21.3 Laceration Management, Complex Wounds & Animal Bites

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

21.3 Laceration Management, Complex Wounds & Animal Bites

Key Takeaways Explain This Topic AI

Pre-procedural neurovascular and tendon evaluation—including two-point discrimination (<6 mm on digits) and active motor testing against resistance—must be documented prior to local anesthetic infiltration; plain lidocaine maximum dose is 4.5 mg/kg, while lidocaine with epinephrine (safe in digital blocks without severe peripheral arterial disease) is 7.0 mg/kg, with buffering using 8.4% sodium bicarbonate (9:1 ratio) significantly reducing injection pain.

High-pressure wound irrigation (7–8 psi using a 30–60 mL syringe with an 18-gauge angiocatheter) with clean potable tap water or sterile 0.9% normal saline effectively decreases bacterial load; pouring cytotoxic chemical antiseptics (povidone-iodine scrub, hydrogen peroxide) directly into open wound tissue is strictly contraindicated due to tissue necrosis and delayed healing.

Primary closure is recommended within 12 to 18 hours for extremity and trunk lacerations and up to 24 hours on the vascular face and scalp; facial sutures (6-0 nylon/polypropylene) must be removed at 3 to 5 days to prevent permanent cross-hatch railroad-track scarring, whereas joint and extensor surface sutures require 14 days.

Cat bites (Pasteurella multocida >75%) present as deep puncture wounds with high rates of closed-space infection, tenosynovitis, and osteomyelitis, and must NEVER be primarily closed; human clenched-fist 'fight bites' over the 3rd or 4th MCP joint inoculate Eikenella corrodens and oral anaerobes, requiring mandatory radiography, exploration, and hand surgery evaluation.

First-line oral antibiotic prophylaxis for mammalian bites is amoxicillin-clavulanate (Augmentin 875/125 mg PO BID for 3–5 days; cephalexin, clindamycin, and macrolides lack reliable Pasteurella and Eikenella coverage and are contraindicated); post-exposure rabies prophylaxis requires human rabies immune globulin (HRIG 20 IU/kg infiltrated around the wound) plus a 4-dose rabies vaccine series on Days 0, 3, 7, and 14 in previously unvaccinated individuals.

Last updated: September 2026

Systematic Wound Evaluation & Pre-Anesthetic Functional Assessment

Minor traumatic soft-tissue lacerations and bite wounds represent common presentations in primary care, urgent care, and emergency departments. Appropriate wound management balances functional preservation, infection avoidance, and optimal cosmetic outcomes.

Step 1: Pre-Anesthetic Neurovascular & Tendon Examination

Infiltrating local anesthetic alters tissue turgor and produces sensory and motor blockade, making subsequent functional testing invalid. Clinicians must perform and document a meticulous distal neurovascular examination PRIOR TO injecting local anesthetics :

Digital Sensory Testing (Two-Point Discrimination) :

Static two-point discrimination testing along the radial and ulnar digital borders using a paperclip or caliper.

Normal Threshold : < 6 mm < 6\text{ mm} < 6 mm at the digital pulp.

Abnormal Threshold : Discrimination ≥ 10 mm \ge 10\text{ mm} ≥ 10 mm (or comparison to the contralateral uninjured digit demonstrating a > 2 mm >2\text{ mm} > 2 mm disparity) is highly sensitive for digital nerve laceration, mandating microvascular surgical repair.

Motor & Tendon Testing Against Resistance :

Flexor Digitorum Profundus (FDP) : The examiner stabilizes the proximal interphalangeal (PIP) joint in full extension and instructs the patient to flex the distal interphalangeal (DIP) joint against manual resistance.

Flexor Digitorum Superficialis (FDS) : The examiner holds all adjacent fingers in complete extension to cancel the mass action of the common FDP muscle belly; the patient is then instructed to flex the PIP joint of the injured finger against resistance.

Extensor Digitorum Communis (EDC) : Assess active extension of the metacarpophalangeal (MCP) and interphalangeal joints against resistance.

Clinical Pearl : A tendon that is 90 % 90\% 90% transected can still produce full active range of motion against gravity . Therefore, testing AGAINST RESISTANCE and visualizing the tendon throughout active range of motion is mandatory to detect partial lacerations.

Wound Exploration Under Hemostasis :

Explore every laceration under a bloodless field (achieved with a sterile finger tourniquet or blood pressure cuff inflated above systolic pressure) through its complete active and passive range of motion. Inspect the full depth of the wound base to exclude foreign bodies (glass, gravel, radiopaque tooth fragments) and joint capsule disruption.

Pharmacology of Local & Regional Anesthesia

Local anesthetics block voltage-gated sodium channels along neuronal membranes, arresting action potential propagation. They belong to two chemical classes: amides (contain an "i" before the "-caine": lidocaine, bupivacaine, mepivacaine, prilocaine) and esters (procaine, tetracaine, cocaine; metabolized by plasma pseudocholinesterases; associated with allergic reactions to para-aminobenzoic acid [PABA]).

Anesthetic Profiles and Safety Thresholds

Anesthetic Agent Maximum Safe Plain Dose Maximum Safe Dose with Epinephrine Onset of Action Duration of Clinical Anesthesia

Lidocaine 1% 4.5 mg/kg 4.5\text{ mg/kg} 4.5 mg/kg (max ≈ 300 mg \approx 300\text{ mg} ≈ 300 mg / 30 mL 30\text{ mL} 30 mL ) 7.0 mg/kg 7.0\text{ mg/kg} 7.0 mg/kg (max ≈ 500 mg \approx 500\text{ mg} ≈ 500 mg / 50 mL 50\text{ mL} 50 mL ) 1 to 2 minutes 30 to 60 minutes (plain); 2 to 4 hours (with epi)

Lidocaine 2% 4.5 mg/kg 4.5\text{ mg/kg} 4.5 mg/kg (max ≈ 300 mg \approx 300\text{ mg} ≈ 300 mg / 15 mL 15\text{ mL} 15 mL ) 7.0 mg/kg 7.0\text{ mg/kg} 7.0 mg/kg (max ≈ 500 mg \approx 500\text{ mg} ≈ 500 mg / 25 mL 25\text{ mL} 25 mL ) 1 to 2 minutes 45 to 60 minutes (plain); 2 to 4 hours (with epi)

Bupivacaine 0.25% (Marcaine) 2.0 to 2.5 mg/kg 2.0\text{ to }2.5\text{ mg/kg} 2.0 to 2.5 mg/kg (max ≈ 175 mg \approx 175\text{ mg} ≈ 175 mg / 70 mL 70\text{ mL} 70 mL ) 3.0 mg/kg 3.0\text{ mg/kg} 3.0 mg/kg (max ≈ 225 mg \approx 225\text{ mg} ≈ 225 mg / 90 mL 90\text{ mL} 90 mL ) 10 to 15 minutes 4 to 8 hours (plain); 6 to 12 hours (with epi)

The Role of Epinephrine & Digital Block Safety

Pharmacological Benefits : Adding epinephrine ( 1 : 100 , 000 to 1 : 200 , 000 1:100,000\text{ to }1:200,000 1 : 100 , 000 to 1 : 200 , 000 ) produces local α 1 \alpha_1 α 1 ​ -adrenergic vasoconstriction. This significantly limits intra-wound bleeding, enhances visualization, delays systemic vascular absorption (increasing maximum allowable doses), and more than doubles the clinical duration of anesthesia .

Overturning Historical Dogma (The Digital Epinephrine Myth) :

Historical medical dogma warned that epinephrine in "fingers, toes, penis, and nose" caused end-artery vasospasm and digital gangrene. Massive prospective trials analyzing > 10 , 000 >10,000 > 10 , 000 digital procedures have completely disproven this myth; historical cases of gangrene were attributable to acidic procaine solutions contaminated with carbolic acid in the early 20th century.

Guideline Consensus : Lidocaine with epinephrine is entirely safe for digital blocks, auricular lacerations, and nasal repairs in healthy individuals . It should be avoided only in patients with severe peripheral arterial occlusive disease (Buerger disease, severe Raynaud phenomenon, or compromised microvascular digital replants). If prolonged vasospasm occurs, it can be reversed with local infiltration of phentolamine ( 5 to 10 mg 5\text{ to }10\text{ mg} 5 to 10 mg diluted in 10 mL 10\text{ mL} 10 mL saline) .

Buffering Local Anesthesia with Sodium Bicarbonate

Commercial lidocaine solutions are packaged at an acidic pH ( 5.0 to 6.5 5.0\text{ to }6.5 5.0 to 6.5 ; or 3.5 to 4.5 3.5\text{ to }4.5 3.5 to 4.5 with epinephrine) to prevent spontaneous oxidative degradation of epinephrine, which causes severe burning and stinging pain upon tissue infiltration.

Buffering Protocol : Mix 8.4 % 8.4\% 8.4% Sodium Bicarbonate with 1 % 1\% 1% Lidocaine in a 1:9 volume ratio ( 1 mL 1\text{ mL} 1 mL of 8.4 % 8.4\% 8.4% bicarbonate added to 9 mL 9\text{ mL} 9 mL of lidocaine).

Mechanism : Neutralizing the solution converts charged cationic lidocaine into uncharged, lipid-soluble free-base lidocaine. This dramatically decreases injection pain and accelerates lipid membrane penetration, speeding the onset of surgical anesthesia.

Topical Anesthetics in Pediatric Wound Care

LET Gel (Lidocaine 4 % 4\% 4% , Epinephrine 0.1 % 0.1\% 0.1% , Tetracaine 0.5 % 0.5\% 0.5% ) : Applied directly onto the open wound base under an occlusive dressing for 20 to 30 minutes prior to repair. Achieves complete dermal anesthesia for facial and scalp lacerations in young children, avoiding needle infiltration anxiety.

Wound Cleansing, High-Pressure Irrigation & Debridement

Copious wound irrigation is the single most effective intervention to prevent post-repair wound infections, reducing bacterial load below the critical infection threshold ( < 10 5 organisms/gram of tissue <10^5\text{ organisms/gram of tissue} < 1 0 5 organisms/gram of tissue ).

High-Pressure Irrigation Mechanics

Required Pressure : Effective mechanical removal of bacterial bioburden, micro-particulates, and organic debris requires an irrigation pressure of 7 to 8 pounds per square inch (psi) 7\text{ to }8\text{ pounds per square inch (psi)} 7 to 8 pounds per square inch (psi) .

Equipment : Achieved by attaching an 18- or 19-gauge angiocatheter (or plastic splash guard) to a 30 to 60 mL 30\text{ to }60\text{ mL} 30 to 60 mL syringe . Gravity bulb syringes or IV tubing bags deliver < 1 to 2 psi <1\text{ to }2\text{ psi} < 1 to 2 psi and are completely ineffective at dislodging bacteria adherent to tissue.

Irrigation Volume : Deliver 50 to 100 mL 50\text{ to }100\text{ mL} 50 to 100 mL of fluid per centimeter of laceration length (minimum 250 to 500 mL 250\text{ to }500\text{ mL} 250 to 500 mL for clean wounds; ≥ 1 , 000 mL \ge 1,000\text{ mL} ≥ 1 , 000 mL for heavily contaminated, crushed, or bite wounds).

Selection of Irrigation Fluid

Tap Water vs. Sterile Normal Saline : Multiple randomized clinical trials and Cochrane reviews confirm that clean, potable municipal tap water is non-inferior to sterile 0.9 % 0.9\% 0.9% normal saline in post-closure infection rates. Clean tap water or sterile saline may be used interchangeably.

Caution

STRICT CONTRAINDICATION: CYTOTOXIC ANTISEPTICS IN OPEN WOUNDS: Hydrogen peroxide, povidone-iodine surgical scrub (Betadine scrub), chlorhexidine, and isopropyl alcohol are STRICTLY CONTRAINDICATED inside open traumatic wounds. These chemical detergents are non-selective cellular toxins that lyse host fibroblasts, keratinocytes, and tissue macrophages, impairing innate defense mechanisms, provoking tissue necrosis, and significantly increasing post-closure infection rates while worsening scar formation . Non-detergent povidone-iodine ( 10 % 10\% 10% ) or chlorhexidine is indicated solely for prepping the intact skin surrounding the wound edges, never for instillation into the open wound base.

• Wound Closure Timing, Suture Selection & Removal
• Timing of Wound Closure

Primary Closure (Primary Intention) : Wound margins are approximated immediately with sutures, staples, or adhesive. Indicated for clean, fresh traumatic lacerations within the "Golden Period" :

Extremities, Trunk, and Back : Within 12 to 18 hours of injury.

Face and Scalp : Up to 24 hours after injury, due to exceptionally rich facial microvascular perfusion, which resists infection and facilitates primary healing.

Delayed Primary Closure (Tertiary Intention) : Indicated for heavily contaminated lacerations, mammalian bite wounds presenting > 12 to 24 hours >12\text{ to }24\text{ hours} > 12 to 24 hours old, or high-velocity blast injuries. The wound is anesthetized, copiously irrigated, conservatively debrided, and packed open with sterile saline-moistened gauze. If no clinical infection develops after 3 to 5 days , the wound edges are closed primarily.

Secondary Intention : The wound is left open to heal spontaneously via granulation tissue formation and myofibroblast-driven wound contraction. Indicated for deep puncture wounds, heavily infected wounds, and cat bite punctures.

Suture Materials & Suture Removal Intervals

Percutaneous Skin Closure : Monofilament non-absorbable sutures ( Nylon [Ethilon] or Polypropylene [Prolene] ) are the gold standard. Their smooth surface minimizes bacterial adherence and tissue reactivity compared to braided silk or braided absorbable sutures.

Deep Dermal Closure : Absorbable polyglactin 910 (Vicryl) or poliglecaprone 25 (Monocryl) sutures eliminate dead space and relieve tension on the epidermal layer, preventing wound spreading and depressed scars.

Suture Removal Intervals : Sutures must remain in place long enough to achieve adequate tensile strength, but must be removed before epithelialization extends along the suture tracts, producing permanent cross-hatch ("railroad track") scars.

Anatomical Location Recommended Percutaneous Suture Size Recommended Suture Removal Timeline Clinical Pearls

Face 6-0 Nylon / Polypropylene 3 to 5 days Remove early to prevent permanent railroad-track scarring; reinforce wound margins with adhesive skin tape (Steri-Strips).

Scalp 4-0 or 5-0 Nylon / Polypropylene (or staples) 7 to 10 days Surgical staples deliver rapid closure through hair-bearing scalp; inspect galea aponeurotica and close separately with 3-0 absorbable suture if torn.

Trunk and Upper Extremities 4-0 or 5-0 Nylon / Polypropylene 7 to 10 days Low-to-moderate tension zones; use horizontal or vertical mattress sutures for eversion if wound edges invert.

Lower Extremities and Back 3-0 or 4-0 Nylon / Polypropylene 10 to 14 days High static skin tension and dependent hydrostatic venous pressure require longer support to avoid wound dehiscence.

Extensor Surfaces of Joints 3-0 or 4-0 Nylon / Polypropylene 14 days Dynamic joint flexion exerts extreme cyclic tension; consider temporary splinting in extension to promote healing.

Mammalian & Human Bites: Microbiology & Clinical Profiles MAMMALIAN BITE CLINICAL SPECTRUM

• DOG BITES (~80-90%) CAT BITES (~10-15%) HUMAN BITES ('FIGHT BITES')
• ┌─────────────────────┐ ┌─────────────────────┐ ┌─────────────────────────┐
• │ • Crushing / tears │ │ • Deep puncture │ │ • Clenched fist over │
• │ • S. aureus, Strep │ │ • Pasteurella (>75%)│ │ 3rd/4th MCP joint │
• │ • Capnocytophaga: │ │ • High infection │ │ • Eikenella corrodens │
• │ Fulminant sepsis │ │ rate (>50-80%) │ │ • Tooth foreign body │
• │ in asplenia │ │ • NEVER close │ │ • Tenosynovitis & │
• │ • Augmentin 1st-line│ │ primarily │ │ septic arthritis │
• └─────────────────────┘ └─────────────────────┘ └─────────────────────────┘
• 1. Dog Bites (Canine Trauma)

Represent 80 % to 90 % 80\%\text{ to }90\% 80% to 90% of all reported mammalian bite wounds.

Mechanism : Large canine jaws deliver crushing forces up to 200 to 400 psi 200\text{ to }400\text{ psi} 200 to 400 psi , producing extensive contusion, tearing, tissue devitalization, and avulsion lacerations.

Microbiology : Polymicrobial mix of canine oral flora and human cutaneous pathogens: Pasteurella canis , Staphylococcus aureus , Streptococcus pyogenes , and anaerobes ( Fusobacterium , Bacteroides ).

Capnocytophaga canimorsus : A fastidious Gram-negative rod present in normal canine saliva. In patients with asplenia, functional hyposplenism, cirrhosis, chronic alcoholism, or severe immunosuppression , C. canimorsus can produce catastrophic, fulminant bacteremia, overwhelming septic shock, disseminated intravascular coagulation (DIC), purpura fulminans , and peripheral symmetrical gangrene, with a mortality rate exceeding 30 % 30\% 30% .

2. Cat Bites (Feline Puncture Wounds)

Represent 10 % to 15 % 10\%\text{ to }15\% 10% to 15% of mammalian bites, but carry an infection rate exceeding 50 % to 80 % 50\%\text{ to }80\% 50% to 80% (more than double that of dog bites).

Mechanism : Long, sharp, slender feline teeth act as natural hypodermic needles, inoculating bacterial pathogens deep through subcutaneous tissue planes into avascular flexor tendon sheaths, joint capsules, and periosteum.

Pathogen : Pasteurella multocida is isolated in > 75 % to 90 % >75\%\text{ to }90\% > 75% to 90% of cat bites. Characterized by an exceptionally rapid incubation period: intense local erythema, warmth, pain, and seropurulent drainage typically develop within 6 to 24 hours of injury .

Complications : High incidence of closed-space hand infections, suppurative flexor tenosynovitis, septic arthritis, and osteomyelitis.

Mandatory Rule : Cat bite puncture wounds should NEVER be closed primarily . They must be left open to heal by secondary intention.

3. Human Bites & Clenched-Fist "Fight Bites"

Mechanism : Human bite injuries occur either via direct occlusional bites or, more ominously, as a Clenched-Fist Injury ("Fight Bite") sustained when a patient punches another individual in the mouth, striking teeth. The impact lacerates the thin dorsal skin overlying the 3rd or 4th metacarpophalangeal (MCP) joint .

Patho-anatomy : During the clenched-fist impact, the extensor tendon and joint capsule are stretched tightly over the metacarpal head and penetrated by teeth. When the hand is subsequently relaxed into an open position, the extensor tendon slides proximally beneath the skin, carrying virulent human oral organisms deep into the subaponeurotic space and MCP joint cavity, where they proliferate under anaerobic conditions.

Microbiology : Polymicrobial infection dominated by Eikenella corrodens (a fastidious facultative anaerobic Gram-negative rod unique to human oral flora), viridans group streptococci, Staphylococcus aureus , and oral anaerobes ( Fusobacterium nucleatum , Prevotella species).

Clinical Diagnostic Rules :

Any laceration overlying the dorsal MCP joints must be presumed a clenched-fist injury until proven otherwise, regardless of patient denial.

Mandatory Radiography : Obtain plain radiographs of the hand in multiple views to rule out metacarpal head fractures ("boxer's fracture"), cortical violation, and radiopaque tooth fragments retained within the joint space.

Kanavel's Four Cardinal Signs of Suppurative Flexor Tenosynovitis :

• Symmetrical, uniform sausage-like swelling along the entire digit;
• The involved digit held in slight flexion at rest;
• Exquisite tenderness along the entire anatomical course of the flexor tendon sheath;

Severe, agonizing pain elicited upon PASSIVE EXTENSION of the digit (the most sensitive early sign).

Management : Clenched-fist wounds must NEVER be closed primarily . They require formal surgical exploration through both flexion and extension, copious high-pressure irrigation, splinting in the position of function, urgent hand surgical consultation, and immediate broad-spectrum intravenous or oral antimicrobial coverage.

4. Puncture Wounds Through Rubber-Soled Shoes

Puncture wounds to the plantar foot sustained while wearing athletic shoes drive rubber and foam shoe debris into deep plantar fascial compartments.

Foam shoe linings harbor Pseudomonas aeruginosa . Deep inoculation into the calcaneus or metatarsals carries a high risk of Pseudomonas osteochondritis and osteomyelitis .

Management : High-pressure irrigation, probing for retained foam/rubber foreign bodies, avoidance of primary closure, and prophylactic treatment with an oral fluoroquinolone covering Pseudomonas ( Ciprofloxacin 500 to 750 mg 500\text{ to }750\text{ mg} 500 to 750 mg PO BID for 7 to 10 days ).

• Antimicrobial Prophylaxis for Bite Wounds
• Indications for Prophylactic Antibiotics (3 to 5 Days)

Routine antibiotic prophylaxis is not necessary for trivial, superficial dog scratches in healthy individuals presenting within a few hours. Prophylactic antibiotics are strictly indicated for:

• All cat bite wounds (due to the > 50 % >50\% > 50% baseline infection rate);
• All human bite wounds (including all clenched-fist injuries);
• All puncture wounds and deep crush wounds ;
• Any bite wound involving high-risk anatomical structures : the hands, feet, face, or overlying major joints;
• Wounds presenting > 8 to 12 hours >8\text{ to }12\text{ hours} > 8 to 12 hours after injury ;

Any mammalian bite in an immunocompromised host (asplenia, cirrhosis, diabetes mellitus, active chemotherapy, chronic steroid use).

First-Line Antimicrobial Regimen

Amoxicillin-Clavulanate (Augmentin) : 875 / 125 mg 875/125\text{ mg} 875/125 mg PO twice daily for 3 to 5 days (prophylaxis) or 7 to 10 days (early established cellulitis).

Coverage : Delivers optimal bactericidal coverage against Pasteurella multocida , Eikenella corrodens , methicillin-susceptible Staphylococcus aureus , Streptococcus , and oral anaerobes.

Penicillin-Allergic Alternative Regimens

Option 1 : Doxycycline ( 100 mg 100\text{ mg} 100 mg PO BID) : Excellent coverage against Pasteurella multocida , Staphylococcus , and Streptococcus . (Preferred oral alternative in non-pregnant adults).

Option 2 : Fluoroquinolone PLUS Anaerobic Coverage : Ciprofloxacin ( 500 mg 500\text{ mg} 500 mg PO BID) PLUS Metronidazole ( 500 mg 500\text{ mg} 500 mg PO TID) .

Option 3 : Trimethoprim-Sulfamethoxazole (TMP-SMX 1 to 2 DS tabs PO BID) PLUS Clindamycin or Metronidazole .

Caution

THE INEFFECTIVE ANTIBIOTIC TRAP: Cephalexin, dicloxacillin, clindamycin, erythromycin, and azithromycin have POOR or NO activity against Pasteurella multocida and Eikenella corrodens . Prescribing cephalexin monotherapy for a cat bite or clenched-fist human bite is a classic board examination error that leads to treatment failure, suppurative tenosynovitis, and permanent joint disability.

CDC & ACIP Rabies Post-Exposure Prophylaxis (PEP)

Rabies is caused by a neurotropic RNA lyssavirus transmitted through the saliva of infected mammals. Once clinical encephalitic or paralytic rabies symptoms develop, the disease carries a virtually 100 % 100\% 100% case fatality rate . Timely post-exposure prophylaxis is 100 % 100\% 100% effective when administered correctly before viral entry into peripheral nerve endings.

Animal Risk Stratification in North America

High-Risk Vectors : Bats, raccoons, skunks, and foxes . In the United States, bats are the leading source of human rabies infections.

The Bat Bedroom Rule : Any direct physical contact with a bat, OR finding a bat inside a room with an unattended infant, a sleeping person, an intoxicated individual, or a cognitively impaired adult constitutes an exposure mandating immediate Rabies PEP, unless the bat is captured intact and tests negative for rabies by public health direct fluorescent antibody testing.

Domestic Dogs, Cats, and Ferrets :

A healthy, domesticated dog, cat, or ferret that bites a human can be quarantined and observed for 10 days by local animal control.

The rabies virus is excreted in saliva only during the immediate pre-symptomatic period (a few days prior to death). If the animal remains healthy, alert, and asymptomatic throughout the 10-day quarantine, it could not have transmitted rabies at the time of the bite, and PEP is not required .

If the animal develops symptoms, dies, or is a stray that escaped quarantine, initiate PEP immediately.

Low-Risk Animals : Small rodents (mice, rats, squirrels, chipmunks, guinea pigs) and lagomorphs (rabbits, hares) almost never survive encounters with rabid predators and have never been documented to transmit rabies to humans in North America. PEP is not routinely indicated.

The ACIP Rabies PEP Protocol ACIP RABIES POST-EXPOSURE PROPHYLAXIS (PEP)

• Suspected Rabies Exposure
• │

Documented Prior Rabies Series?

• │
• ┌────────────────────────┴────────────────────────┐
• ▼ ▼
• PREVIOUSLY UNVACCINATED PREVIOUSLY VACCINATED
• │ │
• ┌───────────────┴───────────────┐ ▼
• ▼ ▼ RABIES VACCINE ONLY
• HUMAN RABIES RABIES (1.0 mL IM in Deltoid)
• IMMUNE GLOBULIN (HRIG) VACCINE • Day 0 and Day 3

• 20 IU/kg body weight (1.0 mL IM in Deltoid) • NO HRIG indicated!

• Infiltrate full volume • Day 0, 3, 7, and 14
• into and around wound margins (4 doses total)
• Remaining volume IM distant • (5th dose Day 28
• from vaccine site if immunocompromised)

For Previously Unvaccinated Individuals :

Human Rabies Immune Globulin (HRIG) :

Dose : 20 IU/kg 20\text{ IU/kg} 20 IU/kg actual body weight administered on Day 0 (can be administered up to Day 7 if not immediately available).

Administration : Infiltrate as much of the full calculated volume as anatomically feasible directly into and around the wound margins . Any remaining volume is injected intramuscularly at an anatomical site distant from the vaccine (e.g., anterolateral thigh).

Rationale : Delivers immediate passive neutralizing antibodies while the patient mounts active humoral immunity.

Rabies Vaccine (HDCV or PCECV) :

Dose : 1.0 mL 1.0\text{ mL} 1.0 mL IM administered on Days 0, 3, 7, and 14 (4 doses total).

Site : Administer strictly in the deltoid muscle in adults (or anterolateral thigh in small children). NEVER administer the rabies vaccine in the gluteal muscle , as gluteal adipose tissue leads to significantly lower neutralizing antibody seroconversion rates.

Immunocompromised Patients : Receive a 5-dose vaccine series (Days 0, 3, 7, 14, and 28) followed by serological titer verification.

For Previously Vaccinated Individuals :

Administer 2 doses of rabies vaccine ( 1.0 mL 1.0\text{ mL} 1.0 mL IM in deltoid) on Days 0 and 3 .

Do NOT administer HRIG , as circulating memory cells mount a rapid anamnestic antibody surge, and exogenous immune globulin blunts this response.

CDC & ACIP Tetanus Wound Prophylaxis Guidelines

Clostridium tetani is a ubiquitous, anaerobic, spore-forming soil bacillus that elaborates tetanospasmin , an exotoxin that blocks inhibitory neurotransmitter (GABA and glycine) release at spinal motor interneurons, producing severe muscle rigidity and painful autonomic spasms. Tetanus prophylaxis is stratified strictly by wound classification and documented immunization history:

Tetanus Prophylaxis Decision Matrix

Wound Classification Primary Series Incomplete ( < 3 <3 < 3 Doses) or Unknown History Primary Series Completed ( ≥ 3 \ge 3 ≥ 3 Documented Lifetime Doses)

Clean, Minor Wounds Administer Tetanus Toxoid Vaccine (Tdap or Td) ;; NO Tetanus Immune Globulin (TIG) Administer vaccine ONLY if ≥ 10 years \ge 10\text{ years} ≥ 10 years since last booster;; NO Tetanus Immune Globulin (TIG)

All Other Contaminated Wounds ; (Soil, feces, saliva, crush, puncture, avulsion, burn) Administer BOTH Tetanus Toxoid Vaccine (Tdap/Td) AND Tetanus Immune Globulin (TIG 250 units IM) at separate anatomical sites Administer vaccine if ≥ 5 years \ge 5\text{ years} ≥ 5 years since last booster;; NO Tetanus Immune Globulin (TIG)

Vaccine Formulations : Tdap (Tetanus, Reduced Diphtheria, Acellular Pertussis) is preferred over Td for any patient ≥ 11 \ge 11 ≥ 11 years of age who has not previously received Tdap.

Tetanus Immune Globulin (TIG) : Administered as 250 units 250\text{ units} 250 units IM using a separate syringe at an anatomical site distant from the vaccine. TIG is indicated solely for contaminated wounds in patients who have received fewer than 3 lifetime doses of tetanus toxoid or whose vaccination status is unknown.

Loading diagram... Mammalian Bite, Wound Closure & Prophylaxis Algorithm