1. Erik Adler, MD
February 4, 2014

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

7. Adequate setting/lighting
 Hemostasis
 Neurovascular exam
 Foreign body
 Radiography


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

10. 
X-Ray

CT Scan/ MRI

US :sensitivity of 95-98% and a specificity of 89-98%

11. Anesthesia :

Local anesthetic injections

Topical anesthetics

Regional anesthetics

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


14. 






Small-bore needles
Buffered solutions
Warmed solutions
Slow rates of injection
Injection through wound edges
Subcutaneous rather than intradermal injection
Pretreatment with topical anesthetics

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.

24. 
Sterile saline solution

Povidone-Iodine Solution
(Betadine®) 10%
- tissue toxic
-did not reduce
infection incidence.

Diluted betadine : use
indeterminate.

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.

36. 
Simple, low-tension pediatric
facial wounds, Steri-Strips™
resulted in a cosmetically
equivalent wound closure
compared to cyanoacrylate
closure

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.