📋 Key Information Summary
- Contusions and haematomas are managed with RICE (rest, ice, compression, elevation); large or expanding haematomas may require aspiration or surgical evacuation.
- Wound assessment must document mechanism, contamination, neurovascular status, tendon/nerve function, and time since injury before any repair.
- Primary closure is appropriate for clean lacerations presented within 6–12 hours (face: up to 24 hours); contaminated wounds may require delayed primary closure at 3–5 days.
- Suture selection: non-absorbable (e.g. nylon, polypropylene) for skin; absorbable (e.g. polyglactin 910, poliglecaprone 25) for deep dermal and mucosal sutures.
- Face wounds: use 5-0 or 6-0 non-absorbable sutures; remove at 5 days to minimise scarring.
- Tetanus prophylaxis must be assessed for every wound; administer tetanus immunoglobulin (TIG) for dirty/tetanus-prone wounds in patients with <3 prior doses or unknown status.
- Lip lacerations involving the vermilion border require meticulous alignment; through-and-through lip wounds are repaired in three layers (mucosa, muscle, skin).
- Full-thickness eyelid lacerations involving the lid margin or levator apparatus require urgent ophthalmology referral for operative repair.
- Tongue lacerations usually heal by secondary intention; repair is indicated only for deep wounds (>1 cm), gaping edges, or active haemorrhage.
- Retained foreign bodies should be suspected with any puncture wound; imaging (X-ray, ultrasound, or CT) is guided by material type and location.
- Wood and organic foreign bodies carry higher infection risk and must be removed promptly; radio-opaque objects may be localised with plain radiography.
- Antibiotic prophylaxis is indicated for contaminated wounds, bite wounds, open fractures, immunocompromised patients, and wounds involving joints or tendons.
- Aboriginal and Torres Strait Islander peoples may present later due to geographic and cultural barriers; telehealth and point-of-care wound care in remote communities improve outcomes.
Introduction & Australian Epidemiology
Skin wounds and foreign bodies are among the most frequent presentations in Australian general practice and emergency departments. Lacerations, contusions, abrasions, puncture wounds, and embedded foreign bodies collectively account for a substantial proportion of primary care consultations. The Royal Australian College of General Practitioners (RACGP) estimates that wound management constitutes approximately 5–10% of all general practice encounters.
In Australia, approximately 500,000 presentations to emergency departments annually involve soft-tissue injuries, with hand and facial lacerations predominating. Paediatric patients account for a large share, particularly toddlers and school-aged children injured during play and sport. Agricultural and industrial settings contribute disproportionately in regional and rural areas.
Timely, evidence-based wound management reduces infection rates, minimises scarring, and prevents complications such as retained foreign bodies. This article provides a practical, guideline-concordant framework for managing common skin wounds and foreign bodies in Australian primary care and general practice settings.
Scope: This article covers superficial to moderate-depth wounds managed in general practice or the emergency department. Complex hand injuries, open fractures, and major trauma are beyond scope and require specialist surgical input.
Contusions & Haematomas
Contusions
A contusion is a closed soft-tissue injury resulting from blunt trauma causing capillary rupture, interstitial haemorrhage, and oedema without a break in the skin. Most contusions are self-limiting and managed conservatively.
Initial Management — RICE Protocol
R
Rest
Immobilise the affected area; avoid weight-bearing or repetitive use for 24–48 hours.
I
Ice
Apply cold packs for 15–20 minutes every 2–3 hours during the first 48 hours. Use a barrier (cloth/towel) to prevent frostbite.
C
Compression
Elastic compression bandage to limit swelling. Ensure distal pulses and sensation are preserved.
E
Elevation
Elevate the injured limb above heart level when possible to reduce oedema.
Analgesia
Paracetamol
Panadol® · Panamax® · Analgesic
Adult dose
500–1000 mg PO every 4–6 hours (max 4 g/day)
Paediatric dose
15 mg/kg PO every 4–6 hours (max 60 mg/kg/day)
Renal adjustment
eGFR 10–50: max 2 g/day; eGFR <10: max 1 g/day
PBS status
✔ PBS General Benefit
Ibuprofen
Nurofen® · Brufen® · NSAID
Adult dose
200–400 mg PO every 6–8 hours (max 1200 mg/day OTC; 2400 mg/day Rx)
Paediatric dose
5–10 mg/kg PO every 6–8 hours
Renal adjustment
Avoid if eGFR <30; use with caution if eGFR 30–60
PBS status
✔ PBS General Benefit
Haematomas
A haematoma is a localised collection of blood within tissues, usually following trauma. They are classified by anatomical location:
| Type | Location | Management |
|---|---|---|
| Subungual haematoma | Beneath nail plate | Trephination (cautery or 18G needle) if >50% nail plate or painful; nail-bed repair if fracture present |
| Auricular haematoma | Between cartilage and perichondrium (pinna) | Aspiration or incision & drainage + compression dressing; ENT referral to prevent cauliflower ear |
| Septal haematoma | Beneath nasal septum perichondrium | Urgent ENT referral for incision & drainage to prevent septal abscess and cartilage necrosis |
| Muscle haematoma | Deep intramuscular | Conservative (RICE); surgical evacuation if compartment syndrome suspected or expanding |
| Scalp haematoma | Subgaleal or subperiosteal | Monitor for underlying skull fracture (CT head if concern); assess for coagulopathy |
Auricular and septal haematomas are emergencies. Failure to drain within 6–12 hours risks permanent cartilage deformity (cauliflower ear) or septal abscess with perforation. Refer to ENT urgently.
Anticoagulant-associated haematomas: Patients on warfarin, DOACs, or antiplatelet agents may develop large haematomas from minor trauma. Assess INR (warfarin), renal function, and consider reversal agents if life-threatening bleeding is present.
Principles of Wound Repair & Suture Materials
Wound Assessment
Before repair, systematically assess the wound using the following framework:
- Mechanism: Sharp (clean edges), blunt (crush/contused edges), penetrating, bite (high contamination).
- Timing: Clean wounds: close within 6–12 hours (face: up to 24 hours). Contaminated wounds: delayed primary closure at 3–5 days or heal by secondary intention.
- Contamination: Soil, organic matter, faeces, or devitalised tissue increases infection risk.
- Neurovascular status: Assess distal pulses, capillary refill, sensation (two-point discrimination), and motor function distal to the wound.
- Tendon function: Test through full range of motion; partial tendon lacerations may present with subtle weakness.
- Foreign body: Visualise and palpate the wound bed; image if suspicion remains.
Wound Irrigation & Preparation
Irrigation is the single most important intervention to prevent wound infection:
- Use potable tap water or normal saline (0.9% NaCl) under pressure (35–70 mL syringe with 18–19G splash guard or IV catheter).
- Minimum 250–500 mL per wound; increase volume for contaminated or heavily soiled wounds.
- Do not use hydrogen peroxide, povidone-iodine solution, or chlorhexidine directly in open wounds as they are cytotoxic to fibroblasts (dilute chlorhexidine 0.05% or povidone-iodine 1% may be used for irrigation).
- Debride devitalised tissue with sharp dissection; remove visible foreign bodies.
Anaesthesia for Wound Repair
Lignocaine (Lidocaine) 1%
Xylocaine® · Local anaesthetic
Adult dose
1–3% solution, local infiltration; max 3 mg/kg (4.5 mg/kg with adrenaline)
Paediatric dose
1% solution; max 3 mg/kg plain (4.5 mg/kg with adrenaline)
Onset / Duration
Onset 2–5 min; duration 30–60 min (plain), 2–4 hours (with adrenaline 1:200,000)
Key note
Use lignocaine with adrenaline (1:200,000) for most wounds — SAFE on digits, ears, nose, penis (contrary to historical teaching). Avoid on tips of digits if there is vascular compromise.
PBS status
✔ PBS General Benefit
Lignocaine / Prilocaine topical (EMLA)
EMLA® cream · Topical anaesthetic
Adult dose
Apply thick layer under occlusive dressing 60 min before procedure
Paediatric dose
Apply 1 hour before; limit to <20 cm² in children <3 months
PBS status
✔ PBS General Benefit
Regional Nerve Blocks
Digital nerve blocks (ring blocks) are preferred for finger and toe lacerations. Use 2–3 mL of 1% lignocaine without adrenaline injected at the dorsal base of the digit on each side. A traditional teaching of avoiding adrenaline in digits has been revised — current evidence supports its safety — however, plain lignocaine remains standard practice in most Australian EDs.
Suture Materials
| Material | Type | Common Use | Removal / Absorption |
|---|---|---|---|
| Nylon (Ethilon®) | Non-absorbable, monofilament | Skin closure (most common) | Remove: face 5 days, trunk 7–10 days, extremities 10–14 days |
| Polypropylene (Prolene®) | Non-absorbable, monofilament | Skin, vascular anastomosis | Removal as per nylon |
| Silk | Non-absorbable, braided | Rarely used for skin; dental use | Remove 7–10 days; high tissue reactivity |
| Polyglactin 910 (Vicryl®) | Absorbable, braided | Deep dermal, muscle, mucosal closure | Absorbed 56–70 days; loses tensile strength at 28 days |
| Poliglecaprone 25 (Monocryl®) | Absorbable, monofilament | Deep dermal (subcuticular), face | Absorbed 91–119 days; tensile strength lost at 7–14 days |
| Polydioxanone (PDS®) | Absorbable, monofilament | Deep closure, fascia, slow-healing wounds | Absorbed 180+ days; prolonged tensile strength |
Suture Size Guide
| Location | Suture Size | Needle |
|---|---|---|
| Face | 5-0 or 6-0 nylon | P-1 or PS-2 (reverse cutting, small) |
| Scalp | 3-0 or 4-0 nylon | FS-2 or P-3 (cutting) |
| Trunk / limbs | 4-0 or 5-0 nylon | FS-2 (cutting) |
| Hands / feet | 5-0 nylon | P-3 or PS-2 (cutting) |
| Deep dermal | 4-0 Vicryl® or Monocryl® | SH (taper point) |
Alternative Wound Closure Methods
| Method | Indication | Advantages | Disadvantages |
|---|---|---|---|
| Tissue adhesive (Histoacryl®, Dermabond®) | Superficial, clean, low-tension lacerations; paediatric facial wounds | No needle, painless, no removal, waterproof | Not for high-tension, deep, or mucosal wounds |
| Adhesive strips (Steri-Strips®) | Superficial, low-tension wounds; as adjunct to deep sutures | Easy, cheap, no needle | Poor hold in hairy or moist areas; may shear off |
| Staples | Scalp lacerations, trunk, linear wounds | Rapid application; less tissue reactivity | Not for face; need staple remover; imprecise edge alignment |
Suture Removal Times
- Face: 5 days (consider subcuticular Monocryl® + tissue adhesive to avoid suture marks)
- Scalp: 7–10 days
- Trunk: 7–10 days
- Upper extremity: 7–10 days
- Lower extremity / joint: 10–14 days
- Overlying joint (knee, elbow): 14 days; consider splinting during healing
Tetanus Prophylaxis
Every wound requires a tetanus risk assessment. Consult the Australian Immunisation Handbook for current recommendations. Key principle: tetanus-prone wounds (contaminated, puncture, devitalised tissue, soil/faecal contamination) require tetanus immunoglobulin (TIG) if the patient has <3 documented doses or unknown vaccination status.
| Vaccination History | Clean Minor Wound | Tetanus-Prone Wound |
|---|---|---|
| <3 doses or unknown | Td/dTpa vaccine | Td/dTpa vaccine + TIG 250 IU IM |
| ≥3 doses, last >5 years ago | No vaccine needed | Td/dTpa booster |
| ≥3 doses, last >10 years ago | Td/dTpa booster | Td/dTpa booster |
Antibiotic Prophylaxis for Wounds
Routine antibiotic prophylaxis is not recommended for clean, non-contaminated lacerations. Indications include:
- Bite wounds (human and animal)
- Heavily contaminated wounds that cannot be adequately debrided
- Open fractures
- Wounds involving joints, tendons, or prosthetic material
- Immunocompromised patients (diabetes, chemotherapy, corticosteroids, HIV with low CD4)
- Significant crush injuries with devitalised tissue
Amoxicillin / Clavulanate
Augmentin® · Co-amoxiclav · β-lactam / β-lactamase inhibitor
Adult dose
875/125 mg PO BD for 5–7 days
Paediatric dose
22.5 mg/kg (amoxicillin component) PO BD for 5–7 days
Renal adjustment
eGFR 10–30: 500/125 mg BD; eGFR <10: 500/125 mg OD
Key note
First-line for bite wounds and contaminated wounds; covers Pasteurella, Eikenella, Streptococci, anaerobes
PBS status
✔ PBS General Benefit
Metronidazole
Flagyl® · Metrogyl® · Nitroimidazole antibiotic
Adult dose
400 mg PO TDS for 5–7 days (or add to amoxicillin/clavulanate for severe contamination)
Paediatric dose
7.5 mg/kg PO TDS for 5–7 days
Key note
Covers anaerobes; avoid alcohol (disulfiram-like reaction)
PBS status
✔ PBS General Benefit
Cefalexin
Keflex® · Ceporex® · 1st-generation cephalosporin
Adult dose
500 mg PO QDS for 5–7 days
Paediatric dose
12.5–25 mg/kg PO QDS for 5–7 days
Key note
Alternative for penicillin allergy (non-anaphylactic); covers skin flora (S. aureus, S. pyogenes)
PBS status
✔ PBS General Benefit
Wound Aftercare & Patient Advice
- Keep wound clean and dry for 48 hours; thereafter gentle washing with soap and water is encouraged.
- Apply a non-adherent dressing (e.g. Melolin®) and change daily or as needed.
- Elevate the affected limb for 48 hours to reduce swelling.
- Avoid swimming, soaking, and contact sport until sutures are removed and wound is fully healed.
- Advise on signs of infection: increasing pain, redness, warmth, swelling, purulent discharge, fever, or red streaking (lymphangitis).
- Scar management: sun protection (SPF 50+) for 12 months; silicone gel sheeting from 2–3 weeks post-closure for cosmetic areas.
Special Wound Techniques
Lip Lacerations
Lip lacerations are common in facial trauma, particularly in paediatric patients and contact sport injuries. Precise alignment of the vermilion border (the junction between the red lip and skin) is the critical cosmetic landmark — even 1 mm of misalignment is visible and cosmetically unacceptable.
Superficial Lip Lacerations (not through-and-through)
- Anaesthetise with local infiltration of 1% lignocaine with adrenaline or infraorbital/mental nerve block.
- First suture at the vermilion border — use 5-0 or 6-0 non-absorbable sutures (nylon or polypropylene). This is the critical alignment stitch.
- Complete closure with 5-0 absorbable sutures (Vicryl®) for muscle and deep tissue; 5-0 or 6-0 nylon for skin.
- Remove sutures at 4–5 days to minimise scarring.
Through-and-Through Lip Lacerations
These penetrate from skin through muscle and mucosa. Repair in three layers:
1
Mucosal Layer (inner)
Close mucosa first with 4-0 or 5-0 absorbable sutures (Vicryl®), knots tied intraorally.
2
Muscle Layer (middle)
Reapproximate orbicularis oris muscle with 4-0 absorbable deep sutures. This restores lip competence and sphincter function.
3
Skin Layer (outer)
Align vermilion border first as the landmark stitch (6-0 nylon), then close remaining skin with 5-0 nylon. Remove at 4–5 days.
Post-operative: Prescribe chlorhexidine 0.12% mouth rinse (Peridex®) TDS to reduce oral contamination. Soft diet for 5–7 days. Consider antibiotics (amoxicillin/clavulanate) for through-and-through wounds due to oral flora contamination.
Eyelid Lacerations
Eyelid lacerations require careful assessment to exclude globe injury, canalicular (tear drainage system) involvement, and levator muscle/ptosis mechanism damage.
Simple Eyelid Lacerations (not involving lid margin, tarsus, or canaliculus)
- Use 6-0 or 7-0 absorbable sutures (Vicryl® Rapide) for skin closure.
- Avoid suturing through the tarsal plate if possible to prevent lid deformity.
- Apply chloramphenicol ointment BD and pad for 24 hours.
Lid Margin Lacerations
Full-thickness lid margin lacerations require specialist repair. Refer to ophthalmology or oculoplastic surgery. Precise alignment of the grey line (mucocutaneous junction) and tarsal plate is essential to prevent notching, trichiasis, and lid malposition. Delayed repair (>24 hours) increases complication rates.
Canalicular Lacerations (Medial Eyelid)
- Lacerations medial to the punctum involving the lower or upper canaliculus require urgent ophthalmology referral for stenting and microsurgical repair.
- A silicone stent (Crawford tube or Mini-Monoka) is placed to maintain canalicular patency during healing.
When to Refer Eyelid Lacerations
- Any laceration involving the lid margin (grey line)
- Medial canthal lacerations (canalicular injury)
- Lacerations with suspected levator/aponeurosis involvement (deep upper lid wounds causing ptosis)
- Associated globe injury (hyphaema, pupil irregularity, loss of vision)
- Any doubt about the extent of injury
Tongue Lacerations
Tongue lacerations are common in children (falls), seizure patients (bitten during tonic-clonic activity), and assault victims. The tongue's rich vascular supply promotes excellent healing, and most lacerations do not require suturing.
When to Repair Tongue Lacerations
- Deep wounds (>1 cm depth)
- Gaping edges that do not fall together with the tongue at rest
- Persistent active haemorrhage not controlled by direct pressure
- Complete or near-complete amputation (rare — emergency)
- Lacerations crossing the tongue tip or involving the tongue base
Repair Technique
- Use 4-0 absorbable sutures (Vicryl® or chromic catgut) — non-absorbable sutures are poorly tolerated in the oral cavity.
- Place a mattress suture through the muscular layer for deep wounds to obliterate dead space and control haemorrhage.
- For children, the "bite block" or tongue-depressor technique with an assistant stabilising the tongue may be used. General anaesthesia may be necessary for uncooperative paediatric patients with significant wounds.
- Prescribe chlorhexidine 0.12% mouth rinse or warm salt water rinse QDS. Soft diet.
- Sutures dissolve spontaneously and do not require removal.
Seizure bite wounds: Tongue lacerations sustained during seizures heal well with conservative management. Bilateral, lateral tongue tip lacerations are characteristic. Refer the patient for neurological reassessment and medication review if the seizure was a new event or breakthrough.
Foreign Bodies
Assessment & Diagnosis
Retained foreign bodies are a significant cause of wound infection, chronic pain, and medicolegal liability. A careful history should identify the mechanism and type of material involved. Clinical examination includes visualisation, wound exploration under good lighting and anaesthesia, and palpation.
High clinical suspicion for foreign body is required in: puncture wounds (especially foot), wounds overlying bony prominences, lacerations caused by glass or wood, wounds with unexplained pain or discharge after initial healing, and wounds where the reported mechanism does not match the wound characteristics.
Imaging for Foreign Bodies
Commonly available
Plain Radiography (X-ray)
Detects radio-opaque materials: metal, glass (>2 mm), bone, gravel. MBS Item 58500 series. First-line for suspected metallic or glass foreign bodies.
Commonly available
Point-of-Care Ultrasound (POCUS)
Superior for radiolucent foreign bodies: wood, plastic, thorns, fish bones in superficial soft tissue. Sensitivity 50–95% depending on operator and depth. Can be performed in the GP or ED setting.
Referral / Imaging centre
CT Scan
For deep foreign bodies, suspected retained gauze/surgical material, or when ultrasound is equivocal. MBS Item 56000 series. Excellent sensitivity for all material types.
Referral / Imaging centre
MRI
Reserved for complex cases with suspected deep soft-tissue foreign bodies near neurovascular structures. Not for metallic foreign bodies (contraindication).
| Foreign Body Type | Radiolucent? | Best Imaging | Infection Risk |
|---|---|---|---|
| Metal (needle, nail, staple) | No (radio-opaque) | Plain X-ray | Low–moderate |
| Glass | No (>2 mm) / Yes (<2 mm) | Plain X-ray ± ultrasound | Low |
| Wood / splinter | Yes | Ultrasound (first-line); CT if deep | High |
| Plastic | Yes | Ultrasound | Moderate |
| Thorn / plant material | Yes | Ultrasound; clinical diagnosis | High (esp. fungal: Sporothrix) |
| Fish hook | No | Plain X-ray | Low–moderate |
| Fish spine / sea urchin | Variable | Ultrasound | High (marine organisms) |
Removal Techniques
General Principles
- Adequate anaesthesia (local or regional block) before exploration.
- Good lighting, tourniquet (extremities), and appropriate instruments (fine forceps, haemostats, curette).
- Extend the wound along the axis of the foreign body's entry tract rather than blindly probing.
- If not visualised after reasonable exploration: image and refer rather than persist with blind attempts.
Fish Hook Removal
1
Advance and Cut (Preferred)
Advance the hook tip through the skin, cut the barb with wire cutters, then back the hook out through the entry site.
2
String-Yank Technique
Press the hook shank down toward the skin; place string/fishing line around the hook bend. Hold the string taut and jerk the hook out with a quick motion in the opposite direction of the barb. Effective for superficial hooks without barbs buried deep.
Glass Foreign Bodies
- Glass fragments are commonly retained in hand and foot lacerations from broken windows and bottles.
- Use ultrasound-guided localisation for non-palpable fragments.
- Explore wounds in a bloodless field (tourniquet) with good lighting; glass can be identified by its glistening quality under direct light.
Wood Splinters
- Wood is radiolucent and carries high infection risk, including fungal (Sporothrix schenckii from rose thorns), bacterial (Staphylococcus, Streptococcus, anaerobes), and tetanus risk.
- Remove promptly; do not leave wood in situ.
- If deep and not palpable, use ultrasound for localisation or refer for surgical exploration.
- Consider antibiotics (amoxicillin/clavulanate) and ensure tetanus vaccination is up to date.
Do not leave foreign bodies in situ except in specific circumstances (e.g. deeply embedded lead shot in stable soft tissue where removal would cause more harm). All organic material (wood, plant, marine spines) must be removed as they cause persistent inflammation and infection. Refer to surgical specialist if complete removal cannot be achieved in the primary care setting.
Post-Removal Wound Care
- Copious irrigation after foreign body extraction (minimum 250 mL normal saline under pressure).
- Assess for tendon, nerve, or vascular injury before and after removal.
- Do not close puncture wounds primarily — allow to heal by secondary intention or delayed primary closure at 3–5 days.
- Tetanus prophylaxis as per Australian Immunisation Handbook guidelines.
- Antibiotics if indicated (contaminated wounds, bite injuries, immunocompromised).
- Follow-up in 48–72 hours to assess for infection or retained material.
Special Populations
Pregnancy
Lignocaine
Category A in pregnancy. Safe for local/regional anaesthesia at standard doses. Adrenaline is safe in standard concentrations.
Paracetamol
Preferred analgesic in pregnancy. Safe at recommended doses throughout all trimesters.
NSAIDs (ibuprofen)
Avoid after 30 weeks gestation (risk of premature closure of ductus arteriosus). Use paracetamol ± codeine (short course, lowest effective dose) as alternatives.
Amoxicillin / Clavulanate
Safe in pregnancy (Category A). First-line antibiotic prophylaxis for contaminated or bite wounds.
Tetanus vaccine (dTpa)
Recommended at 28–32 weeks gestation for every pregnancy (routine); safe to administer at any gestation if tetanus prophylaxis is indicated.
Paediatrics
Topical anaesthesia
EMLA® cream (apply 60 min prior) or LET (lignocaine–epinephrine–tetracaine) gel is preferred for wound anaesthesia in young children to reduce distress.
Tissue adhesive (Histoacryl®)
First-line for simple, superficial lacerations in children. Reduces procedural distress and is cosmetically equivalent to sutures for appropriate wounds.
Lignocaine dose
Maximum 3 mg/kg plain (4.5 mg/kg with adrenaline). Use 1% solution; calculate carefully for small patients.
Non-pharmacological
Consider intranasal fentanyl (1.5 µg/kg) or nitrous oxide (50–70%) for procedural sedation/anxiolysis in moderate laceration repair.
Developmental considerations
Young children may bite sutures out of lips/tongue. Use absorbable sutures intraorally. Consider sedation or general anaesthesia for complex wound repair in uncooperative children.
Elderly
Anticoagulant assessment
Commonly on warfarin, DOACs, or antiplatelets. Check INR (warfarin) or renal function (DOACs). Do NOT routinely cease anticoagulants for minor wound repair — apply haemostatic pressure and consider absorbable haemostatic agents.
Skin fragility
Elderly skin tears easily; use wider suture bites (5–8 mm from wound edge), lower tension, and avoid excessive knot pressure. Consider adhesive strips or tissue adhesive for fragile skin.
Delayed healing
Consider nutritional status (albumin, zinc, vitamin C), diabetes control (HbA1c), and polypharmacy. Remove sutures 2–3 days later than standard timelines to allow for slower healing.
Falls risk assessment
Wounds from falls in the elderly should trigger a falls risk assessment (medication review, orthostatic hypotension, visual acuity, home hazards).
Renal Impairment
NSAIDs
Avoid if eGFR <30. Use paracetamol as first-line analgesic. Short courses of low-dose ibuprofen permissible if eGFR 30–60 with monitoring.
Antibiotic adjustments
Amoxicillin/clavulanate: reduce dose if eGFR <30 (500/125 mg BD; <10: OD). Metronidazole: no dose change for mild–moderate; reduce frequency if severe impairment. Cefalexin: reduce dose proportionally.
Bleeding risk
Uraemic platelet dysfunction increases bleeding. Apply prolonged pressure; consider desmopressin (DDAVP) 0.3 µg/kg IV for significant surgical bleeding in severe CKD.
Hepatic Impairment
Coagulopathy
Check INR and platelet count in significant liver disease. Coagulopathy (INR >1.5) may require correction with vitamin K or fresh frozen plasma for wound repair. Refer to haematology if severe.
Paracetamol
Safe at standard doses (max 4 g/day) in stable liver disease. Reduce to 2 g/day in severe hepatic impairment or active alcohol-related liver disease.
Metronidazole
Use with caution; avoid in severe hepatic impairment. Consider alternatives (amoxicillin monotherapy).
Immunocompromised
Lower threshold for antibiotics
All immunocompromised patients (DMARDs, biologics, chemotherapy, high-dose corticosteroids, HIV/CD4 <200, transplant recipients) should receive prophylactic antibiotics for any wound with potential contamination.
Delayed healing
Expect delayed wound healing. Consider longer suture retention times (add 3–5 days). Close monitoring for wound dehiscence.
Atypical organisms
Consider atypical infections: fungal (especially in transplant), mycobacterial, and resistant organisms (MRSA). Collect wound swabs if infection develops and send for culture and sensitivity.
Medication interactions
Methotrexate: avoid concurrent trimethoprim. Warfarin: amoxicillin/clavulanate may increase INR — monitor. Check anticoagulant interactions.
Aboriginal and Torres Strait Islander Health Considerations
Aboriginal and Torres Strait Islander Health
📚 References
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