2. A 6 year old boy presents with a scalp laceration that
requires suturing . His mother tells you that he is scared
of needles and is liable to become upset. Are there other
options?
3. A patient presents to the Emergency Department with a
laceration to the right forearm. He sustained the injury
while intoxicated last night. Upon waking, he noticed the
wound and came to the ED. The injury was 14 hours
ago. He requests it be stitched closed.
4. A 28 year old man attends the emergency department with
a simple laceration requiring suturing. You wonder
whether application of a topical antibiotic ointment may
promote healing and reduce incidence of infection. You
also wonder if washing the wound with tap water is
appropriate.
5. Create optimal conditions for healing.
Preserve function.
Minimize complications.
Improve the chances of a cosmetically
pleasing result.
6.
Secondary survey
Mechanism of injury
Elicit host factors that adversely affect wound outcome
◦
◦
◦
◦
◦
◦
Increased age
Diabetes
Peripheral Vascular Disease
Smokers
Wound width
Contamination or foreign body.
Tetanus immunization
8.
5th cause of malpractice claims against emergency
physicians
50% was glass
Anver and baker 1992: 7% missing. 21% in deeper
wounds.
In a medical/legal review, Kaiser et al: unsuccessful
defense in 60% of cases.
When in doubt, do the X-ray!
9.
Reactive materials, such as wood and vegetative
material
Contaminated material
Clothing (should always be considered contaminated)
Most foreign bodies in the foot
Impingement on neurovascular structure
12. Essential skill for all ED physicians
Save time
Decrease possibility of systemic toxicity
Less painful than local infiltration
Does not cause volume-related tissue distortion
13. While data is convincing that local anesthetics
with epinephrine do not cause long term damage
to tissue with single blood supply (fingers, toes,
nose, penis), it is still recommended that local
anesthetic with epinephrine be avoided in these
areas.
Epinephrine will cause vasoconstriction, which
can be beneficial when requiring bloodless field
15.
LET (lidocaine, 4%; epinephrine, 0.1%; tetracaine, 0.5%)
Face and scalp
Liquid or gel forms
16. Lidocaine
Marcaine (Bupivicaine)
◦ Drug concentration is expressed as a percentage (eg,
bupivacaine 0.25%, lidocaine 1%).
◦ Percentage is measured in grams per 100 mL (ie, 1% is
1 g/100 mL [1000 mg/100 mL], or 10 mg per mL).
17.
Toxic Doses◦ Lidocaine without epinephrine- 4.5 mg/kg; not to exceed
300 mg total dose
◦ Lidocaine with epinephrine- 7 mg/kg
◦ Bupivicaine without epinephrine- 2.5 mg/kg; not to
exceed 175 mg total dose
◦ Bupivicaine with epinephrine- Not to exceed 225 mg total
dose
18. While generally safe, local anesthetic agents can
be toxic if administered inappropriately.
Central Nervous System, Cardiovascular System,
Methemoglobinemia, Allergic Response.
Etiology
◦
◦
◦
◦
Inadvertent intravascular administration
Excessive dose or rate of injection
Delayed drug clearance
Administration into vascular tissue
19.
Ruthman et al : closure of lacerations without caps and
masks did not lead to an increased incidence of wound
infection
Worral and later Perelman: sterile versus nonsterile
gloves found no difference in wound infection rates.
20.
Non-sterile gloves, which provide “universal precaution “
is appropriate.
Latex gloves should also be avoided
21.
Reduce quantity of bacteria on the surface of the skin
Shaving the hair does make closure easier
Increased risk of wound infection by inducing trauma
Seropian and Reynolds : infection risk increased from
0.6% to 5.6% when hair was shaved from a wound
The use of clippers .
22.
Most important step
Remove bacteria and contamination
15 psi removed 85% of bacterial contamination from a
wound, whereas (1 psi) removed only 49%
5 – 8 psi
30-60-cc syringe to push fluid through a 18-gauge
catheter with maximal hand pressure.
23.
Minimum of 250 cc
60 cc/ cm wound length
Large volume with low pressure may be good.
25.
Hydrogen peroxide no role, tissue toxic.
Tap water : low cost, available.
Sandy : Medline 1966-10/03, 397 papers found
Tap water is a safe and effective solution for cleaning
recent wounds requiring closure and is the treatment of
choice
26.
Cochrane review database :
-Although evidence is limited, there is no difference in
wound infection rates with the use of tap water as an
irrigation fluid.
27.
“Safe” time interval from wounding that allows
primary wound closure
The ACEP clinical policy for penetrating injury of
the extremity supports an 8-12-hour cutoff for
primary wound closure.
6-10 hours - wounds of the extremities — and
up to 10-12 hours or more for the face and scalp
28.
Bites
◦ Appropriate to close bites if on the face, but loose
approximation preferred to tight closure.
◦ All other bites should be left for delayed primary closure
or closure by secondary intent.
◦ All bites deserve ABX (Augmentin is preferred)
Stab Wounds
◦ Wound packing with wet to dry for 5 days followed by
delayed primary closure
Infected tissue or significantly contaminated tissue
29.
The standard for wound closure
Percutaneous sutures are used for low- to mediumtension wounds
Absorbable suture material for dermal stitches
Interrupted versus other types of sutures has no effect
on infection rate
30.
Faster repair time
Less painful
Eliminate the risk for needle sticks
Antibacterial effect
Does not require removal of sutures
31.
FDA approval in 1998
=Dermabond®
50% of the strength of
5-0 suture material.
Cochrane review :
comparable cosmetic
outcomes compared to
standard suturing
32.
Short (< 6-8 cm)
Low tension (< 0.5 cm gap)
Clean edged
Straight to curvilinear
wounds that do not cross
joints or creases
33.
Stellate lacerations
Bites, punctures or crush
wounds
Contaminated wounds
Mucosal surfaces
Axillae and perineum (highmoisture areas)
Hands, feet and joints
(unless kept dry and
immobilized)
34.
Fast ,low wound reactivity and infection rate.
Less expensive.
Less needle sticks risk.
No cosmetic difference.
Scalp, trunk, and extremity.
35.
Least reactive of all
closure techniques
Lowest tensile strength
May require tincture of
benzoin
Avoid in hairy and wet
area.
37.
Twisting hair on either side
of the wound and tying the
twists together to pull
together and close the
wound.
Lacerations 10 cm or less in
length and hair longer than
3 cm .
Close the outermost skin
layers, no hemostasis .
38.
Much underused method of wound care .
Reduced the infection rate by 50% in 104 extremity
wounds
Recommended technique for contaminated wounds that
present to the ED
Technique : clean and debride then separate wound
edges with gauze, and apply bulky dressing.
39.
Allowing a wound to heal without formal closure .
Simple but more wound scaring.
Quinn et al in 2002 : conservative management resulted
in no cosmetic or functional difference compared to
primary closure in selected hand lacerations.
40.
Prophylaxis studies : no benefits.
Indications For Prophylactic Antibiotics:
-Presence of prosthetic device(s) Class III
-Patients in need of endocarditis prophylaxis Class III
-Open joint or fractures associated with wound Class I
-Human, dog, and cat bites Class II
-Intraoral lacerations Class II
-Immunocompromised patients Class III
-Heavily contaminated wounds (eg, feces, etc) Class III
41.
Dire et al (1995), triple antibiotic ointment reduced the
incidence of postclosure infection compared to a
petroleum jelly control (4.5-5.5% for bacitracin and
Neosporin® vs 17.6% for petroleum control).
Important to address patient allergies and avoid if
allergic to Neomycin, Bacitracin, Polymyxin.
42. Tetanus History
Clean Minor Wounds
All Other Wounds
< 3 doses in primary
series
Primary 3 Series
Completed
Last < 5 years ago
Td
Td + TIG
Nill
Nill
Last > 5 years ago and <
10
Last > 10 years ago
Nill
Td
Td
Td
43. 1. Staples and glue are the quickest closure
methods.
2. Small, simple hand lacerations (< 2 cm) do not
require primary closure.
3. Sterile gloves have no advantage over
nonsterile gloves in reducing wound infection.
44. 4. Clean tap water is as effective as (and cheaper
than!) sterile saline for wound irrigation.
5. Cyanoacrylates or absorbable sutures are
cost-effective for patients, as they do not
require return visits.
6. Application of LET in triage allows a wound to
be anesthetized by the time you see the patient.
45.
High-pressure irrigation with normal saline or tap water.
Clean wounds presenting within 8 hours of occurrence
can typically be closed primarily. This does not apply to
wounds on the face or scalp
PE alone is inadequate for ruling out a foreign body in a
wound.
46.
Determine if it is appropriate to close a wound primarily
Prevention of a wound infection
Multitude of wound closure methods including
“needleless” methods.
