Wound Care

Hydrogen Peroxide

The most important aspect of wound management in overall reduction of infection rate is mechanical cleansing. When possible, perform this using high-pressure irrigation (eg, syringe and <19-gauge needle/catheter). Irrigant fluid can be saline, lactated Ringer solution, or, if out of hospital, soap and water. Use a minimum of 200 mL; higher volumes are more effective. Avoid peroxide, Betadine, and chlorhexidine, which damage viable tissue. Soaking wounds in antiseptic solution is not beneficial. Half-strength peroxide swabbed on sutured wounds every 6 hours will reduce scarring from blood clot.

Topical antibiotics

Antibiotic ointment (eg, bacitracin) has been shown to reduce incidence of wound infections, as compared to effects of a placebo.

Tetanus

Classify wounds as tetanus prone or not. Tetanus-prone wounds are deep (incl puncture), dirty (dirt, soil, feces, saliva), devitalized, burns, frostbite, crush injuries or older than 6 hours. About 60 cases of tetanus occur in the United States per year, mostly in elderly patients whose immunity has waned.

Quiz yourself: classify patients by poorly or well immunized, then by dirty or clean wound.

If poorly immunized (tetanus status unknown or 2 or fewer tetanus vaccines)

• IF tetanus-prone wound (dirty): active and passive immunization (this is the only situation to give TIG)
• IF non-tetanus-prone wound (clean): active immunization only

If well immunized (patient has 3 or more tetanus vaccines)

• IF dirty wound:
  • AND last tetanus within 5 years: no immunization necessary
  • AND last tetanus > 5 yrs ago: active immunization only
• IF clean wound:
  • same as above, but make cutoff 10 years

*Active immunization: In children 7 or younger give diphtheria, pertussis, and tetanus (DTaP).  In children 8 or older, give dT as booster.
**Passive immunization is tetanus immune globulin (TIG)