下面使用google中文翻譯. 原文放後面
術後照護：局部抗生素和傷口敷料－對於縫合閉合的創傷性撕裂傷，我們建議使用局部抗生素軟膏[ 22,23 ]。我們傾向於選擇不含硫酸新黴素的軟膏（例如局部桿菌肽鋅軟膏），因為許多人對新黴素過敏[ 24 ]。對於先前使用新黴素未出現不良反應的患者，一個合理的替代方案是使用含有硫酸新黴素、桿菌肽鋅和硫酸多粘菌素B的複方軟膏。對於已知對新黴素過敏或先前因使用抗生素軟膏而出現皮膚炎的患者，一個合理的替代方案是使用不含局部抗生素的凡士林軟膏。為了促進傷口癒合，我們建議縫合傷口後，根據預計滲液量，先用開放式或半封閉式敷料覆蓋：●可能滲液或使用不可吸收縫線縫合的傷口－使用無菌紗布敷料或醫用膠帶（開放式敷料）。●無滲液或使用可吸收縫線（快速吸收腸線或Vicryl Rapide）縫合的傷口－可使用開放式或半封閉式敷料，例如聚合物薄膜（如Tegaderm、Cutifilm、BlisterFilm或Bioclusive），以保持縫線乾燥。聚合物薄膜可使患者更方便地淋浴而不會弄濕傷口，並允許在不移除敷料的情況下檢查傷口是否有感染跡象。敷料應保留至少24小時，之後傷口即可暴露於空氣中。也可在傷口上塗抹抗生素或凡士林軟膏，並指導患者在家中每天塗抹兩次，直到拆線。一項納入 426 名接受縫合修復創傷性撕裂傷的成年患者的試驗支持使用局部抗生素軟膏。在該試驗中，與凡士林軟膏對照組相比，僅含桿菌肽鋅的局部軟膏或含有硫酸新黴素、桿菌肽鋅和硫酸多粘菌素 B的複方軟膏均能降低傷口感染率（分別為 5.5%、4.5% 和 17.6%）[ 22 ]。另一項納入 177 名輕微傷口（大多為擦傷、磨損和割傷）兒童的試驗表明，與安慰劑組相比，使用含有西曲溴銨、桿菌肽和多粘菌素 B 的凝膠治療的患者感染率較低（1.6% 對 12.5%），儘管對照組的感染率高於預期[ 25 ]。局部應用抗生素並未顯示出能預防感染或加速輕微皮膚手術（例如，穿刺活檢或皮膚切除術）後的癒合；建議改用凡士林軟膏以避免潛在的接觸性皮膚炎。 （請參閱「皮膚切片技術」中的「傷口敷料」部分。）傷口封閉有助於維持濕潤環境，從而促進傷口癒合。評估手術傷口的小型交叉試驗也表明，傷口封閉可加速上皮再生，但與未覆蓋的傷口相比，完全癒合的時間似乎大致相同[ 26,27 ]。 （請參閱「急性傷口處理原則」中的「傷口敷料」部分。）清洗和沐浴－對於使用不可吸收縫線（例如，尼龍、聚丙烯）縫合的撕裂傷患者，我們建議在縫合後24小時內使用溫和的肥皂和水或半濃度的過氧化氫溶液進行輕柔清潔，以防止縫線結節處結痂。此外，這些患者可以淋浴或用肥皂和水清洗傷口，而不會增加感染風險。使用可吸收縫線縫合的撕裂傷，可在縫合後24至48小時進行輕柔清潔，但一些專家建議保持縫線乾燥，直至其基本吸收（通常快速吸收的腸線需要5天，Vicryl Rapide縫線需要7至10天）。應避免長時間浸泡縫線，包括在含氯水中游泳，因為理論上存在縫線抗張強度過早喪失導致傷口裂開的風險。縫合後的患者也不應在天然水體中游泳，因為這可能增加感染風險。目前關於縫合後何時洗澡的證據有限，僅能提供間接指引。例如，一項納入857例接受小面積皮膚切除術（採用不可吸收縫線縫合，並用乾紗布包紮）患者的試驗表明，術後12小時內清洗傷口並保持傷口開放的患者，與傷口保持乾燥並覆蓋至少48小時的患者相比，感染率相似（分別為8.4%和8.9%）[ 28,29 ]。研究建議患者避免在傷口處使用消毒液或抗菌皂，且未給予局部抗生素，這可能解釋了這些清潔手術傷口感染率相對較高的原因。另一項觀察性研究納入100例接受皮膚或軟組織病變切除術或局部皮瓣縫合術的患者，這些患者在術後24小時內開始每天清洗傷口兩次，結果發現所有傷口均未發生感染或裂開[ 30 ]。預防性抗生素的作用－對於健康患者，若僅有無併發症的皮膚撕裂傷，常規使用預防性全身性抗生素並非必要。所有患者應接受指導，告知若有傷口感染跡象（例如疼痛、發紅、腫脹、膿液流出或發熱），應及時返回醫院評估。縫合簡單撕裂傷後，正確的傷口準備是預防傷口感染的關鍵措施。 （請參閱「輕微傷口評估和縫合準備」。）有證據表明，對於健康患者，預防性使用抗生素並不能降低清潔皮膚撕裂傷的感染率。一項包含七項試驗（共1701例患者，其中110例發生傷口感染）的統合分析顯示，對於非咬傷性傷口的健康患者，預防性使用抗生素並未降低感染率（比值比1.2，95%置信區間0.8-1.7；對照組平均感染率為6%）[ 31 ]。對於某些感染風險較高的傷口，預防性使用抗生素的情況將在後續章節中詳細討論：●動物和人類咬傷●口腔撕裂傷●甲床損傷●傷口污染嚴重（例如，土壤或水污染）的病人 拆線－不可吸收縫線的拆線時間因解剖部位而異，取決於預期癒合速度27 5至7天●頭皮 – 7天●軀幹和上肢 – 7至10天●下肢 – 8至10天●手指、手掌和足底 – 10至14天隨訪－大多數清潔傷口無需醫生復診，直至拆線（如果使用了不可吸收縫線）或…可吸收縫線未按預期溶解。感染風險較高的傷口（例如，因動物或人類咬傷而縫合的撕裂傷，或有感染風險因素的患者[例如，糖尿病、免疫功能低下或傷口污染]）需要在48至72小時後進行追蹤評估。 兒科注意事項：焦慮的照顧者－照顧者是孩子的重要支持者，他們的擔憂需要耐心和理解。臨床醫生難免會遇到一些照顧者，他們要求為簡單的撕裂傷修復手術進行整形外科醫生的診治，或者要求對一些其實可以通過分散患者註意力、局部或註射麻醉劑以及助手幫助固定孩子來輕鬆處理的撕裂傷進行鎮靜。最好的方法是先傾聽，然後再提出合理的替代方案。在某些情況下，諮詢外科醫生是別無選擇。而在其他情況下，照顧者會聽取這樣的解釋：對於簡單的、乾淨的撕裂傷，無論由外科醫生或其他臨床醫生進行修復，美容效果都是可以接受的。有時，也可能是整形外科醫師的檔期問題。如果照顧者要求對簡單的撕裂傷進行鎮靜，他們必須明白，如果存在合理且安全的替代方案，鎮靜就存在不必要的風險。應向照顧者解釋分散注意力的方法和局部麻醉劑的使用。如有兒童生活專家在場，他們可以提供寶貴的幫助，並可安排一名助手固定兒童。兒童生活專家可以透過與患者一起閱讀書籍、播放影片或提供視覺想像等方式有效地分散許多患者的注意力。 不配合的兒童－焦慮且不配合的患者是一個挑戰，有時可以透過助手固定兒童並使用類似的分散注意力和視覺想像方法來處理，但有時則別無選擇，只能進行鎮靜麻醉以縫合傷口。我們發現，對於幼兒和其他焦慮兒童的簡單撕裂傷，通常可以使用局部麻醉劑（例如，利多卡因-腎上腺素-丁卡因[LET]）、鼻內咪達唑侖（表4）以及兒童生活專家或照顧者透過播放適合年齡的影片或遊戲來安撫和分散兒童的注意力，從而成功處理。鎮靜劑的選擇取決於年齡、受傷機制和修復所需時間，具體內容將另行詳細討論。
病患資訊
UpToDate 提供兩種類型的病患教育材料：「基礎知識」和「進階知識」。 「基礎知識」患者教育材料使用淺顯易懂的語言，閱讀難度相當於小學五、六年級水平，解答患者可能對特定疾病提出的四五個關鍵問題。這些文章最適合希望了解疾病概況且偏好簡短易讀資料的患者。 「進階知識」病患教育材料篇幅更長、內容更深入、更詳細。這些文章的閱讀難度相當於小學十年級至十二年級水平，最適合希望獲得深入資訊且能夠理解一些醫學術語的患者。
以下是與本主題相關的病患教育文章。我們鼓勵您列印或透過電子郵件將這些主題發送給您的患者。 （您也可以透過搜尋「病患資訊」和您感興趣的關鍵字，找到各種主題的病患教育文章。）
● 基礎知識主題
（請參閱「病患教育：縫線和縫合釘（基礎知識）」和「病患教育：拆線（基礎知識）」）總結並建議●一期縫合的適應症 – 當傷口深度過深，若傷口邊緣未正確對合會導致過度瘢痕形成時，縫合是合適的。傷口感染的擔憂是傷口不宜一期縫合的主要原因（參見上文「第一期縫合的適應症」）：• 對於健康患者，身體任何部位的清潔、未感染的撕裂傷，可在受傷後18小時內進行一期縫合，而不會顯著增加傷口感染的風險。• 因感染或傷口癒合不良的風險較低，所有患者的臉部傷口均可在受傷後24小時內進行第一期縫合。對於部分患者（無感染跡象、身體健康且傷口易於對合），臉部傷口可在受傷後48至72小時內進行縫合。不宜直接縫合的傷口以及需要諮詢整形外科醫生或其他外科專家的指徵包括：嚴重污染的撕裂傷、動物咬傷、大型/複雜撕裂傷以及為確保最佳美容效果而需要的特殊修復。●麻醉－對於大多數患者，局部浸潤麻醉可有效控制撕裂傷修復過程中的疼痛（表3）。對於臉部或頭皮無併發症的撕裂傷兒童，我們使用局部利多卡因-腎上腺素-丁卡因（LET）進行鎮痛。●傷口準備－傷口沖洗、異物取出和壞死組織清創是預防組織感染的主要措施。建議的溶液和這些措施的正確操作方法將在其他章節中詳細討論。 ●縫合技術的選擇－對於大多數無併發症的皮膚撕裂傷，簡單的間斷縫合即可提供足夠的閉合（圖11和圖16）。對於較深或較寬的撕裂傷，臨床醫師應先進行真皮縫合（圖 12）。 （請參閱上文「間斷經皮縫合」和「真皮縫合」。）其他縫合技術可能更適用於以下傷口：• 帶皮瓣的三角形傷口 – 半埋褥式縫合（圖 19）（參見上文「角縫合」） • 張力傷口 – 垂直縫合（圖20）或水平骨的連續傷口（圖 21褥）（圖 2 以及20 ） ●術後護理 – 對於接受縫合修復外傷性皮膚撕裂傷的患者，我們建議使用局部抗生素軟膏（第1B 級）。局部抗生素軟膏可以降低傷口感染的風險。我們傾向於選擇不含硫酸新黴素的軟膏（例如桿菌肽鋅軟膏），因為許多人對新黴素過敏。對於已知對抗生素軟膏過敏的患者，凡士林軟膏是一個合理的替代方案。
我們首先使用開放式敷料（例如，無菌紗布或創可貼）或半封閉式敷料（例如，聚合物薄膜）覆蓋傷口。保持傷口濕潤有助於傷口癒合。敷料應保留至少24小時，之後傷口即可暴露於空氣中。對於使用不可吸收縫線縫合的撕裂傷患者，我們建議在縫合24小時後使用溫和的肥皂水或半濃度的過氧化氫溶液輕輕清潔傷口，以防止縫線結節處結痂。
對於健康患者，如果僅有無併發症的皮膚外傷撕裂傷，則無需預防性使用全身性抗生素。
●拆線 – 不可吸收縫線的拆線時間因解剖部位而異，取決於預期癒合速度。
•眼瞼 – 5天（低張力傷口3天，高張力傷口最多7天）
•臉部 – 5天
•頸部 – 5至7天
•頭皮 – 7天
•軀幹和上肢 – 7至10天
•下肢 – 8至10天
•手指、手掌和足底 – 10至14天
AFTERCARETopical antibiotics and wound dressing — For traumatic lacerations closed with sutures, we recommend application of a topical antibiotic ointment [
22,23]. We prefer an ointment that does not contain
neomycin sulfate (such as topical
bacitracin zinc ointment) because many people have a neomycin sensitivity [
24]. In patients who have used neomycin previously without issues, a reasonable alternative is a combination ointment containing neomycin sulfate, bacitracin zinc, and
polymyxin B sulfate. For patients with a known sensitivity to neomycin or prior dermatitis from an antibiotic ointment, a reasonable alternative is a petrolatum ointment without topical antibiotics.
To enhance healing, we also suggest that lacerations repaired with sutures be initially covered with an open or semiocclusive dressing, as determined by the amount of anticipated drainage:
●Wounds with potential drainage or closed with nonabsorbable sutures – Sterile gauze dressing or adhesive bandage (open dressing).
●Wounds without drainage or closed with absorbable sutures (fast-absorbing gut or Vicryl Rapide) – Either an open or semiocclusive dressing such as a polymer film (eg, Tegaderm, Cutifilm, BlisterFilm, or Bioclusive) can keep the sutures dry. Polymer films may permit the patient to shower more easily without getting the wound wet and permit examination of the wound for signs of infection without removing the dressing.
The dressing should be left in place for at least 24 hours, after which time, wounds can be left open to air. An antibiotic or petrolatum ointment can be applied to the wound as well, with instructions to apply the ointment two times per day at home until suture removal.
The use of a topical antibiotic ointment is supported by a trial of 426 adults undergoing traumatic laceration repair with sutures in which a topical ointment containing only
bacitracin zinc or a combination ointment containing
neomycin sulfate, bacitracin zinc, and
polymyxin B sulfate, as compared with a petroleum ointment control, reduced the rates of wound infection (5.5, 4.5, and 17.6 percent, respectively) [
22]. In another trial of 177 children with minor wounds, most of which were grazes, abrasions, and cuts, patients treated with a gel containing cetrimide, bacitracin, and polymyxin B, as compared with placebo, had lower rates of infection (1.6 versus 12.5 percent), although the rate of infection in the control group was higher than expected [
25].
Topical antibiotics have not been shown to prevent infection or hasten healing after minor skin surgery (eg, punch biopsy or skin excision); petrolatum ointment is suggested instead to avoid potential contact dermatitis. (See
"Skin biopsy techniques", section on 'Wound dressing'.)
Occlusion of the wound helps to maintain a moist environment, which enhances wound healing. Small crossover trials evaluating surgical wounds also indicate that occlusion of the wound increases the speed of re-epithelialization, although complete healing appears to occur at approximately the same time when compared with uncovered wounds [
26,27]. (See
"Principles of acute wound management", section on 'Wound dressings'.)
Washing and bathing — For patients with lacerations closed with a nonabsorbable (eg, nylon, polypropylene) suture, we advise gentle cleaning using mild soap and water or one-half-strength peroxide 24 hours after closure to prevent crusting over the suture knots. Furthermore, these patients may be allowed to shower or wash the wound with soap and water without risking increased rates of infection.
Lacerations closed with percutaneous absorbable sutures may also be gently cleaned 24 to 48 hours after placement, although some experts advise keeping the suture dry until it is mostly absorbed (typically five days for fast-absorbing gut or 7 to 10 days for Vicryl Rapide).
Prolonged soaking of sutures, including swimming in chlorinated water, should be avoided because of the theoretical risk of premature loss of suture tensile strength with wound dehiscence. Patients with sutures should also not swim in natural bodies of water because of a potential increased risk of infection.
Evidence is limited and provides only indirect guidance in the timing of bathing after suture placement. As examples, in a trial of 857 patients who underwent minor skin excisions that were repaired with a nonabsorbable suture and were dressed with dry gauze, those who washed the wound site within 12 hours after suture placement and left the wound open had similar infection rates compared with those who kept their wounds dry and covered for at least 48 hours (8.4 versus 8.9 percent, respectively) [
28,29]. Patients were advised to avoid the use of antiseptic solutions or antibacterial soap on the wound site and were not given topical antibiotics, which likely explains the relatively high rates of infection in these clean surgical wounds. An observational study of 100 patients who underwent primary excision of a skin or soft-tissue lesion or local flap closure and began washing their wounds twice daily within 24 hours of surgery found no wounds that developed infection or dehiscence [
30].
Role of prophylactic antibiotics — For healthy patients with uncomplicated traumatic skin lacerations, routine use of prophylactic systemic antibiotics is not necessary. All patients should receive instructions advising that they return for evaluation if they develop signs of wound infection (eg, pain, redness, swelling, drainage of pus, or fever).
Proper wound preparation is the essential measure for preventing wound infection after suturing simple lacerations. (See
"Minor wound evaluation and preparation for closure".)
Evidence suggests that the use of prophylactic antibiotics does not reduce wound infections in healthy patients with clean traumatic skin lacerations. In a meta-analysis of seven trials (1701 total patients with a total of 110 wound infections), prophylactic antibiotics in healthy patients with wounds other than bite wounds did not decrease the infection rate (odds ratio 1.2, 95% CI 0.8-1.7; mean infection rate among controls 6 percent) [
31].
The use of prophylactic antibiotics for selected wounds with higher baseline risks of infection are discussed in detail separately:
●Animal and human bites
●Intraoral lacerations
●Nailbed injuries
●Patients with excessive wound contamination (eg, soil or water contamination)
Suture removal — The timing of nonabsorbable suture removal varies with the anatomic site, according to the expected rate of healing [
2,3]:
●Face – 5 days
●Eyelids – 5 days (3 days for low-tension wounds and up to 7 days for high-tension wounds)
●Neck – 5 to 7 days
●Scalp – 7 days
●Trunk and upper extremities – 7 to 10 days
●Lower extremities – 8 to 10 days
●Digits, palm, and sole – 10 to 14 days
Follow-up visits — Most clean wounds do not need to be seen by a clinician until suture removal (if nonabsorbable sutures were placed) or if absorbable sutures have not dissolved as expected.
Wounds at higher risk for infection (eg, repaired lacerations due to animal or human bites or in patients with risk factors for infection [eg, diabetes mellitus, immunocompromised host, or contaminated wound]) warrant evaluation at a follow-up visit in 48 to 72 hours.
PEDIATRIC CONSIDERATIONSAnxious caregiver — A caregiver is an important advocate for their child, and their concerns need to be addressed with patience and understanding. It is inevitable that the clinician will encounter some caregivers who demand a plastic surgeon for simple laceration repairs or procedural sedation for a laceration that easily could be managed with patient distraction, topical and/or injectable anesthetics, and an assistant to help hold the child still. The best approach is to listen first and to suggest reasonable alternatives later.
In some instances, there is no choice but to consult a surgeon. At other times, caregivers will listen to the explanation that for a simple, clean laceration, the cosmetic outcome will be acceptable whether repaired by a surgeon or another clinician. At times, it is also an issue of plastic surgeon availability.
In cases where a caregiver demands procedural sedation for a simple laceration, they must understand that sedation has risks that are unnecessary if a reasonable and safe alternative exists. The use of distraction methods and the use of topical anesthetics should also be explained to the caregiver. Child life specialists, if available, can provide invaluable assistance in this scenario, along with an assistant to hold the child still. The child life specialist can adequately distract many patients by reading books with the patient, playing a video, or providing visual imagery.
Uncooperative child — The anxious and uncooperative patient is a challenge that, at times, can be managed with an assistant to hold the child still and to use similar methods of distraction and imagery, but, at other times, leaves no choice but to perform procedural sedation to repair the laceration. We have found that simple lacerations in toddlers and other anxious children can often be successfully managed with topical anesthesia (eg, lidocaine-epinephrine-tetracaine [LET]), intranasal
midazolam (
table 4), and a child life specialist or caregiver to soothe and distract with age-appropriate videos or games. Sedation choices vary depending upon age, mechanism of injury, and time required for repair and are discussed in detail separately.
INFORMATION FOR PATIENTS
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics
(see "Patient education: Stitches and staples (The Basics)" and "Patient education: Removing stitches (The Basics)")SUMMARY AND RECOMMENDATIONS●Indications for primary closure – Sutures are appropriate when the depth of the wound will lead to excessive scarring if the wound edges are not properly apposed. Concern about wound infection is the main reason not to close a wound primarily (see
'Indications for primary closure' above):
•Clean, uninfected lacerations on any part of the body in healthy patients may be closed primarily for up to 18 hours following the injury without a significant increase in the risk of wound infection.
•Because of the lower risk of infection or poor wound healing, facial wounds may be closed primarily up to 24 hours following the injury in all patients. In selected patients (no signs of infection, otherwise healthy patient, and easily approximated wound), closure of facial wounds may occur up to 48 to 72 hours after injury.
Contraindications to primary closure and indications for consultation with a plastic surgeon or other surgical specialist include grossly contaminated lacerations, animal bites, large/complex lacerations, and specialized repair necessary to ensure optimal cosmetic outcomes.
●Anesthesia – For most patients, infiltration of a local anesthetic is effective for pain control during laceration repair (
table 3). We use topical lidocaine-epinephrine-tetracaine (LET) for pain control in children with uncomplicated facial or scalp lacerations
●Wound preparation – Wound irrigation, foreign body removal, and necrotic tissue debridement are the main preventive measures against tissue infection. Suggested solutions and proper performance of these measures are discussed in detail separately.
●Choice of suturing technique – The simple interrupted suture provides adequate closure for most uncomplicated skin lacerations (
figure 11 and
figure 16). For deep or wide lacerations, the clinician should first perform dermal closure (
figure 12). (See
'Interrupted percutaneous closure' above and
'Dermal closure' above.)
Wounds that may benefit from other closure techniques include:
•Triangular wound with a flap – Half-buried mattress (
figure 19) (see
'Corner stitch' above)
•Wounds under tension – Vertical (
figure 20) or horizontal mattress (
figure 21) (see
'Mattress sutures' above)
•Long, straight wounds – Running suture (
figure 22)
●Aftercare – For patients undergoing repair of traumatic skin lacerations with sutures, we suggest application of a topical antibiotic ointment (
Grade 1B). Topical antibiotic ointment may reduce wound infection. We prefer an ointment that does not contain
neomycin sulfate (such as topical
bacitracin zinc ointment) because many people have a neomycin sensitivity. Petrolatum ointment is a reasonable alternative in patients with a known sensitivity to antibiotic ointment.
We initially cover with an open (eg, sterile gauze or adhesive bandage) or semiocclusive (eg, polymer film) dressing. Maintaining a moist environment enhances wound healing. The dressing should be left in place for at least 24 hours, after which wounds can be left open to air. For patients with lacerations closed with nonabsorbable sutures, we advise gentle cleaning using mild soap and water or one-half-strength peroxide 24 hours after closure to prevent crusting over the suture knots.
For healthy patients with uncomplicated traumatic skin lacerations, prophylactic systemic antibiotics are not necessary.
●Suture removal – The timing of nonabsorbable suture removal varies with the anatomic site, according to the expected rate of healing
•Eyelids – 5 days (3 days for low-tension wounds and up to 7 days for high-tension wounds)
•Face – 5 days
•Neck – 5 to 7 days
•Scalp – 7 days
•Trunk and upper extremities – 7 to 10 days
•Lower extremities – 8 to 10 days
•Digits, palm, and sole – 10 to 14 days
