 hours as needed for associated nausea
- Pain control as needed (narcotics as well as ketamine are approved for use)
- Position the patient with the head elevated, if possible.
- Ultrasound evaluation is contraindicated when open globe injury is suspected.
- The best results are achieved if surgery occurs within 24 hours of injury.

Animal Bites

- All animal bite treatments should begin with immediate, thorough cleaning of all wounds with soap and water.
- Most animal bites should be allowed to heal by secondary intent (especially puncture wounds).16
- Moxifloxacin 400mg PO daily OR Augmentin (amoxicillin/clavulanic acid; GlaxoSmithKline, http://us.gsk.com/) 875/125mg PO every 12 hours for 7 days are the best choices for most animal bites. Doxycycline (100mg PO twice a day) or clindamycin (300mg PO 3 times a day) with levofloxacin (750mg PO daily) are acceptable alternatives.
- Consider the need for rabies vaccination (Appendix E).

Aquatic Exposure

- Management of wounds exposed to fresh or salt water is unchanged; however, additional agents are occasionally required for adequate antimicrobial coverage.17
- Levofloxacin 750mg PO daily (second-line doxycycline 100mg PO twice daily) to cover for Aeromonas species and Vibrio species.

Given the risk of atypical infections, telemedicine consultation should be sought if the wound worsens.

Chronic Nonhealing Wounds

If a wound has not healed by 2 weeks, it is likely the result of underlying infection (consider osteomyelitis as a potential cause), inadequate tissue perfusion, or inadequate nutrition.18 Often it is multifactorial and so more than one source needs to be addressed.

Consider telemedicine consultation if the wound is not healing.

- Packing and Planning Considerations. See Appendix F.
- Wound Management Summary Table. See Appendix G.