Musculoskeletal & Integumentary · Topic 11 of 11

Wound Management, Debridement & Closure

Skin & wounds · repair and healing

Wound Management, Debridement & Closure

Dose the lidocaine by weight, irrigate, remove dead tissue, then close early or late depending on wound age and contamination.

Key numbers

Lidocaine max 4.5 mg/kg; 7 with epinephrine4.5 / 7 mg/kg

Close clean wounds primarily within 6–8 hours< 6–8 h (face 12–24 h)

01 · GiveLidocaine max 4.5 mg/kg; 7 with epinephrine

Maximum infiltrated lidocaine is 4.5 mg/kg (generally ≤ 300 mg) without epinephrine and 7 mg/kg (generally ≤ 500 mg) with epinephrine; exceeding it risks local anesthetic systemic toxicity.

02 · DoClose clean wounds primarily within 6–8 hours

Primary closure suits uninfected, relatively uncontaminated wounds under 6–8 hours old (under 12–24 hours on the well-perfused face and scalp), although no time limit is evidence-based.

03 · AvoidNo NPWT on eschar, untreated osteomyelitis, cancer

Negative-pressure wound therapy is contraindicated with necrotic tissue and eschar, untreated osteomyelitis, nonenteric or unexplored fistulas, malignancy in the wound, and exposed blood vessels, nerves, anastomoses or organs.

What it is

Core idea

Healing: hemostasis, inflammation, proliferation, maturationHealing runs from hemostasis (vasoconstriction, platelets) to inflammation (neutrophils, macrophages clear debris) to proliferation (fibroblast collagen from about 48 hours, peaking near day 7) to maturation as collagen cross-links over months.

Causes & risk factors

Why it happens

Steroids, anticoagulants, undernutrition impair healingHealing is impaired by delayed treatment, contamination, crush injury, hematoma, glucocorticoids, immunosuppressants, antiplatelets and anticoagulants, chronic kidney disease and undernutrition, including vitamin C deficiency.

Diagnosis & monitoring

Work-up

1% lidocaine = 10 mg/mLA 1% solution contains 10 mg/mL, so a 70-kg adult may receive about 30 mL of 1% plain lidocaine (300 mg) or about 49 mL with epinephrine (7 mg/kg = 490 mg).

Management

Orders

Know the five debridement types must knowDebridement is sharp/surgical (fastest; thick eschar or infection), mechanical (wet-to-dry, nonselective, painful), autolytic (occlusive dressings; not for infected wounds), enzymatic (collagenase) or biologic (maggots eat only dead tissue).

Bupivacaine lasts longer; max 2.5 mg/kgBupivacaine has a slower onset but lasts 2–4 hours versus 30–60 minutes for lidocaine (maximum about 2.5 mg/kg plain). Epinephrine 1:100,000 prolongs anesthesia and aids hemostasis and is now considered safe in digits.

Toxicity: stop injecting, give 20% lipid emulsionFor local anesthetic toxicity stop injecting, give 100% oxygen, benzodiazepines for seizures and 20% lipid emulsion (100 mL over 2–3 minutes if > 70 kg, then infusion); use amiodarone and epinephrine ≤ 1 mcg/kg.

Contaminated wounds: delayed primary closureOld or heavily contaminated wounds are explored, debrided, packed loosely with moist saline gauze and closed after several days (delayed primary closure); leave small hand or foot bites, punctures and high-velocity wounds open.

Irrigate with saline under pressureIrrigate with a high-velocity stream of sterile saline (20–50 mL syringe, 20-gauge catheter) until contamination is gone; keep full-strength povidone-iodine, chlorhexidine and peroxide out of the wound; clip, never shave, hair.

Remove facial sutures in 3–5 daysRemove sutures from the face in 3–5 days; torso and upper extremities in 7–10 days; hands, extensor surfaces of elbow and knee, and anywhere below the knee in 10–12 days.

Prophylactic antibiotics only for high-risk woundsGive prophylactic antibiotics only for extremity bite wounds, human bites, wounds involving tendon, bone or joint, and some heavily contaminated wounds; update tetanus immunization as needed.

NPWT promotes granulation and removes exudateNegative-pressure wound therapy (commonly about −125 mmHg through foam) contracts wound edges, stimulates granulation and removes exudate; use caution with bleeding risk or anticoagulants, sharp bone fragments, and retained foam pieces.

Red flags & don'ts

Avoid harm

Limit epinephrine in cardiac disease and PVD avoidIn cardiac disease limit epinephrine to about 3.5 mL of 1:100,000 solution or use plain anesthetic, and consider avoiding epinephrine in the distal extremities of patients with peripheral vascular disease.

Systemic toxicity: CNS signs, seizures, arrest complicationLocal anesthetic systemic toxicity causes CNS symptoms progressing to seizures, arrhythmias and cardiac arrest; intravascular injection can present with seizure or arrest, and about 22% of cases start more than 30 minutes after injection.

The rules

Know these

No staples on the faceStaples are not used on the face because they scar more; tissue adhesives (cyanoacrylates) suit linear, low-tension lacerations, and antibiotic ointment is not applied over adhesives or adhesive strips.

Primary or delayed primary closure?

Commonly confused

Which wounds	Clean, uninfected, relatively uncontaminated
Wound age	< 6–8 h (< 12–24 h face and scalp)
First visit	Anesthetize, explore, debride, close
When it is closed	Immediately

More detail

Reference

Show 4 reference facts

A repaired wound has about 30% of its final tensile strength at 3 weeks and 80% at 3 months, and never regains the strength of uninjured skin; epithelium seals a sutured wound in 12–24 hours.

Reduce injection pain with a 27-gauge needle, slow subcutaneous (not intradermal) injection, warmed anesthetic, and lidocaine buffered with 8.4% sodium bicarbonate.

Topical LET is limited to 3 mL, and when it is combined with lidocaine infiltration the total lidocaine dose must stay within the weight-based maximum.

A wound infection that begins more than 5–7 days after injury suggests a retained foreign body; deep wounds near a major artery or entering a joint or body cavity need operative exploration.

Pearl

Lidocaine 1% is 10 mg/mL: 4.5 mg/kg plain, 7 mg/kg with epinephrine — know the milliliters before you draw up.

Sources · Merck Manual Professional — Skin Lacerations (physiology, anesthesia, closure, aftercare) · Xylocaine (lidocaine HCl) injection prescribing information — DailyMed (maximum recommended dosages) · Merck Manual Professional — Pressure Injuries (debridement methods) · Clinician.com (2010) — FDA alert on negative-pressure wound therapy contraindications and risk factors (reaffirmed in the FDA Safety Communication of Feb 24, 2011) · The Underlying Mechanisms and Role of Negative Pressure Wound Therapy in Chronic Diabetic Wound Healing: A Systematic Review and Meta-Analysis. Int Wound J 2026 · Merck Manual Professional — How To Do Local Wound Infiltration · UCSF Pain Management Education — Local Anesthetic Systemic Toxicity (summarizes the 2020 ASRA LAST checklist) · Washington State L&I — Negative Pressure Wound Therapy coverage (lists the contraindications from the FDA Safety Communication of Feb 24, 2011) · Starter sheet built from the verified AGACNP fact map (facts reviewed 2026-10-15).