For the majority of lacerations sutured in the ED, patients should be instructed that a small amount of bloody discharge is to be expected; enough only to form a small surface clot or to stain the dressing. More than that is unexpected, and if such is found, the patients should return for recheck. Deep, complex lacerations that require drains or remain open may bleed more, and the patient should receive appropriate instructions to this potential.
Patients should be instructed about early symptoms and signs of infection: increasing pain, redness that extends more than 4 in. (5 mm) beyond the wound edges, red streaks that extend from the wound, purulent drainage, and fever. As noted above, many patients unfortunately do not recognize these signs of infection; in a study of 433 patients with 21 physician-diagnosed wound infections, only 11 (52 percent) were able to self-diagnose their infection. 7 Instructions must be clear, simple, and specific.
Wounds may open spontaneously, especially during the vulnerable period: 7 to 10 days after injury. Infection, fluid, and blood collections within the wound facilitate dehiscence. Patients should be instructed to return if a wound opens, particularly if blood or pus is expressed.
Patients discharged with a planned delayed primary closure require additional instructions:
1. They will generally be given antibiotics to take after they are sent home
2. They should leave the dressing intact until they return for a recheck
3. A recheck is generally done within 4 to 5 days
In carefully selected patients, delayed primary closure is associated with a low incidence of wound infection. 8
Patients may inquire about the long-term outcome of the wound; in such instances, the physician should respond with a candid prognosis explaining that wound outcome is primarily determined by factors beyond the physician's control, including:
1. Wounding mechanism
2. Type of wound
3. Location of wound
Patients should be told that the wound's appearance will change during the healing process and that the ultimate cosmetic outcome cannot be predicted at the time of suture removal.9!0 If necessary, wound revision should wait about 6 to 9 months from the initial injury. Some wounds on sun-exposed areas may be less pigmented than the surrounding skin and more sensitive to ultraviolet radiation. Color generally fills in over the next 12 months and sunscreens may be required for several months.
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