Wound Management: The Days After…
I put in a fair amount of stitches. I also decide NOT to put in stitches. Sometimes I use skin glue, and occasionally, I don’t close up a laceration at all. I’ve come to know pretty well which cuts need which treatment. But medical decision making aside, if I look at how I spend my time at work, a not small amount of it is dealing with kids who have fallen, run into a door or edge of a table, or cut themselves some other way.
To stitch or not to stitch?
When kids get cuts (or lacerations when we’re using their fancy name), there’s generally a lot of focus placed on whether or not stitches are required. That’s understandable, right- getting a good closure helps the healing process and decreases scarring, and that’s pretty important stuff. There’s a lot written about this topic: from what kinds of cuts should be stitched or glued, to how long stitches should stay in, to whether or not the absorbable kind should be used. As with much of medicine, art and science collide here and there are really a wide range of answers to most management questions on this topic.
What I find doesn’t get a lot of attention are the details surrounding the days AFTER the initial treatment of the laceration. There are a few key points to remember, and if they go well, they can really have long term effects on the outcome.
First, it’s important to think about what the wound looked like before it got treated.
Was there a bunch of dirt and debris in it?
Was it deep?
Was it located on a part of the body that is near fluids and possibly more prone to being in contact with bacteria?
These are all important questions to ask because “dirty” wounds have a higher risk of getting infected, and while all wounds need to be watched very closely because anytime the skin barrier is disrupted a chance of infection exists, dirty wounds need extra close observation. In fact, kids who sustain a dirty cut will often be asked to return 24-48 hours after the initial exam to be re-evaluated, or to have what we call a “wound check”- before the stitches are ready to come out, just to make sure that healing is progressing as it should.
There’s no real diplomatic way to say this, but most cuts look sort of terrible for the first 1-3 days after they happen.
They are red and angry and sore, even when they’re not infected. They look that way because they are inflamed, because the body is doing its job to help heal the wound. I expect this, and you should too. That being said, there’s a fine art of understanding when wounds go from this healing phase to getting infected. There are a few telltale signs—increasing pain, redness and swelling rather than decreasing is often concerning, and cloudy yellowish drainage that we call pus. Sometimes there may even be fever. Wound infections can be treated successfully with antibiotics but the early they are caught the better, so if there’s any question in your mind about whether or not a wound is infected, get it checked out by a healthcare professional—better to err on the side of caution.
For the first 24-48 hours, wounds shouldn’t get wet.
People often ask about when their child can wash the affected area after stitches. Keeping the area dry for a day or two can really help the healing process. Getting the skin barrier closed is the goal, and so it’s important to jump start this by initially keeping the area dry, then after about 24-48 hours the area can be washed with soapy water and patted dry, then covered with an antibiotic ointment. Avoid completely submerging a wound until it is well healed (showers only for a week or so). When a wound that hasn’t completely healed gets submerged, dirt can seep into it and it can delay the healing process as well.
A few other tips to aid the wound healing process:
- Try to keep the wound covered until it is dry and no fluid is draining out. This just acts as a barrier between a partially open wound and dirt that may potentially get in.
- Don’t scratch or pick at the wound. Sometimes they can be very itchy, but healing will be improved and scarring will be less if the wound hasn’t been agitated.
- Eat a nutritious diet! A well rounded diet full of minerals and vitamins will help the body heal faster.
Your healthcare professional will let you know if/when any stitches should be removed, and please remember this—we want to keep stitches in for enough time to make sure that the wound edges are lined up nicely for healing, but not too much time that they get embedded and become difficult to get out. If they stay in for too long, they can be irritating and the body may react against the stitches themselves, which is also not optimal. So if the stitches are supposed to come out in a week, make it so.
And finally, I’ve said it in this forum before but it bears repeating:
COVER ALL SCARS with SUNSCREEN, even well healed ones.
Scars absorb more sunlight and can darken quicker than intact skin, so make sure that they are well covered, even in winter. All the dermatologists and plastic surgeons in the world say thank you. And so will your skin.
Remember that the care plan is only just beginning when a wound gets treated at a medical visit, and that the bulk of care comes in the days following. Pay attention to any small changes in the appearance and follow all the directions you were given closely. Get any concerns checked out on the early side, and remember sun protection even months and years after the injury. Optimizing results here is a marathon not a sprint, which always seems ironic to me given that the injury itself usually happens in the blink of an eye.
May all your wounds heal quickly and easily.