Abstract
Wounds and lacerations are common complaints of patients seen in doctors’ offices and urgent care centers. Wound assessment, patient’s medical history, and physician experience are important considerations in the management of wounds and lacerations. This chapter reviews wound assessment, preparation, local anesthesia, options for laceration repair, and wound care. It also includes wound care for specific wound types and wounds that require care by surgical subspecialty.
Keywords
laceration, wound
1
What are important details that one must pay attention to when assessing a laceration?
There are several factors that can affect both the incidence of infection and scar formation.
Laceration factors —mechanism of injury, wound age, possibility of foreign body, and/or contamination, location
Individual factors —underlying medical history/disease state (diabetes, immunocompromised, connective tissue disease, etc.), immunization status
2
Past medical history is important. What questions do we need to ask?
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Do you have any allergies to antibiotics, latex, anesthetics?
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Is there any history of keloid formation?
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Is your tetanus up to date?
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Are you taking any medications currently (i.e., corticosteroids, anticoagulants, nonsteroidal antiinflammatories, antineoplastic medicine)?
3
How and why are bites managed differently?
Bites, particularly from dogs, are more likely to have components of a crush injury. Crush injuries have devitalized tissue, which is more likely to become infected due to compromised circulation around wound edges. Dog bites have an overall infection rate between 2% and 20%, compared to cat bites with 28%–80% and human bites with 2%–3%. Bite wounds to the hand carry an especially high risk for serious complications because the skin’s surface is so close to the underlying bones and joints. One should manage an open wound to the metacarpophalangeal joint from a punch to the mouth as a human bite.
4
What is the concept of the “golden period”?
It is an assumption that bacterial proliferation within wounds is dependent on time from initial insult to repair. Six hours or less was originally designated as the “golden period.”
In recent years, this golden period has steadily become longer. This period can range from 6 hours for wounds on the hands and feet to 24 hours or more for clean lacerations on the face.
8
When should one consider radiographic images?
If one suspects a fracture, a joint disruption, or a foreign body (FB), then radiographic imaging should be considered. A detailed history, exploration with visualization of the base of the wound, and radiography reduce the risk of missing a foreign body but do not eliminate the possibility that one is present. Fragments of glass and metal if larger than 2 mm usually can be identified on plain radiography. Studies show that ultrasound is better to detect plastic, wood, and glass, depending on the operator ability and other confounding factors. Patients should always be told of the possibility of a retained foreign body and what symptoms they should look for.
10
What should be done about surrounding hair?
Hair need not be removed unless it interferes with wound closure. Clipping the hair rather than shaving is preferred as shaving causes small dermal wounds that allow bacteria to penetrate deeper structures and can potentially cause infection. Eyebrows should not be clipped or shaved because they serve as a landmark during repair. In addition, eyebrow growth is unpredictable. Lubrication (i.e., petroleum jelly, bacitracin) can be used to comb the hair away from the laceration.
11
What type of fluid solution should be used for irrigating a wound?
Isotonic (normal) saline is frequently used for irrigation of uncomplicated wounds. Tap water has been shown to be an acceptable alternative solution without increasing risk of infection. Hydrogen peroxide, povidone iodine scrub solution, and chlorhexidine should not be used because of their cytotoxic effects. For contaminated wounds, a 1:10 dilute solution of 10% povidone iodine solution may be used. The area should be anesthetized prior to irrigation. Warming the fluid may also decrease discomfort during wound irrigation.
12
How much fluid should be used to irrigate a wound?
The volume depends on location and mechanism of injury—about 100–200 cc for a clean, uncomplicated 2-cm laceration. Larger volumes may be needed for contaminated wounds. Adequate pressure (5–8 psi) may be obtained by using a 20–50 mL syringe with a splash guard or 19-gauge catheter.
13
What can be done to reduce pain associated with lidocaine injection?
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Use a small gauge needle (27G or 30G).
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Buffer with sodium bicarbonate.
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Slow the rate of injection.
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Warm the local anesthetic.
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Preanesthetize with topical anesthetic.
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Infiltrate the anesthetic through the edge of the wound.
Buffering can be done by adding 1 mL sodium bicarbonate (44 mEq/50 mL) to 9 mL 1% lidocaine. Buffering reduces the shelf life of lidocaine to at least 7 days.
14
What topical anesthetics are available?
Topical anesthetics have the advantage of being administered without using a needle and help reduce pain associated with injection of local anesthetic. There are two topical anesthetics available for laceration repair: lidocaine, epinephrine, tetracaine (LET) and tetracaine, adrenaline, cocaine (TAC). TAC is safe if used properly but has fallen out of favor because it is expensive and contains cocaine, which is a controlled substance. Both LET and TAC are contraindicated for use on mucous membranes as this may result is systemic absorption. LET should not be used on end organs such as tip of the nose, ear, digits, or penis. Other topical anesthetics include eutectic mixture of local anesthetic (EMLA), which contains lidocaine and prilocaine in a cream base, and liposomal lidocaine (LMX). Both are currently approved for use on intact skin and are helpful prior to venipuncture, intravenous (IV) placement, and portacath access.
15
What are the components of LET and how is it used?
LET contains 4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine. It can be mixed with methylcellulose gel or as a solution. About 1–3 mL can be mixed with methylcellulose to make a gel, which then can be applied over the wound and secured with gauze or occlusive dressing (i.e., Tegaderm or OpSite for about 20–30 minutes). It can also be applied by placing solution on a cotton ball, which is then applied over the wound for about 20 minutes. Duration of action lasts 45 to 60 minutes.
16
A 9-year-old boy comes in with a scalp laceration after hitting his head on a wall while running. There was no loss of consciousness, and on exam he has a 4–5 cm superficial laceration on the right parietotemporal area. What are the options for closure of this laceration?
Primary closure is preferred for scalp laceration through the dermis. The wound is anesthetized and irrigated, and options for wound closure include:
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Staples are particularly useful in children.
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Hair apposition technique ( Fig. 44.1 ) involves hair on each side of the scalp being twisted together and then secured with tissue adhesive. This technique is ideal for lacerations that are linear, nonstellate, and <10 cm and in patients with hair >2 cm. Hemostasis is not achieved by this technique, so it should not be used in wounds with significant bleeding.
Fig. 44.1
Hair Apposition Technique. Strands of hair on each side are twisted and drop of glue applied.
From Hock MO, Ooi SB, Saw SM, et al: A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp laceration (HAT study). Ann Emerg Med 40:19-26, 2002.
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Simple interrupted sutures can be used if staples are not available or if hemostasis is required. Absorbable sutures may be used, especially in young children.
17
If the scalp laceration extends into the galea aponeurotica, why is it important to repair the galea?
The scalp consists of five layers: skin, superficial fascia, galea aponeurotica, loose areolar tissue, and pericranium. The galea aponeurotica anchors the frontal muscles; thus, failure to repair galeal lacerations in the frontal scalp may result in abnormalities in facial expression. Large galeal lacerations in other areas of the scalp help prevent hematoma formation and infection.
18
What are tissue adhesives, and what are the indications for their use?
Tissue adhesives provide an alternative method for wound closure that is painless, fast, and does not require a follow-up visit for removal. The most common components of tissue adhesives are 2-octyl-cyanoacrylate (Dermabond, Surgiseal) and n-2-butyl-cyanoacrylate (Histoacryl Blue, Periacryl). The 2-octyl-cyanoacrylate is preferred because of its plasticity and flexibility. Tissue adhesives are liquid monomers that undergo an exothermic reaction upon exposure to a moist surface (skin), changing to a polymer that forms a strong tissue bond. The wound edges are approximated and two to three layers of tissue adhesive applied. Indications for the use of tissue adhesives include:
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Superficial lacerations
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Length <5 cm
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Low wound tension
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Good wound approximation
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After placement of deep sutures to close skin
20
What are the complications with tissue adhesive use?
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Infection, especially if the tissue adhesive goes into the wound or if the wound was not adequately cleaned.
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Adhesion of the eye if tissue adhesive gets into the eye. The eye should be protected when using glue near the eye by covering with a gauze impregnated with petroleum. If the tissue adhesive causes adhesion of the eyelids, antibiotic ointment can be applied over the area and manual traction gently applied to open the eye. Ophthalmology should be consulted if this fails to open the eye.
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Glove sticking near site of laceration
21
How do I decide which suture material to use?
There are two types of suture material—absorbable and nonabsorbable. Absorbable sutures are used for deep and subcutaneous repair; nonabsorbable sutures are used to repair superficial skin. However, absorbable sutures (fast-absorbing gut) may be used for closure of facial lacerations, especially in children where suture removal can be a challenge. A recent meta-analysis comparing absorbable and nonabsorbable sutures for skin closure showed no significant difference in postoperative morbidity or cosmetic outcomes. Table 44.1 shows suture material selection by site and depth of laceration.
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