Decisions before Closure: Timing, Débridement, and Consultation




Key Practice Points





  • Because wounds are often contaminated with bacteria, there is a time limit (the “golden period”) between the laceration and closure with sutures. It varies between 6 hours (hand and feet) and 24 hours for the vascular face.



  • Wounds outside the “golden period” can heal by secondary intention or by delayed primary closure.



  • Whenever suspicion exists that a wound has injured a tendon, nerve, joint, or other important anatomic structure, or has been caused by a foreign body, the wound should be explored before repair.



  • Because blood vessels often run in bundles with nerves, the use of “blind” clamping with a hemostat to achieve hemostasis is strongly discouraged. Most hemostasis in wound care can be achieved with pressure alone.



  • Some contamination requires sharp débridement and excision of foreign material, to lower the risk of infection, before the wound can be closed.



  • If débridement is necessary, it is important to sacrifice as little tissue as possible.



  • Wound drains can act as an ingress of bacteria and should be avoided unless there is active drainage, such as in the case of an abscess.



Before proceeding with definitive management, such as suture placement, several issues have to be considered and decisions made that are separate from the choice of closure method. Time from the injury, tissue condition, level of contamination, and potential for foreign material all are factors that affect the total care. Planning the care and closure is as important as the repair itself.




Timing of Closure


Determining the time of injury is important for wound repair. The chance of developing a wound infection increases with each hour that elapses from the time of injury. Traditionally, it has been taught that there is a “golden period” within which a wound or laceration can be safely closed primarily (primary intention). The exact length of that period is influenced by factors such as the mechanism of injury, anatomic location, and level of contamination. As a rough guideline, 6 to 8 hours from the time of injury has been considered a safe interval within which to repair the average uncomplicated laceration. This period can range from 6 hours for wounds of the hand and foot to 24 hours or more for clean lacerations of the face. The following is a summary including recommendations for wound closure.


Primary Closure (Primary Intention)


Lacerations that are relatively clean and uncontaminated, with minimal tissue loss or devitalization, are considered for primary closure. These can be caused by sharp-edged objects such as knives (common injury during food preparation) and glass. Repair of these wounds usually is necessary within 6 to 8 hours from the time of injury on most regions of the body. Wounds of the highly vascular face and scalp often can be sutured 24 hours after injury. Because there are no definitive rules that govern every possible situation, the following recommendation is offered: Any injury, less than 24 hours from time from injury, that can be converted with cleansing and débridement to a fresh-appearing, slightly bleeding, nondevitalized wound, with no visible contamination or debris after aggressive cleansing, irrigation, and débridement, can be considered for primary closure.


Secondary Closure (Secondary Intention)


Skin ulcerations, abscess cavities, punctures, small cosmetically unimportant animal bites, and partial-thickness (abrasions, second-degree burns) tissue losses often are better left to heal by secondary intention. Wound care consists of thorough cleansing, irrigation, and débridement of devitalized or contaminant-impregnated tissue. These wounds are not closed with sutures and are allowed to heal gradually by granulation and eventual reepithelialization. They heal best if covered with a sterile, nonadherent dressing that can be changed every 1 to 3 days.


Tertiary Closure (Delayed Primary Closure)


Some wounds are candidates for delayed closure. Bite wounds and lacerations beyond the golden period can be considered for this technique. Although there are no technical contraindications to sutures or staples, these wounds have a high bacterial count and excessive devitalized tissue. In a study of human bites to the face, primary closure led to a 40% wound infection rate. None of the wounds closed after débridement and 48 hours of antibiotics became infected. Delayed wounds can be “converted” to “fresh” ones by cleansing, irrigation, and débridement followed by a 3-day to 5-day period during which the natural host defenses reduce the bacterial load to acceptable minimal levels ( Fig. 9-1 ). Antibiotics can aid these defenses.




Figure 9-1


Graph showing the incidence of wound infection risk after injury and optimal timing of tertiary or delayed wound closure.

(Adapted from Edlich R, Rodeheaver GT, Morgan RF, etal: A manual for wound closure, St Paul, Minn, 1979, Surgical Products Division, 3M.)


Technique for Delayed Primary Closure


The clinician cleanses, irrigates, and débrides as much as possible during the initial encounter. The wound is covered with a bulky, absorbent gauze dressing. Oral antibiotics are administered after initial care before delayed closure. Dicloxacillin or a first-generation cephalosporin is appropriate. Erythromycin or clindamycin can be administered to patients who have a significant history of allergy to the penicillins. Amoxicillin/clavulanate can be used for bite wounds.


If no signs of infection or excessive discomfort develop beforehand, the patient should return in 4 to 5 days. If the wound appears clean and uninfected, it can be closed with sutures, tapes, or staples. Dermal (deep) or subcutaneous sutures are avoided in this setting. These wounds can accumulate excessive granulation tissue during the 4-day to 5-day period. This tissue can be excised judiciously to permit better wound edge apposition. The intervals for suture or staple removal are the same as for primary closure starting at the time of closure. Delayed closure is associated with a low (2% to 3%) infection rate.




Wound Exploration


Some surface wounds and lacerations require thorough inspection and exploration. It is always important to evaluate the functional status of the relevant nerves, tendons, arteries, joints, and other related structures of the wounded area and to remain alert for potentially occult, serious underlying structural damage. Although more specific information is included in other chapters and sections specific to special anatomic sites and problems, the following are general guidelines for wound exploration:




  • Suspicion of a foreign body, particularly if it is potentially organic, such as wood or plant material. Radiographs are taken before exploration when glass, gravel, or metallic foreign bodies are suspected.



  • Lacerations in the proximity of joint capsules.



  • Lacerations over tendons, particularly if functional testing of the hand or foot is “normal.” It is common to find serious partial tendon lacerations solely by direct visualization. Unrepaired partially lacerated (≥50%) tendons can undergo delayed rupture within 12 to 48 hours if untreated.



  • Scalp lacerations that are large or are caused by a significant force. Unrecognized skull fractures can be found by exploration and palpation of the skull through the wound.



  • Lip lacerations, if a tooth or fragment of a tooth cannot be accounted for. A radiograph is another method to reveal missing teeth.



Techniques for Wound Exploration


Often the wound can be exposed adequately with a hemostat by separation of the wound edges. In other cases, the hemostat can be used to grasp the superficial fascia (subcutaneous tissue) of one wound edge while the tissue forceps are applied to the other edge to retract and gain exposure. If available, small self-restraining retractors (mastoid or Wheatlander retractors) are recommended. A second pair of hands is optimal. An assistant can retract the wound with small retractors or skin hooks.


If exposure is still not adequate, a small wound extension incision can be made through the dermis with a knife handle and a no. 15 blade or with iris scissors. The extension begins at one wound end and should proceed carefully to avoid accidental injury to underlying structures ( Fig. 9-2 ). On the face, extension incisions are made parallel to the skin tension lines discussed in Chapter 3 . When the epidermis and dermis are divided, the superficial fascia (subcutaneous tissue) is not incised but is spread apart gently with forceps or tissue scissors to reveal any suspected foreign body or tendon or joint capsule injury.




Figure 9-2


Technique to extend a wound for better deep-structure exploration and evaluation. The incision is at a slight angle from the original axis of the wound and is parallel to underlying structures.




Hemostasis


Wounds often bleed actively, particularly during assessment and exploration. In addition to the problem of adequate wound visualization with active bleeding, hematomas can cause an increase in the rate of wound infection and can delay the healing process.


The simplest and most effective way to stop bleeding is to apply direct pressure to the wound with handheld surgical 4 × 4 sponges. Continuous pressure has to be applied for a minimum of 10 minutes. Because of the time involved, sponges secured with an Ace wrap can be substituted if the wound is in an anatomic area that lends itself to wrapping.


An epinephrine-moistened (1:100,000) sponge applied, also with pressure, to the wound for 5 minutes often suffices in cases in which direct pressure fails. Epinephrine is contraindicated, however, for use on the fingers, toes, ears, penis, and tip of the nose. Packing the wound with topical hemostatic agents, such as Gelfoam, Surgicel, and others, is another hemostatic strategy. These agents are useful for persistent oozing or minor capillary bleeding. Arterial “pumpers,” even small ones, can wash these agents out of the wound. Use of these agents should be considered only if all other methods fail. These products can have adverse effects such as interference with suture closure and foreign-body reactions.


Direct clamping with a hemostat and a hand-tied ligature with an absorbable suture is reserved for larger, single-bleeding vessels that can be directly visualized under optimal conditions of lighting, instrument preparation, and operator comfort. Because blood vessels often travel with nerves and arteries, “blind” clamping in a bleeding wound, in the hope of grasping the bleeder, is strongly discouraged. Unnecessary tissue damage can occur, particularly in areas where important structures such as nerves and tendons are likely to be found.


Tourniquet Hemostasis


Definitive hemostasis of the extremity can be achieved by the use of tourniquets. Strict observance of proper technique and the time limits of application is imperative. Complications of tourniquets include ischemia of the extremity, compression damage of blood vessels and nerves, and jeopardy to marginally viable tissues.


Technique for Large-Extremity Tourniquet Application


Before placing a single-cuff sphygmomanometer, the extremity is elevated for approximately 1 minute. The cuff is inflated to a pressure higher than the patient’s systolic pressure or to a point when the bleeding stops. However, the pressure should not exceed 250 mm Hg. The clinician clamps the cuff tubing with a hemostat instead of closing the air release valve to prevent slow leakage of air and to ensure a rapid release method if needed. Patient discomfort becomes apparent by 30 to 45 minutes of cuff time. The maximal cuff inflation time is 2 hours, although a limit of 30 to 60 minutes is recommended to ensure patient safety.


Technique for Digital Tourniquet Application


A digital tourniquet is often used to repair finger wounds. Lacerated fingers can bleed profusely and visualization is difficult. The clinician unfolds a 4 × 4 gauze sponge to its fullest length and folds it in half so it appears to be an 8-inch band. The band is moistened with saline. The clinician wraps the band firmly around the finger, starting at the tip and proceeding to the base. A Penrose drain is stretched around the base of the finger in a slinglike fashion, and a hemostat is applied to the drain to form a tight “ring” at the base of the finger. The sponge wrapping is removed. A Penrose drain also can be substituted for the gauze sponge wrap. A digital anesthetic block is recommended before applying the tourniquet.


There are preformed disposable tourniquets (Tourni-Cot, T-Ring) that “roll” or slide onto the finger and exsanguinate it before coming to rest at the digit base ( Fig. 9-3 ). After use, they can be easily removed. These tourniquets are easier to apply and are effective in most cases in which the digit circumference can accommodate them. The maximal allowable tourniquet time for a finger is 20 to 30 minutes.


May 12, 2019 | Posted by in ANESTHESIA | Comments Off on Decisions before Closure: Timing, Débridement, and Consultation
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