Ebook Emergency medicine procedure (2nd edition): Part 2

(BQ) Part 2 book Emergency medicine procedure presents the following contents: Skin and soft tissue procedures, neurologic and neurosurgical procedures, anesthesia and analgesia, obstetrical and gynecologic procedures, genitourinary procedures, ophthalmologic procedures, otolaryngologic procedures, dental procedures, podiatric procedures, miscellaneous procedures.

7

S E C T I O N

Skin and Soft Tissue Procedures

1 year after wounding The skin will eventually regain only 70% to 90% of its original tensile strength

FACTORS AFFECTING NORMAL REPAIR

The most common causes of improper wound healing are tension on the wound edges, necrosis and/or ischemia of the tissues from local conditions (e.g., crush injuries and contusions decrease blood flow and lymphatic drainage, which alters local defense mechanisms),

or shock Hypovolemia is the major deterrent to wound healing in patients with hemorrhage and shock, hemorrhage from inadequate hemostasis, infection, or retention of foreign bodies Systemic con-ditions such as malnutrition, immunosuppression, shock, diabe-tes secondary to microangiopathy, decreased oxygen and nutrient delivery to the wound, renal insufficiency, cytotoxic drugs, vitamin deficiency, trace metal deficiency, and collagen vascular disease can result in poor wound healing Polymorphonuclear leukocyte func-tion is known to be impaired from hyperglycemia, jaundice, uremia, cancer, or chronic infections

Drugs and medications can contribute to good wound healing or affect it adversely Malnutrition, lack of protein, and lack of vita-mins (e.g., vitamins A and C) may inhibit or prolong healing Zinc deficiency, which is reversible, may play a role in retarding the heal-ing process.3 Anti-inflammatory drugs (e.g., colchicine, aspirin, and glucocorticoids) disrupt macrophage function, collagen synthesis, and polymorphonuclear neutrophil concentrations Pretreatment

or early introduction of glucocorticoids results in retarded wound repair by slowing cell proliferation.4

SCAR FORMATION

Some 6 to 12 months are required to form a mature scar This explains why scars should not be revised until 12 months have passed A wider scar, inadequate wound closure, or a wound dehis-cence may occur in areas with increased skin tension or if the

wound is in an area of excessive motion (e.g., over joints) Adequate

immobilization of the approximated wound (but not necessarily the entire anatomic part) is mandatory after wound closure for efficient healing and minimal scar formation Contractures can

develop when a scar crosses perpendicular to a joint crease These patients may require physical therapy to prevent the loss of range of motion secondary to contractures

Hypertrophic scars result from full-thickness injuries

Hyper-trophic scars are characterized by a thick and raised scar that remains within the boundaries of the original injury They must

often be corrected by surgical intervention.1

Keloids are hypertrophic scars (i.e., thick and raised) that exceed the boundaries of the initial injury They can develop

from superficial injuries and appear to have a genetic basis Surgical intervention rarely resolves keloids They may be prevented or minimized by the local application of pressure dressings, Silastic dressings, glucocorticoids, and calcium channel blockers.1

The repair procedure may result in more scar tissue Absorbable suture materials contribute to the formation of suture marks because

of their increased reactivity, whereas nonabsorbable materials do

General Principles of Wound Management

Lisa Freeman Grossheim

INTRODUCTION

An acute wound can be defined as an unplanned disruption in the

integrity of the skin, including the epidermis and dermis The goals

of wound management are to restore tissue continuity and

func-tion, minimize infecfunc-tion, repair with minimal cosmetic

defor-mity, and be able to distinguish wounds that require special

care The principles of wound management should be emphasized

over the repair technique Appropriate wound management prior

to approximating the wound will allow it to heal with minimal

complications This includes wound cleansing, debridement of the

wound edges, wound approximation, and prevention of secondary

injury

HEALING OF WOUNDED TISSUE PHASES OF WOUND HEALING

The response of tissue to an injury is described in three phases The

first phase is coagulation and inflammation The second phase is

the proliferative phase The final phase is the reepithelialization or

remodeling phase

Phase I consists of coagulation and inflammation It occurs in

the first 5 days This phase is also known as the vascular phase A

fibrin clot forms a transitional matrix that allows for the migration

of cells into the wound site over a period of 72 hours Inflammatory

cells (i.e., neutrophils, monocytes, and macrophages) kill microbes,

prevent microbial colonization, break down soluble wound debris,

and secrete cytokines The cytokines signal synthetic cells, such

as fibroblasts, to initiate phase II Most sutured wounds develop

an epithelial covering that is impermeable to water within 24 to

28 hours

Phase II is the proliferative phase It occurs during days 5 to

14 after the injury Fibroblasts proliferate and synthesize a new

con-nective tissue matrix that replaces the transitional fibrin matrix

Granulation tissue consisting of fibroblasts, immature connective

tissue, epidermal cells that have migrated, and abundant capillaries

forms within the wound Fibroblasts release collagen, a protein

sub-stance that is the chief constituent of connective tissue At 5 days,

the tensile strength of the wound itself is 5% that of normal skin

Collagen formation peaks at day 7.

Phase III is known as the remodeling, reepithelialization, or

mat-uration phase It occurs from day 14 and lasts until there is complete

healing of the wound The new granulation tissue is being converted

into a scar The scar consists of a rich matrix with decreasing cell

density, decreasing vascular density, and increasing thickness of

collagen fiber bundles packed in parallel arrays.1 The wound will

have 15% to 20% of its full strength at 3 weeks and 60% of its full

strength at 4 months Tensile strength continues to increase up to

92

can greatly improve healing by primary intention.

SECONDARY INTENTION

Secondary intention involves allowing the wound to heal without

any surgical intervention The wound is left open and allowed to heal

from the inner layer to the outer surface It is a more complicated

and prolonged healing process than primary intention Infection,

excessive trauma, tissue loss, or imprecise approximation of tissue

can result due to healing by secondary intention Wound

contrac-tion by granulacontrac-tion tissue containing myofibroblasts is the major

influence on this type of healing Wound contraction becomes more

significant when the dermis is lost

Concave skin wounds heal with the best results These areas often

heal better by secondary intention than by primary intention Such

concave areas include the inner ear, the nasal alar crease, the

naso-labial fold, the temple, and the concave areas of the pinna Flat

sur-faces can also heal well by secondary intention, although surgical

intervention may be best Some examples include the forehead, the

side of the nose, and periorbital areas Wounds on convex surfaces

are not optimal for healing by secondary intention Convex surfaces

include the malar cheek, the tip of the nose, and the vermilion

bor-der of the lip.2

TERTIARY INTENTION

Tertiary intention, or delayed primary closure, can often decrease

infection rates Wound closure by tertiary intention is

accom-plished 3 to 5 days following the initial injury It is a combination

of allowing the wound to heal secondarily for 3 to 5 days and then

primarily closing the wound It is the safest method of repair for

wounds that are contaminated, dirty, infected, traumatic,

associ-ated with extensive tissue loss, at high risk for infection, and for

wounds that are “too old” to close The ultimate cosmetic result is

the same as that of primary wound closure This method may not

be suitable for young children, having to return a second time for

an uncomfortable procedure

During the interim period, instruct the patient to apply

wet-to-dry dressing changes twice a day Upon the patients return,

assess the wound for any signs of infection Anesthetize and

wound.2 They also secrete other factors that lead to excess matory cells in the wound, which also injures the tissue.2

inflam-PATIENT EVALUATION AND ASSESSMENT HOST HISTORY

A thorough and accurate history and physical examination are essential for optimum wound management Documentation of the patient’s age, prior tetanus immunization history, systemic illnesses, medications, allergies (such as to latex or local anesthetics), and the circumstances of the injury are essential to good wound man-agement These principles are emphasized because the presence of disease processes (such as diabetes mellitus, chronic malnutrition, alcoholism, hepatic or renal insufficiency, asplenism, malignancies, and extremes of age) may impair host defenses or complicate wound healing.6,7 Second, the wound itself is often less important than an

associated injury to an adjacent structure or cavity Associated injuries can easily be missed without a specific directed search for their presence.

TETANUS PROPHYLAXIS

A thorough history must be obtained concerning the patient’s nus immunization status Important factors to consider in assessing the risk of developing tetanus include prior immunization history, the type of wound, the degree of wound contamination, the time from injury to treatment, and the presence of underlying medical disease

teta-Wounds may or may not be prone to tetanus (Table 92-1)

The administration of tetanus prophylaxis is based upon the patient’s immunization history and the risk of developing tetanus

(Table 92-2) Current guidelines state that tetanus toxoid (Td) may

be deferred in patients with “clean, minor” wounds who have pleted a primary series or received a booster dose (Td 0.5 mL IM) within 10 years Consider tetanus immune globulin (TIG 250 to

com-500 U IM) in addition to Td for patients at risk of developing nus Elderly patients without documentation of a primary series, patients from nonindustrialized nations, and those from rural or

teta-TABLE 92-1 Characteristics of Tetanus-Prone and Non-Tetanus-Prone Wounds

CHAPTER 92: General Principles of Wound Management

inner-city areas may never have received tetanus immunization and

should be considered for TIG

MECHANISM OF INJURY

Severity of injury as well as associated injuries can be anticipated by

determining the precise mechanism of injury This will often

indi-cate additional soft tissue injury, the presence of a foreign body, or

the amount of contamination present

Soft tissue injuries are rarely surgical emergencies The patient’s

general condition should be attended to, with priority given

to observing the ABCs (airway, breathing, and circulation) of

Emergency Medicine The skin margins of a laceration can be

tacked together with well-placed atraumatic sutures and the wound

covered with a moist pressure dressing until the time is more

oppor-tune for definitive repair

Important questions and answers that must be documented

are exactly how the injury occurred, when and where the injury

occurred, and what contaminants were present or involved If the

injury involves the hand, what position was the hand in at the time

of the injury, what kind of work does the patient do, and which is

the patient’s dominant hand? Complicated wounds, such as those

caused by animal or human bites, chemical exposure, or high-

pressure injection may require a more extensive evaluation and

consultation with the appropriate specialist

CLASSIFICATION OF WOUNDS

Wounds are described and classified based upon their cause and

the type of injury Abrasions are the result of grinding or abrading

forces on the skin The epidermis and/or dermis is disrupted but

not removed in its entirety Crush injuries are due to compressive

forces The patient sustains a large amount of kinetic energy that

results in microvascular disruption, edema, and devitalized tissue

Crush wounds are 100-fold more likely to become infected than

lacerations because of the much lower bacterial loads required for

infection.8

Lacerations are wounds that are caused by shear forces that result

in a tearing of the tissue They are subclassified as avulsion, shear,

or tension lacerations Avulsion lacerations are injuries where there

is sharp trauma at an angle that removes the epidermal and possibly

also the dermal layer of skin The injury creates a skin flap Shear

lacerations are produced by a sharp force, usually perpendicular to

the skin surface, that results in a tidy or clean wound These wounds

are usually caused by knives, glass, or sharp metal objects There is

little tissue damage, and this type of wound is not prone to infection

Tension or tensile lacerations are injuries with jagged or contused

edges that are created by a compressive force These wounds pose a

greater risk for infection than shear lacerations.8

Punctures result in a wound that is deeper than it is wide The

skin opening is small and the depth of the wound is often unknown

Such wounds are made by discrete and thin objects, and they carry a

high risk for infection Irrigation is mandatory for puncture wounds;

however, the pressure must not be so high as to drive contaminants

deeper into the wound

The wound may also be clinically classified based upon an mate of microbial contamination and the subsequent risk of infec-tion Clean wounds are those that occur under aseptic technique These are usually surgical incisions that are elective in nature and preceded by a thorough skin cleansing and decontamination pro-cess Clean-contaminated wounds are those associated with the usual and normal flora of the region There is no contamination from foreign bodies or pus Contaminated wounds are those that are traumatic (e.g., lacerations, open fractures), less than 12 hours old, or associated with a break in aseptic technique Most wounds seen in the Emergency Department are of the contaminated type They may be associated with the introduction of “dirt” or foreign bodies into the wound Dirty wounds are those that are heavily contaminated (e.g., soil or feces), occur through infected tissue, are over 12 hours old, are associated with retained foreign bodies,

esti-or associated with devitalized tissue

TIME OF INJURY

This is probably the most pertinent factor of the history After

3 to 6 hours, the bacterial count in a wound increases cally Few studies have been conducted to determine the maximal time in which lacerations can be closed without resulting in infec-tious complications One study performed in an underdeveloped country indicated that wounds might be closed up to 18 hours postinjury.9 Lacerations of the face and scalp that are reasonably clean may be closed primarily up to 12 to 24 (or even 48) hours postinjury with little risk of infection because of the excellent cir-culation in these areas Other lacerations may generally be closed primarily if they are less than 6 to 12 hours old provided that they are not heavily contaminated or located in high-risk areas (i.e., hand or foot) The infection rate rises rapidly after 12 hours

Hemostasis can be achieved by direct pressure with a gauze sponge or gloved finger for simple lacerations Suturing the wound best controls bleeding of the scalp Extremity wounds, particu-larly of the wrist and hand, should have a pneumatic tourniquet applied after the extremity is elevated for 1 minute to promote venous drainage Inflate the cuff above the patient’s systolic blood pressure for 20 to 30 minutes at a time A blood pressure cuff may

be substituted if a pneumatic tourniquet is not available For more severe bleeding, there are several commercial tourniquets available,

as well as new hemostatic agents such as Quick Clot.37–39 Vascular

TABLE 92-2 Tetanus Prophylaxis

Td, tetanus and diphtheria toxoids; TIG, tetanus immune globulin.

the infection rate and the degree of inflammation in contaminated

wounds and do not significantly increase the degree of

inflamma-tion in noncontaminated wounds.12 Sutures placed in fat contribute

no strength to the repair and fail to prevent hematoma formation

and infection Deep absorbable sutures may be placed to repair

the periosteum, muscles, or fascia or to minimize tension on skin

sutures Use only enough subcutaneous sutures to restore

ana-tomic and functional integrity In most wounds, however, leaving

potential space may be preferable to attempting to obliterate it

It is important to explore the deep structures through a full range

of motion in order to detect partial tendon lacerations or joint

cap-sule disruption Tendons can be evaluated by inspection, but

indi-vidual muscles must also be tested for full range of motion and

full strength.

A distal neurologic and vascular examination should be

per-formed on extremity injuries Capillary refill should be checked

dis-tally and take less than 2 seconds Neurologic assessment involves

checking distal muscle strength and sensation Check two-point

discrimination prior to the administration of anesthesia for

hand and finger lacerations Two-point discrimination at 5 mm on

the radial and ulnar aspects of the finger pads is the most efficient

method of assessing median and ulnar nerve function Two-point

discrimination should be less than 1 cm at the fingertips A crush

injury may be associated with decreased two-point discrimination

and may take several months for recovery Numbness may also be

the first sign of a developing compartment syndrome Nerve

lac-erations can be repaired immediately or the wound can be loosely

approximated and repair of the lacerated nerve delayed

Obvious as well as questionable fractures should receive a

radio-graph of the area Bone injuries require checking the overlying skin

to exclude an open fracture An open fracture is an indication for

surgical debridement and repair except in the case of a distal

pha-lanx fracture, which can be treated with copious irrigation, oral

anti-biotics, and detailed discharge instructions

WOUND FOREIGN BODIES

Failure to identify foreign bodies in wounds may lead to complications

such as an increased risk of infection, delayed wound healing, and

loss of function.36 Foreign bodies and foreign matter greatly enhance

the infectivity of a given bacterial inoculum.13 Retained foreign

bod-ies are a common complication of simple wound repair Perform a

thorough inspection to attempt to diagnose the presence of a

for-eign body Missed forfor-eign bodies are the second leading cause (14%)

of lawsuits brought against Emergency Physicians.14 Some foreign

bodies cause an inflammatory reaction (e.g., wood, thorns, splinters,

cloth, teeth, and rubber from shoes or foam insoles), while others do

not (e.g., metal, glass, most plastics, and pencil graphite)

Wound exploration, irrigation, and radiography may be

needed when the clinical setting suggests a possible foreign body

Spread the tissue during exploration Do not cut tissue and risk

often not removed from lacerations This is especially true if there are multiple fragments or if excessive tissue disruption will result

with attempted removal The patient should be made aware of any

retained foreign bodies at the time of discharge, their benign presence, why removal was not attempted, the possibility of later infection, and the fact that they may eventually self-extrude This must also be documented in the medical record If the wound is

in a complex area, such as the palm, it may be necessary to gain consultation for immediate or delayed removal The wound can be approximated loosely and immobilized for comfort and to avoid further tissue disruption, antibiotics prescribed, and arrangements made for appropriate out-patient follow-up in 24 to 48 hours

Soils have varied levels of contamination potential Sandy soils present a low risk of wound contamination Clay-containing soils are pyogenic because they impair host defense mechanisms and

promote inflammation Organic soils contain Clostridium tetani

and a more concentrated bacterial inocula Soil contaminants, when present, can be removed by copious irrigation These contaminated wounds should be left open and allowed to heal by secondary or tertiary intention

HIGH-RISK WOUNDS

Many wounds require special consideration in deciding upon the method of closure, the type of suture to use, and the use of antibiotic prophylaxis These include wounds contaminated by saliva, feces,

vaginal secretions, soil, and organic material Wounds in

immu-nocompromised patients or patients taking immunosuppressive drugs may require antibiotics and longer times for the sutures to remain before removal Hand wounds, including bite wounds, and

foot wounds require special care Wounds greater than 6 to 12 hours old, other than wounds on the face, may require delayed closure

Puncture wounds may require radiographs, incision and tion, and antibiotic prophylaxis Wounds accompanied by excessive tissue damage and devitalization or crush injuries are prone to infec-tion Wounds with retained foreign bodies may require radiographs, exploration, and removal Major tissue defects may be closed with advanced wound closure techniques Wounds overlying sites of active infection require antibiotics and delayed closure These topics are covered further on in this chapter and in other chapters of this book (see Chapters 95 through 98 for details)

explora-SKIN AND WOUND PREPARATION ANESTHESIA

Wounds must be anesthetized with either local or regional niques prior to cleansing and repair Local anesthesia distorts wound edges; therefore regional nerve blocks should be used where appropriate (e.g., the hand, face, ear, nasal cartilage, palm, sole)

tech-Refer to Chapters 123 through 129 for a complete discussion of local

CHAPTER 92: General Principles of Wound Management

anesthetic agents, regional anesthesia, topical anesthesia, nitrous

oxide anesthesia, and procedural sedation

Lidocaine (Xylocaine) in a dose not to exceed 4.5 mg/kg is an

effective and standard local anesthetic agent Lidocaine anesthesia

lasts approximately 60 to 90 minutes If a longer period of

anesthe-sia is required, bupivacaine may be used It provides approximately

120 to 180 minutes of anesthesia The addition of a 1:100,000

dilu-tion of epinephrine to lidocaine or bupivacaine will prolong the

duration of anesthesia, promote hemostasis, allow a larger dose to

be used, and reduce systemic absorption of locally infiltrated local

anesthetic solution Epinephrine is a potent vasoconstrictor and

should not be used near end organs such as the fingers or toes It

may decrease blood flow and induce ischemia Epinephrine should

also be avoided near the tip of the nose, the ear, and the penis

Animal model studies have consistently shown that epinephrine

increases the incidence of infection in contaminated wounds This

may be due to vasospasm-induced local ischemia Epinephrine

should not be used to enhance local anesthesia in contaminated

wounds Consider the use of regional anesthesia or procedural

seda-tion in these patients

The pain of local anesthetic injection can be reduced The use

of a 27 or 30 gauge needle, slower and deeper infiltration (into the

dermis), warming the local anesthetic solution, and the addition of

bicarbonate to lidocaine (9 mL lidocaine to 1 mL of bicarbonate)

may decrease the pain of anesthetic injection.21–26 Other strategies

involve anesthetizing as much tissue as possible through a single

site, starting proximally on the extremity and moving distally

Infiltration of the local anesthetic solution through the wound edges

is less painful than through intact skin

Most “allergic” reactions are actually vasovagal or other adverse

responses Allergies to “caines” are attributed to what is often a

vaso-vagal or other side effect True allergies to local anesthetics are rare

and are generally seen only with the ester class of local anesthetics

If an allergy to lidocaine (an amide class of local anesthetic) is

sus-pected, the use of an ester class of local anesthetic is suggested An

alternative is the use of cardiac lidocaine, the prefilled syringes used

in codes and cardiac arrests, which contains no preservative It is felt

that the preservative in lidocaine is responsible for the allergic effect

Another alternative is to use a 1% to 2% solution of

diphenhydr-amine (Benadryl) This provides adequate but not ideal anesthesia

The most common complication of local anesthesia infiltration is

hypotension and bradycardia as a result of a vasovagal reaction

Topical anesthesia is an attractive alternative to injection,

particu-larly in the management of pediatric patients with simple wounds

Lidocaine, epinephrine, and tetracaine (LET) gel or tetracaine,

adrenaline, and cocaine (TAC) are two agents that can be used as

effective local anesthesia.27 Both of these agents contain epinephrine

and should not be used on areas involving an end artery or

contam-inated wounds TAC involves expense and incorporates problems

with the use and maintenance of a controlled substance TAC also

has the potential for toxicity, especially when applied to mucosal

surfaces EMLA (eutectic mixture of local anesthetics) cream, also

used for local anesthesia, has been found to provide effective

anes-thesia for extremity lacerations EMLA is a combination of 2.5%

lidocaine and 2.5% prilocaine suspended in an oil-in-water

emul-sion Studies have found that it takes longer to obtain optimal

anes-thesia with EMLA than with TAC.28

SKIN CLEANSING

Meticulous preparation of the skin surrounding the wound and

the actual wound, irrigation, and wound debridement are

tanta-mount to good wound healing The goal is to remove bacteria,

foreign matter, and tissue debris Wounds should be adequately

anesthetized prior to cleansing and/or local exploration Adequate

light, anesthesia, and equipment are a must in order to avoid inadequate debridement, a retained foreign body, or a wound hematoma that can result in a necrotizing soft tissue infection.

Disinfecting the intact skin surrounding the wound and ridding it

of foreign bodies, debris, and particulate matter is the initial step in wound preparation This technique can be accomplished by scrub-bing the skin with povidone iodine, chlorhexidine, or poloxamer

188 (Shur Clens) skin-prep solutions Do not expose the wound

itself to these solutions Povidone iodine and chlorhexidine

solu-tion are bactericidal and work as it dries Its toxicity to wound tissue

is controversial Shur Clens has no tissue toxicity but also has no antibacterial activity A wide area surrounding the wound should be prepped with an antimicrobial agent, preferably povidone iodine or chlorhexidine solution

HAIR REMOVAL

Hair removal is often unnecessary prior to closing wounds, can be embarrassing for the patient after discharge from the Emergency Department, and may increase the risk of wound infection Shaving can cause minimal soft tissue trauma and wound infections.17

Eyebrows should never be shaved, as they can grow back dictably or not at all Simple scalp lacerations can be exposed by

unpre-using antibiotic ointment (or lubricating gel) to move the hair away from the wound margins prior to placing sutures

WOUND IRRIGATIONWound cleansing and preparation have been proven to be the foundations of proper wound management and the prevention

of wound infections Irrigation removes contaminants, reduces infection, and improves visualization There are two concerns

regarding wound irrigation: the pressure required for adequate cleansing of the wound and the means to irrigate the wound safely while protecting the healthcare worker from the threat of human immunodeficiency virus and hepatitis B (by contamination of their own skin surfaces, mucosal surfaces [eyes, nose, or mouth], or minor open skin wounds)

Irrigation pressures of 5 to 8 pounds per square inch (psi) are felt to be adequate to cleanse a wound that is not heavily contami-nated This surface pressure can be generated by the combination

of a 35 mL syringe and a 19 gauge angiocatheter held 2 cm from the wound surface.18,40–42 Unfortunately, this process can be quite

messy (Figure 92-1) High-pressure irrigation, which generates

FIGURE 92-1. Wound irrigation with an angiocatheter on a syringe This process

is quite messy and can result in an occupational exposure (Photo courtesy of Zerowet Incorporated.)

fine-mesh gauze or a micropore sponge using a 1% solution of

povi-done iodine or poloxamer 188 Tap water can be used for irrigation

with no increased incidence of infection, especially when a large

volume of irrigant is required.43–47 Soaking of wounds is

discour-aged as a poor substitute for the preparation of contaminated or

clean wounds Do not soak wounds in any fluid Soaking does not

reduce bacterial contamination or decrease infection rates It may

actually increase infection rates Do not use undiluted

povidone-iodine, hydrogen peroxide, or detergents in the wound as they

cause tissue toxicity.48

Numerous commercially available devices are available to irrigate

a wound (Figure 92-2) The Combiport ( Moog Medical Devices,

Salt Lake City, UT) is a wound irrigation device that inserts directly

into the port of an intravenous fluid bag (Figure 92-2A) Squeeze

tion process There are several barrier devices on the market that decrease the splatter of irrigation fluid19 (Figure 92-2) Some of these

devices are preattached to a wound irrigation device Others can be attached to a wound irrigation device The Zerowet Supershield (Zerowet Inc., Palos Verdes Peninsula, CA) is a dome-shaped

device that attaches to a syringe (Figure 92-2C) The Combiguard

Irrigation Splash Guard (Moog Medical Devices, Salt Lake City, UT)

is similar in function to the Zerowet Splashield and has a slightly different shape The Combiguard can attach to a syringe or the

Combiport Wound Irrigation Device (Figure 92-2D) The Igloo

Wound Irrigation System (Bionix Medical Technologies, Toledo, OH) is a similar device that provides a multiport shower effect to

deliver the irrigation solution (Figure 92-2E) The Irrijet (Cooper

Surgical, Trumbull, CT) is a spring-loaded, self-refilling system that

A

B

FIGURE 92-2. Commercially available wound irrigation devices A. The Combiport

Wound Irrigation Device (Moog Medical Devices, Salt Lake City, UT). B. Wound

Wash Saline (Church & Dwight, East Princeton, NJ)

FIGURE 92-2. (continued ) C The Zerowet Supershield (Zerowet Inc., Palos

Verdes Peninsula, CA) D. The Combiguard (Moog Medical Devices, Salt Lake

City, UT) attaches to the Combiport or a syringe E. The Igloo Wound Irrigation

System (Photo courtesy of Bionix Medical Technologies, Toledo, OH) F The Irrijet

(Cooper Surgical, Trumbull, CT) G The Canyons Wound Irrigation System (Wolf

Tory Medical Inc., Salt Lake City, UT)

J

K

H

FIGURE 92-2. (continued ) H. The Squirt Wound Irrigation Kit (Merit Medical

Systems Inc., South Jordan, UT) I. The Klenzalac (Zerowet Inc., Palos Verdes

Peninsula, CA) J. The Splashcap (Splash Medical Devices, Atlanta, GA) K. The

Irrisept (Photo courtesy of Irrisept, Gainesville, FL)

CHAPTER 92: General Principles of Wound Management

FIGURE 92-3. Wound debridement Removal of the wound edges with a scissors

(or a scalpel)

FIGURE 92-4. Wound excision Removal of an ellipse of tissue that contains the wound results in smooth, clean edges that can be approximated

is operated with one hand (Figure 92-2F) A Splashield or Splash

Guard can be attached to the Irrijet The Canyons Wound Irrigation

System (Wolfe Tory Medical Inc., Salt Lake City, UT) is a similar

device with the exception of using the built-in Zerowet Splashield

(Figure 92-2G) The Squirt Wound Irrigation Kit (Merit Medical

Systems Inc., South Jordan, UT) is a manually operated system that

may be used alone or attached to the Splashield, Combiguard, or an

angiocatheter (Figure 92-2H) The Klenzalac (Zerowet Inc., Palos

Verdes Peninsula, CA) is a similar device with the exception of

using the built-in Zerowet Splashield (Figure 92-2I) The Splashcap

(Splash Medical Devices, Atlanta, GA) attaches to a bottle of

ster-ile saline (Figure 92-2J) The Irrisept (Irrisept, Gainesville, FL)

attaches to a proprietary bottle containing a saline and

chlorhexi-dine mixture (Figure 92-2K).

WOUND DEBRIDEMENT

Debridement creates straight and clean wound edges that are easier

to repair by removing tissue that is devitalized, contaminated by

bacteria, or contaminated by foreign matter and may impair the

ability of the tissue to resist infection Successful wound closure may

require the transformation of a ragged laceration, the removal of

devitalized tissue, or the removal of contaminated tissue in order

to convert a traumatic wound into a surgical wound Devitalized

and necrotic tissue must be removed in order to remove a nidus for

bacterial growth and wound infection.20

Close approximation of the wound requires that debridement

of jagged edges not be too vigorous in order to avoid widening

the scar and making it difficult to close Wounds of the face or

areas that are devoid of redundant tissue require conservative

debridement Debridement to simplify wound closure is not

always the answer for a superior cosmetic result in the repair of

irregular wound edges The meticulous repair of complex wound

edges can often provide a superior cosmetic result.

Debridement can be accomplished mechanically,

hydrody-namically, or with a combination of both methods Tissue must be

removed mechanically with a #11 or #15 scalpel blade or a scissors

(Figure 92-3) Superficial debris and contaminants can be removed

with a pulsatile stream of normal saline solution during the

irriga-tion process Debridement must be performed using aseptic

tech-nique Scrubbing is not a substitute for debridement of heavily

contaminated tissue Wound edges should be handled delicately

or gingerly in order to avoid further soft tissue damage and talization of injured tissue.

devi-WOUND EXCISION

The entire wound may be excised in areas of excess tissue or tissue laxity if no blood vessels, nerves, tendons, or joints lie within or at

the base of the wound (Figure 92-4) The excision of a wound

cre-ates smooth, clean edges that may be approximated with sutures This is especially useful in wounds that are heavily contaminated

Most wounds are excised with an elliptical incision (Figure 92-4)

Other types of wound excision are discussed in Chapters 95 and 96

Carefully plan the excision before removing any tissue Mark

the edges of the proposed incision with a marking pen The long axis of the ellipse should be two-and-a-half to four times as long

as the greatest width of the ellipse Removal of too much tissue will produce a large defect that may not be possible to close primarily Remove the tissue using aseptic technique, preventing any contami-nation of the new wound edges

WOUND UNDERMINING

The undermining of tissue creates a “flap” that involves the aration of the skin and superficial subcutaneous tissue from the

sep-deeper subcutaneous tissue and fascia (Figure 92-5) The process

of undermining tissue minimizes skin tension, allows for eversion

of the approximated skin edges, and relieves the extrinsic

ten-sion from sutures Undermining is performed when the wound

cannot be closed due to a tissue defect or if a wound is under tension This procedure requires the Emergency Physician to be

familiar with the local anatomy so that no blood vessels, nerves,

or tendons are injured in the process Do not undermine

con-taminated wounds Undermining large areas can separate the

skin from its underlying blood supply and result in a diminished blood flow that predisposes the area to infection and necrosis Undermining may be useful on the forehead, scalp, arm, forearm,

thigh, calf, and torso Never undermine wounds on the palms,

soles, and face.

Undermine tissue at the dermal-epidermal junction or within the subcutaneous adipose tissue The amount of undermining neces-sary to close a laceration is approximately double the width of the gap of the laceration at its widest point A 1 cm wide laceration should be undermined for 1 cm on both sides of the wound, includ-

ing the ends (Figure 92-5) The use of a Mayo scissors versus a #15

scalpel blade to undermine tissue is based on physician experience

and preference A Mayo scissors is recommended as it may cause

less secondary injury, especially in experienced hands

EMERGENCY DEPARTMENT VERSUS

OPERATING ROOM MANAGEMENT

OF WOUNDS

Laceration repair may sometimes have to be performed in the

oper-ating room Indications for operoper-ating room repair of lacerations

include those associated with open fractures, major or complex

wounds involving devitalized tissue, heavily contaminated wounds,

wounds with associated injuries (e.g., visceral, neurovascular,

frac-ture, and tendon), perineal wounds, large or complicated soft tissue

injuries, compartment syndromes, wounds with extensive amounts

of necrotic or ischemic tissue, the total local anesthetic solution

required would exceed toxic tissue levels, and high-pressure

injec-tion injuries

ANTIBIOTIC PROPHYLAXIS

Despite the best wound care and management, the rate of infection

has been determined to be approximately 1% to 12% Not all wounds

result in infection Most uncomplicated wounds heal without the

need for antibiotics Wounds associated with an increased risk for

infection are those of the extremities (especially the lower), complex

wounds, or wounds over 3 to 5 cm in length The use of antibiotics

for traumatic wounds is controversial Prophylactic antibiotics are

not indicated for uncomplicated minor wounds with a low chance

of becoming infected It has not been proven that oral antibiotic

administration following injury actually reduces the probability of

infection However, the use of topical antibiotics can decrease the

rate of wound infection.34 Useful preparations include bacitracin,

triple antibiotic ointment, or silver sulfadiazine

It is necessary to identify those patients who may benefit from

early antibiotics Antibiotic therapy should be considered in the

following situations: where wounds are heavily contaminated or

associated with major soft tissue injury; open fractures, intraoral

lacerations, wounds associated with active infection; when there is

a delay in care that results in a prolonged time from debridement or

treatment (>3 hours); when the patient is immunocompromised or

has cardiac valvular disease; when there are bites to the hand or face,

deep puncture wounds, or lacerations to lymphedematous tissue; or

when the patient has prosthetic joints (Table 92-3).

SUTURES SUTURE TYPES

Proper size suture material can be summarized as the smallest

suture needed to approximate the edges of a wound This will reduce

tissue damage caused by the suture, and the resulting scar will be minimized The tensile strength of the suture should never exceed the tensile strength of the tissue, or it can pull through and damage the tissue The sutures should be at least as strong as the normal tis-sue through which they are being placed

The size of the suture material is related to the diameter of the suture As the number of 0s in the suture size increases, the diameter

of the strand decreases For example, size 5-0, or 00000, is smaller in diameter than size 4-0, or 0000 The smaller the size, the less tensile strength the suture will have

Suture description entails numerous characteristics Sutures can be classified into two major groups based upon the number

of strands of which they are composed Monofilament sutures are made of a single strand of material They encounter less resis-tance passing through tissue and resist harboring organisms that may cause suture-line infections Multifilament sutures consist of several filaments, or strands, that are twisted or braided together

This affords greater tensile strength, pliability, and flexibility

Unfortunately, bacteria can migrate between the filaments and into the wound

Another classification is based on the ability of the body to break down and absorb the suture material Absorbable sutures are digested

by body enzymes or hydrolyzed in body tissue Nonabsorbable sutures are not digested by body enzymes or hydrolyzed

Absorbable suture can be made of natural or synthetic rial Natural absorbable suture is classified as surgical gut (plain or chromic) Plain surgical gut is composed of collagen from bovine

mate-or sheep intestine It is rapidly absmate-orbed, maintaining its tensile

TABLE 92-3 Antibiotic Prophylaxis for High-Risk Wounds35

Situation Antibiotic of choice Days of treatment

Open fractures First Generation Cephalosporin

Add an aminoglycoside for more extensive injuries

OrAugmentin

3–5

Dog/cat bites First dose: parenteral ampicillin

sulbactam or carbapenem or clindamycin, then clindamycin plus fluoroquinolone

OrAugmentin

3–5

CHAPTER 92: General Principles of Wound Management

strength for only 7 to 10 days, and is completely absorbed within

70 days Chromic gut is treated with a chromium salt solution to

resist body enzymes It retains its tensile strength for 10 to 14 days

and is absorbed over 90 days

Synthetic absorbable sutures include polyglactin 910 (Vicryl,

Ethicon) and polyglycolic acid (Dexon) They were developed

because of the tissue reaction, suture antigenicity, and unpredictable

rates of absorption of natural absorbable sutures These sutures are

braided synthetic materials that retain 50% of their initial strength

at 4 weeks The synthetic absorbable sutures retain their tensile

strength long enough to ensure the security of the subcutaneous

layers after the removal of percutaneous sutures

Nonabsorbable sutures are made of silk, nylon, polypropylene,

cotton, linen, or metal They can be monofilament or

multifila-ment in construction Nylon is the most commonly used suture in

the Emergency Department It is used to approximate lacerations

at the skin surface Silk may occasionally be used in the mouth It

causes significant tissue reactions that result in inflammation and

granuloma formation as the body “fights off ” this natural fiber The

other types of nonabsorbable sutures are generally not utilized in

the Emergency Department

Several factors must be considered in choosing suture material

Choose sutures that match the healing properties of the tissues

Approximate slow-healing tissues (e.g., fascia and tendons) with

nonabsorbable sutures or a long-lasting absorbable suture Foreign

bodies in potentially contaminated tissues may result in an

infec-tion Multifilament sutures can act as a foreign body and may

con-vert a contaminated wound into an infected one Multifilament

sutures should generally be avoided Use monofilament sutures or

absorbable sutures that resist harboring infection Use the smallest

inert monofilament suture materials (such as nylon or

polypropyl-ene), avoid using skin sutures alone (use subcuticular closure

when-ever possible), and use sterile skin closure strips for apposition when

possible Use the smallest possible size of the chosen suture type

that is capable of closing the wound to help minimize scarring.

NEEDLES

Needles are generally of two types, tapered and cutting

(Figure 92-6) Cutting needles have sharp ends and sharp edges

that act as a cutting instrument (Figure 92-6A) The cutting needle

is commonly used for tougher tissues such as subcutaneous,

intra-dermal, and cutaneous (skin) closure In addition to the two cutting

edges, conventional cutting needles have a third cutting edge on the inside concave curvature of the needle This needle type may

be prone to “cutout” of tissue because the inside cutting edge cuts toward the edges of the incision or wound

Reverse cutting needles are as sharp as the conventional cutting needle except that the third cutting edge is located on the outer

convex curvature of the needle (Figure 92-6B) Reverse cutting

needles have more strength than similar-sized conventional ting needles The danger of tissue “cutout” is greatly reduced The hole left by the needle leaves a wide wall of tissue against which the suture is to be tied

cut-Taper point needles have a pointed end (Figure 92-6C) The rest

of the needle is a smooth, rounded tube with no cutting edges This type of needle is commonly used in surgery to close tissues with minimal trauma It is used for all tissues except skin

Two other types of needles are often available but not used in the Emergency Department The blunt point needle has a smooth tip

and tapered body (Figure 92-6D) It is used for suturing friable

tis-sue and blunt dissection The taper cut needle has a cutting tip and

a tapered body (Figure 92-6E) It is a combination of the tapered

point and cutting needle It is used to place sutures through tough tissues Numerous other needles are available, as are modifications

of the five basic needle types These needles are used by Surgeons for specialized tissues

Always keep some general principles in mind when suturing

Needles should be pulled through tissue using a needle driver and never a hemostat A hemostat or other clamp can damage the

needle Avoid injury to yourself and others Keep all open

nee-dles in a place so that they will not injure you or your assistant

Account for and discard all suture needles in a “sharps” container Following these two steps will dramatically decrease the chance for

an appropriate size for the needle that is to be grasped A 4.5 to 6 in long needle driver is appropriate for Emergency Department use Grasp and remove a clean needle from its package with your hands,

FIGURE 92-6. Common types of suture needles A. The ting needle B. The reverse cutting needle C. The taper point needle D. The blunt point needle E. The taper cut needle

cut-A

B

Some needle drivers are designed to be snag-free (Figure 92-8) Two

of these, the Centurion SnagFree (Centurion Healthcare Products, Howell, MI) and the SutureCut (SutureCut LLC, Lexington, KY) needle drivers, are available both as individual disposable instru-ments and in disposable laceration repair trays

Suturing lacerations can take a significant amount of time Much

of this time is spent tying knots or switching between instruments (i.e., the needle driver and scissors) Two needle drivers are designed

to also cut suture This decreases the total time required to repair

a laceration as well as avoiding the constant switching between instruments The SutureCut (SutureCut LLC, Lexington, KY) and the Olsen-Hagar (Henry Schein Inc., Port Washington, NY) needle drivers cut the suture in their specially designed joint located at the base of the jaws

We are all not fortunate to have suture-cutting needle ers in our laceration repair trays A needle driver and scissors can

driv-be simultaneously held in the same hand to improve efficiency

(Figure 92-9) While awkward at first, this technique is easy to learn Grasp a scissors with the tip pointing ulnarly (Figure 92-9A)

Insert your middle finger through the adjacent ring on the handle

Grasp a needle driver in the same hand with the tip pointing

radi-ally (Figure 92-9A) Insert your thumb and ring finger through the

rings on the handle of the needle driver Grasp a suture needle with the needle driver Place a stitch and tie it Remove your thumb from the ring of the needle driver and place it in the open ring of the scis-sors Use the thumb to open and close the scissors Cut off the excess

suture (Figure 92-9B) Place your thumb back into the ring of the

needle driver and place the next stitch Repeat this process until the laceration is closed

WOUND CLOSURE

The goal of wound closure is approximation of the skin under minimal tension while achieving eversion of the wound edges (Chapter 93) Wound eversion slightly raises the wound edges

to keep the epidermal cells from migrating into the dermal

lay-ers, therefore leaving a flat scar (Figure 92-10) Sutures should

be placed closely enough to approximate wound edges, but not so tight as to cause tissue necrosis The time from the injury to the

forceps, or a needle driver Securely grasp the proximal one-third to

one-half of the needle with the needle driver (Figure 92-7A) Do

not grasp the distal one-third of the needle This can damage its

cutting surfaces Always use the tips of the needle driver to grasp

the needle (Figure 92-7B) Grasping a needle with the base of the

jaws may damage the needle

Use the needle driver when pushing the needle through the tissue

to place a suture (Figure 92-7C) Apply the force in a direction

fol-lowing the curve of the needle Do not twist or force the needle

to push the point through the tissue and out the other side Use a

larger needle if the first one is too short or too small Do not use a

needle that has become dull and difficult to pass through the

tis-sue Obtain a new needle and continue the procedure Grasp the

distal tip of the needle with a needle driver when it emerges from

the tissues (Figure 92-7D) Always grasp the needle proximal to

its distal third to prevent damage to the cutting edges.

Always use caution when handing a needle driver armed with

a needle to another person Grasp the needle driver between the

thumb, index, and middle fingers (Figure 92-7E) Hand the base of

the needle driver to another person Do not blindly pass the needle

driver Do not pass the needle driver over a third party without

their knowledge of the transfer Never grasp the distal end of an

armed needle driver.

Typical needle drivers contained within most disposable,

com-mercially available laceration repair trays are not ideal The suture

often snags on the jaws or hinge when performing an instrument tie

FIGURE 92-7. Using a needle driver A. Grasp the proximal one-third to one-half

of the needle B. Always use the tips of the jaws to grasp the needle C. Drive the

needle through the tissue following the natural curve of the needle D. Grasp

the distal needle proximal to the cutting edges E. Correct method to pass a needle

driver armed with a needle

FIGURE 92-8. Examples of snag-free needle drivers From left to right: The Centurion SnagFree (Centurion Healthcare Products, Howell, MI), the SutureCut needle driver (SutureCut LLC, Lexington, KY), and the Olsen-Hegar needle driver (Henry Schein Inc., Port Washington, NY)

CHAPTER 92: General Principles of Wound Management

presentation and the mechanism of injury will indicate whether

the laceration mandates delayed closure instead of primary closure

and whether tetanus prophylaxis is required With the exception of

patients who are immunocompromised or taking

immunosuppres-sive therapy, those with high-risk wounds should be considered for

delayed closure

SINGLE-LAYER VERSUS MULTILAYER CLOSURE

The greatest strength of the skin (and of the wound) is contained

within the dermis The better the coaptation of the dermal edges,

the narrower the scar will be The best results occur when the entire

depth of the dermis is accurately approximated to the entire depth

of the opposite dermis Dermal closure is best performed with

syn-thetic monofilament absorbable suture that requires enzymatic

degradation (e.g., Vicryl) Chromic or plain catgut suture dissolves

much more rapidly by means of hydrolysis

Close the wound in multiple layers if the goal is cosmesis Close

the wound with a minimal number of sutures in a single layer if the

goal is a functional result Do not suture through fat and muscle

Fat has no tensile strength Sutures placed tightly in fat can cause

ischemia and necrosis in the wound and increase the risk of a

wound infection Muscle fibers do not support sutures Muscle is best treated by repair of the overlying fascia and immobilization to prevent motion and to allow coaptation of the muscle fibers

STERILE GLOVES

It is a common practice to wear sterile gloves when repairing a ation The advantages of sterile gloves include a better fit, improved tactile sensitivity, and improved dexterity The use of sterile gloves for laceration repair costs significantly more than using nonster-ile, clean gloves from a box Clean, nonsterile, powder-free, boxed examination gloves can be used for uncomplicated wound repair

lacer-in the Emergency Department No cllacer-inically important differences

in infection rates has been found when comparing sterile gloves to clean gloves.49,50

The use of clean gloves from a box is not always ideal Clean gloves come in a limited number of sizes (i.e., extra small, small, medium, large, and extra large) The fit and feel of clean gloves may not be as comfortable for the Emergency Physician Clean gloves may have more manufacturing defects when compared to sterile gloves.51 These defects can result in the loss of personnel protection and the potential to contaminate the wound Others have shown clean gloves to have comparable quality to sterile gloves.52–54 A box

of clean gloves that has become wet can harbor mold.55 While the use of clean gloves in uncomplicated wound repair is acceptable, the decision is physician dependent

WOUND CLOSURE PROCEDURE

Clean any dirt and debris from the skin Scrub the skin surrounding the wound with an antiseptic skin cleanser (e.g., povidone iodine or chlorhexidine) Anesthetize the wound with a 27 to 30 gauge hypo-dermic needle and local anesthetic solution Irrigate the wound with normal saline Use a mask with a face shield to prevent exposure

to the patient’s blood and tissue fluid Debride and undermine the wound as necessary Irrigate the wound again to remove exposed debris and devitalized tissue Repair the wound with sutures or pack

it with saline-soaked fine-mesh gauze for delayed closure Clean the repaired wound with normal saline and apply a dressing for com-fort and protection Consider the application of a splint for wounds across joints or muscle lacerations

Write a procedure note describing the sterile preparation of the wound, the type and volume of anesthesia administered, the type

of suture(s) used in the repair, the layers repaired, the type of repair

FIGURE 92-9. A one-handed method to simultaneously hold a needle driver and scissors A. Placing a stitch B. Cutting the suture

FIGURE 92-10. Eversion of the wound edge signifies proper suture placement

and knot tension

pendent of the underlying disease process The application of an

occlusive dressing has been shown to increase the rate of wound

healing by approximately 40%, as well as preventing environmental

trauma and keeping bacteria out of the wound

Dressings, regardless of the type used, should produce a moist

but not macerated wound that is free of infection, toxic chemicals,

and foreign material while maintaining an optimum temperature

and pH Layered dressings of nonadherent gauze, such as Xeroform,

covered with dry gauze can be used for large sutured lacerations

and abrasions This dressing draws exudate into a layer that can be

replaced without disturbing the underlying wound Shear wounds

or hematomas may require gauze that is fluffed and formed into a

pressure dressing Dressings of antibiotic ointment with a standard

adhesive bandage (e.g., Band-Aid) provide adequate healing and

protection for smaller repaired lacerations The topical application

of topical antibiotics to the suture line after wound closure may help

to protect against exogenous bacterial contamination No

stud-ies have shown that topical antibiotic ointments have an effect on

the final outcome of a wound Despite this, their use is still

recom-mended because they keep the wound surface moist and their use

has not been shown to have any negative effects The use of paper

gauze and Telfa pads is not advisable

DISCHARGE INSTRUCTIONS

High-risk wounds such as animal and/or human bites, hand wounds,

heavily contaminated wounds, and wounds that require

prophylac-tic antibioprophylac-tic coverage should be reevaluated within 24 hours

Patients should be made aware, orally and in writing, that up to

one in 10 persons develops a wound infection that can be treated

with an oral antibiotic Puncture wounds are considered high-risk

injuries that can result in bone infections Patients should

immedi-ately return to the Emergency Department or their primary

physi-cian if a wound becomes red or has a discharge, if redness or red

streaks are emanating from the wound, or if they develop a fever

Explain briefly the progression of healing The new scar’s

appear-ance is usually worst at 3 to 5 weeks Most scars remodel within 6 to

12 months Any revision of the wound should be postponed for at

least 6 to 12 months from the time of injury

SUTURE REMOVAL

The length of time that the sutures remain in place depends upon

the location of the wound, the amount of tension on the wound,

and the healing time of the involved tissue Some general

guide-lines are listed in Table 92-4 Appropriate and timely removal of

sutures minimizes scarring Full-thickness sutures can be left in

place for 2 or more weeks without risk of suture-track formation in

areas where sebaceous glands and other adnexal structures are not

present, such as the plantar and palmar surfaces Leaving sutures in

place too long results in epithelialization of the suture tracts, larger

scars, and possibly infections Suture removal kits are commercially available They typically contain a metal or plastic forceps, a scis-sors, and a few gauze squares These kits are inexpensive, disposable, and intended for single-patient use

Sutures should be removed using aseptic and sterile techniques

Clean the wound with saline Apply hydrogen peroxide to remove any dried blood and serum encrusted around the sutures Grasp

the suture at the knot with forceps (Figure 92-11) Lift the knot

off the skin Cut the suture as close to the skin as possible with a

scissors and where the suture enters the skin (Figure 92-11) This

will avoid drawing contaminated suture through the depth of the wound Sutures that are close together, small, or tight may require

a #11 scalpel blade to cut them rather than a scissors Gently pull the suture strand out of the tissue with the forceps and across the wound Pulling a suture out away from the wound may result in the wound edges opening (dehiscing) Remove one to three sutures and ensure that the wound edges do not dehisce Remove the remain-ing sutures Apply skin adhesive strips (e.g., Steri-strips) across the wound to provide support

MANAGEMENT OF PUNCTURE WOUNDS

Puncture wounds are considered to be at higher risk for tion than simple lacerations They should be allowed to heal by delayed intention, particularly if they penetrate into the subcuta-neous tissues Local cleansing is the initial step in management

infec-High-pressure irrigation, coring, and probing are generally not recommended

Infection is most frequently due to Staphylococcus aureus,

Staphylococcus epidermidis, or streptococcal species Treatment

should be reserved for compromised hosts, dirty wounds, or actual infected wounds.30 Puncture wounds of the foot are of special con-

cern due to the risk of Pseudomonas aeruginosa infection,

particu-larly with wounds through athletic shoes A tender wound that

is not infected usually indicates that there may be a retained eign body Persistent infection from a plantar wound suggests an

for-FIGURE 92-11. Suture removal

CHAPTER 93: Basic Wound Closure Techniques

underlying osteomyelitis that requires radiographs and treatment

with a fluoroquinolone.31

PEDIATRIC ISSUES OF WOUND HEALING

Pediatric patients less than 15 years of age experience infection rates

of less than 1% for clean surgical wounds.7 This is less than that seen

in adults Young children, despite the ultimate in the way of gentle

reassurance, will sometimes require sedation in order to make

pain-ful or difficult procedures possible Safe and effective procedural

sedation for patient comfort or cooperation to facilitate or expedite

medical care is described in Chapter 129 Undermining is not useful

in most pediatric wounds as they do not usually require

advance-ment of skin over a significant tissue defect Scalp lacerations

account for 30% of pediatric lacerations Scalp lacerations are well

suited for single-layer repair with staples Cosmetic results are

com-parable with those of sutured repairs, with no differences in

compli-cation and infection rates Staples are six times faster, less expensive

in cost of supplies and physician time than standard sutures, and

can be implanted rapidly and accurately, even in a moving child

ALTERNATIVE CLOSURES

Alternative methods of wound closure include skin closure tapes,

tissue adhesives, and staples These are mentioned briefly below A

more complete discussion can be found in Chapters 93 and 94

SKIN CLOSURE TAPES

Skin closure tapes are adhesive strips that are used when skin tension

and wound contamination are not concerning factors

Adhesive-backed long and narrow strips are used for approximating the edges

of lacerations (with or without staples or sutures) and for closing the

skin following many operative procedures The most common type

is the Steri-strip Skin closure tapes are felt to develop and increase

wound tensile strength faster than sutured wounds because

uni-formly orienting collagen fibers apply equal stress across the wound

Skin closure tapes are porous, which allows for good air inflow and

the escape of water vapor from the wound during the healing

pro-cess Strips are placed perpendicular to the wound in conjunction

with an adhesive such as tincture of benzoin, taking care not to get

benzoin in the wound

TISSUE ADHESIVES

Tissue adhesives such as the older and weaker butyl cyanoacrylates

focused on small linear lacerations Newer and stronger

medical-grade octyl cyanoacrylate formulations have been approved by the

US Food and Drug Administration It has been clinically proven

that there is no difference 1 year after treatment in the cosmetic

out-come of wounds repaired with suture versus those closed with octyl

cyanoacrylate tissue adhesive.32

STAPLES

Staple closure is time-efficient compared to the suture repair of

lac-erations.33 It is primarily used for large wounds that are not on the

face, neck, hands, or feet Stapling is especially useful for closure of

incisions in hair-bearing skin (i.e., scalp) areas as well as the trunk

and extremities The wound edges require manual eversion with

forceps prior to placing the staples

SUMMARY

Expert wound management consists of attention to the details

sur-rounding the wound, gleaning important information

concern-ing the host’s history, as well as meticulous wound preparation

Aggressive attention to the presence of foreign bodies, underlying injury to anatomic structures of significance, and the possibility of subsequent wound infection should be kept in mind at all times

An effort should be made to educate the patient about the possible outcomes of wounds and lacerations and to encourage expedited follow-up

Basic Wound Closure Techniques

Eric F Reichman and Candace Powell

INTRODUCTION

Wound management is crucial to the practice of Emergency Medicine Emergency Physicians routinely care for wounds ranging from simple lacerations to complex injuries in the trauma patient.1–6

Wound repair is always secondary to the evaluation and stabilization

of any life-threatening and limb-threatening emergencies However, patients are often legitimately concerned about the outcome of wounds and lacerations There are several basic suture principles that will help to provide optimal wound healing and ensure a more than acceptable cosmetic result The previous chapter outlines the essential principles of wound management This chapter describes the basic methods used to close wounds

SUTURES

The choice of suture materials is important in wound closure Sutures are made of a wide variety of materials, both natural and synthetic Natural substances include gut (sheep and beef), cotton,

and silk Natural substance sutures cause more tissue reactions

and scarring, which limits their use Cotton sutures are not

dis-cussed, as they are no longer used in clinical practice Synthetic sutures can be made of nylon, polyethylene (Dacron), polygla-ctin (Vicryl), polypropylene (Surgilene, Prolene), polyglycolic acid (Dexon), poliglecaprone (Monocryl), polydiaxanone (PDS), polyglyconate (Maxon), and metal.6 Metal sutures are used in the Operating Room and not in the Emergency Department as they are difficult to handle, prone to breakage, and indicated in only

a few situations Synthetic sutures tend to have a problem with

“memory.” That is, they tend to retain the shape of their ing This can make it difficult to manipulate the suture during wound closure

packag-Sutures are constructed as monofilaments or polyfilaments Polyfilament fibers consist of multiple filaments braided together

to form one suture They are easier to handle than monofilament sutures, as they tend to be more pliable Polyfilament sutures have better knot security and therefore reduce the incidence of knot slippage However, they can be associated with a higher incidence

of infection than monofilament sutures They allow bacteria to migrate (or wick) between the strands of the suture located at the skin surface and into the wound

Select the smallest diameter suture that can adequately hold the tissue edges together in order to reduce tissue damage and scarring The largest suture material available is size #5 The suture

sizes decrease to zero (#4, #3, #2, #1, #0) and then are followed by

#00 (2-0), #000 (3-0), and #0000 (4-0), in decreasing size The est suture commonly used in the Emergency Department is 6-0 for facial lacerations, nail bed lacerations, as well as lacerations in cos-metically sensitive areas The tensile strength of sutures is related

small-93

to their size The tensile strength of suture increases as the size

increases For example, 4-0 is stronger than 5-0

The other main category of suture classification is absorbable

versus nonabsorbable In the past, absorbable sutures were

pri-marily used to close the subcutaneous layers of a wound More

recently, absorbable sutures have also been used for skin closure

Nonabsorbable sutures are primarily used for skin closure

ABSORBABLE SUTURE MATERIALS

Absorbable sutures are degraded by the body and do not require

removal They usually do not maintain their tensile strength for

lon-ger than 60 days Body enzymes dissolve the absorbable sutures with

the aid of an inflammatory reaction The rate of absorption of the

sutures varies based upon the tissue where it is placed, the

compo-sition of the suture, and the size of the suture Absorbable sutures

placed in mucous membranes absorb faster than those placed in

muscle tissue or fascia Smaller sizes of suture dissolve faster than

larger sizes

There are several types of absorbable sutures, both natural and

synthetic (Table 93-1) The most commonly used absorbable

sutures in the Emergency Department are plain gut, chromic gut,

polyglycolic acid (Dexon), polyglactin (Vicryl), and Vicryl Rapide

Plain gut and chromic gut are both natural forms of absorbable

sutures They are made from the intestines of sheep and cattle Gut

is a tissue irritant and can cause a substantial tissue reaction while

it is being absorbed and degraded by the body Chromic gut is plain

gut that has been soaked in chromic acid salts This process helps to

extend the half-life of the suture and allows it to maintain its tensile

strength longer than plain gut Chromic gut may retain its tensile

strength for 2 to 3 weeks, while plain gut retains its tensile strength

for 1 to 2 weeks Both types of gut are packaged wet in order to keep

them from drying out and becoming too stiff

Synthetic absorbable sutures, such as Dexon and Vicryl, are typically used more often than natural absorbable sutures in the Emergency Department They are degraded by the body more slowly than natural fibers and can therefore help maintain the strength of the wound longer Vicryl and Dexon maintain their tensile strength

at 80 days and 120 days, respectively They cause less reaction in the tissues as they break down when compared to natural absorbable sutures

Recently, absorbable sutures have gained some popularity for use

in skin closure.7–10 Absorbable sutures have been shown to yield equal results in their rate of dehiscence, rate of infection, and cosme-sis when compared to nonabsorbable sutures.7 Absorbable sutures have the added benefit for the patient of not having to return to have their sutures removed Vicryl Rapide is a newer form of Vicryl that

is especially suited for this purpose This type of suture is rapidly absorbed They begin to fall off in 7 to 10 days as the wound heals

This can be especially useful for children in whom suture removal can be difficult, under casts, or if a patient will not be able to follow

up due to travel

NONABSORBABLE SUTURE MATERIALS

Nonabsorbable sutures are not degraded by the body and must

be removed They maintain their tensile strength for longer than

60 days They are composed of monofilament or polyfilament strands

of organic, synthetic, or metal fibers (Table 93-2) Nonabsorbable

sutures generally have greater tensile strength and lower tissue tivity than absorbable sutures They are used in a variety of appli-cations including skin closure Nonabsorbable sutures can be used within a body cavity and subcutaneously, where they will eventually become encapsulated in connective tissue

reac-Nonabsorbable sutures can be classified as organic, synthetic, and wire Organic sutures include those made of cotton or silk Cotton

TABLE 93-2 Nonabsorbable Suture Materials

Silk (braided) Organic protein Gradual loss by progressive

degradation

by connective tissueEthilon Polyamide (nylon) Progressive hydrolysis may result

in gradual loss of tensile strength

by connective tissueNurolon Polyamide (nylon) Progressive hydrolysis may result

in gradual loss of tensile strength

by connective tissue

CHAPTER 93: Basic Wound Closure Techniques

is the oldest of the nonabsorbable sutures It is not discussed here

as cotton sutures are no longer used in general medical practice

Silk is a polyfilament suture that has limited use in the practice of

Emergency Medicine There are several advantages to silk suture

material Its pliability makes it very easy to handle It holds knots

better than other types of suture However, as with all natural and/

or polyfilament sutures, it has a greater tendency to cause wound

infections The polyfilament braids can provide a place for bacteria

to lodge Silk suture may actually protect the bacteria from attack

by the body’s defenses if the wound becomes infected The primary

use of silk sutures is for the repair of lip, oral cavity, and tongue

lacerations

Synthetic nonabsorbable sutures are available in monofilament

and polyfilament forms Commonly used synthetic sutures include

nylon, polypropylene, polybutester, and Dacron Nylon,

polypropyl-ene, and polybutester are monofilament synthetic sutures Dacron

is a polyfilament synthetic suture The synthetic nonabsorbable

sutures have several advantages over the natural nonabsorbable

sutures They are less reactive in tissues, generally stronger than the

natural sutures, and retain their tensile strength over many years

Nylon (Ethilon, Dermalon) is the most common nonabsorbable

suture used in the Emergency Department It is a monofilament

suture, it is inert, and it does not tend to harbor bacteria It is

pri-marily used for skin closure Nylon has good tensile strength and

minimal tissue reactivity However, nylon is difficult to handle and

difficult to tie It requires more knots to achieve good knot security

than other types of suture This is primarily due to the tendency of the

suture to return to its packaged shape This tendency is also known

as “memory.” Because the knot can unravel or slip, it is important to

place at least four or five knots when using nylon suture

Polypropylene and polybutester are less commonly used

syn-thetic nonabsorbable sutures Polypropylene (Prolene) is stronger

but more difficult to work with than nylon because it has greater

memory Polybutester (Novafil) is a newer suture in this category

It is stronger than the other monofilaments and does not have

sig-nificant memory Therefore, it is easier to work with than the other

monofilament synthetic sutures

• Iris scissors, straight 4 in and curved 4 in

• Suture scissors, 6 in

• Forceps, toothed Adson

• Metzenbaum scissors, curved 6 in

• Hemostats, straight 6 in., and curved mosquitoes

• Suture material

• Skin closure tapes

• Benzoin solution, swabs, or spray

• Gum mastic (e.g., Mastisol)

Much of the above equipment can be purchased in

single-use, sterile, and disposable suture kits from several commercial

manufacturers (Figure 93-1A) These kits tend to be expensive and

occasionally have a limited amount of equipment Many hospitals

package and sterilize their own wound repair kits (Figure 93-1B)

This decreases the cost, as the equipment can be repeatedly ized and reused It also allows the kits to contain a wide variety of instruments for multiple situations (e.g., minor laceration, large lac-eration, and plastics closure)

steril-Needle drivers come in a variety of sizes A 4.5 in needle driver can be used comfortably with most types of needles A 6 in needle driver may be required if large needles are used to close a wound Hold the needle driver with the fingertips to provide greater flex-ibility The fingers can also be placed through the finger holes, but this is not as efficient when closing a wound Grasp the needle one-third of the way from the swag (distal) end with the tip of the needle driver

The skin must be grasped and manipulated during wound repair

to allow for proper suture placement Forceps are most commonly

used to grasp and manipulate the skin Smooth (nontoothed)

for-ceps should never be used to grasp skin They require the

applica-tion of a large amount of force to grasp the tissue This can crush tissue very easily An Adson forceps is the forceps of choice It has fine teeth that grasp tissue securely with minimal force

A

B

FIGURE 93-1. The equipment required for basic wound closure techniques

A. The contents of a disposable and commercially available wound closure kit

B. A hospital packaged kit with reusable instruments

the wound edge and grasps the tissue from the undersurface It

pro-duces a small puncture wound in the subcutaneous tissues and does

not penetrate the skin surface Skin hooks are preferable to forceps,

as they do not crush tissues A skin hook is awkward to use at first

With proper instruction and experience, the Emergency Physician

will most certainly prefer a skin hook to forceps

Several types of scissors are required for proper wound closure

Iris scissors have sharp, delicate tips for making precise cuts in

tis-sue They should not be used to cut suture material, as this rapidly

dulls and nicks the blades Suture scissors have one blunt tip and one

pointed tip Both blades of the suture scissors are sharp Suture

scis-sors are used to cut adhesive tape, gauze, rubber drains, and suture

material Metzenbaum scissors should be used to debride heavy

tis-sue, bluntly dissect tistis-sue, and undermine tissue

Hemostats are used to clamp small vessels that are bleeding,

to explore a wound, and to grasp fascia Hemostats are available

in a variety of sizes and styles A straight 6 in hemostat is used

for most purposes during wound repair A curved 5 in mosquito

hemostat can be used for small wounds or delicate tissues Do not

use a hemostat to grasp or drive the suture needle The suture

needle can bend, rotate, and break as it enters tissue if driven by a

hemostat

Three different scalpel blades should be available when a wound

is being repaired A #11 blade is used to make stab incisions It is

often used for the incision and drainage of abscesses,

cricothyroid-otomies, and the removal of small or tight sutures A #10 blade is

used to make straight cuts in the skin and debride wound edges It

is rarely used in laceration repair A #15 blade is small and curved

to allow precise incisions It is used for excising foreign bodies and

wound debridement

SUTURE TECHNIQUES

Proper wound closure requires an understanding of certain basic

principles The needle should enter and exit the skin at a 90°

angle and perpendicular to the wound edges By doing so, when

the suture loop is closed, the wound edges will be everted Sutures

should be placed as close to the wound edge as possible (2 to

3 mm) in order to avoid excessive tension on the wound More

force will be required to close the wound if the sutures are placed too

far from the wound edge Edema develops in a wound in the first

48 hours after closure Sutures placed too far from the wound edge

can result in large scars when the edema subsides

The layers of the wound should be matched evenly and each

layer should be closed separately If a wound involves the deeper

layers of skin, fascia should be matched to fascia, dermis should be

matched to dermis, and epidermis should be matched to epidermis

The proper matching of layers avoids an uneven closure, helps to

prevent an unnecessarily large scar, and eliminates dead space.

The epidermal edges of the wound must be everted to allow

for proper healing Scars contract with time They will flatten and

slightly elevated The wound edges will contract into a “pit” below the plane of the skin, will be more noticeable, and the final result will

be less appealing cosmetically if the wound edges are not everted

Handle the tissues gently and do not squeeze or twist them too tightly with the instruments This helps to avoid strangulation,

which can result in tissue necrosis The sutures should be placed

carefully and with the proper amount of tension to help promote healing Sutures should be snug Attempts should be made to avoid

excessive tension on the wound edges in order to prevent wound dehiscence The use of the smallest suture size necessary to approxi-mate the wound edges will reduce tissue damage and minimize scar-

ring Table 93-3 lists the appropriate suture types and sizes for each

body region

If there will be a temporary delay in the closure of a laceration because of other injuries that may be life-threatening or of greater importance, cover the wound with a saline-soaked gauze in order to keep the tissues from drying

PRINCIPLE OF HALVING

Large wounds gape open and are difficult to approximate Closure

of the deeper layers will often bring the skin edges into apposition If not, the principle of halving may be used to approximate the wound

(Figure 93-2) Identify the midpoint of the laceration Place the first suture at the midpoint (Figure 93-2A) This stitch is known as the

central suture The next sutures are placed in halves on each side

of the central suture (Figures 93-2B & C) Continue the process by

placing sutures halfway between previous sutures until the wound is approximated This results in even closure of the wound edge This principle can be used for closure of both the deep layers and the skin

TWO-HANDED SQUARE KNOT

This is the easiest and most reliable method of tying most suture materials It involves the classic “right-over-left and left-over-right”

FIGURE 93-2. The principle of halving A. The first suture is placed in the middle

of the laceration B. The second suture is placed halfway between the first suture and the upper end of the laceration C. The third suture is placed halfway between the first suture and the lower end of the laceration

CHAPTER 93: Basic Wound Closure Techniques

tie (Figure 93-3) The incorrect “right-over-left and right-over-left”

is a granny knot, which will slip if it is tied in this manner This

square knot is quick and simple to perform However, it does take

significant practice to master this technique

Place a suture through the skin on both sides of the laceration

(Figure 93-3A) Pull the suture through the wound until half is

on each side of the laceration Grasp the right half of the suture

with the right thumb and index finger (Figure 93-3A) Grasp

FIGURE 93-3. The two-handed square knot

the left half of the suture with the left third through fifth fingers

and the suture draped over the thumb (Figure 93-3A) Cross

the right hand toward the left hand (Figure 93-3B) Continue to

move the right hand until the suture is between the left thumb

and index finger (Figure 93-3C) Close the left thumb and

index finger to entrap the right half of the suture in the pads

of the fingers (Figure 93-3D) Pull the right hand down and to

the left so that the two halves of the suture form an X over the

left thumb (Figure 93-3E) Flex the left wrist to slide the X off

the left thumb and onto the left index finger (Figure 93-3F)

Lift the left thumb backward and upward so that the X overlies

the tip of the left index finger (Figure 93-3G) Reapply the left

thumb over the left index finger to entrap the X (Figure 93-3H)

Extend the left wrist to push the left thumb and the X through

the loop (Figure 93-3I) Release the suture held with the right

hand (Figure 93-3J) Regrasp the suture with the right hand after

it passes through the loop (Figure 93-3K) Pull the suture

com-pletely through the loop with the right hand Simultaneously move the left hand toward the left and move the right hand toward the

right (Figure 93-3L) Cross the hands so that the left hand goes

toward the right side and the right hand goes toward the left side

(Figure 93-3M) Continue to pull both sides of the suture until the knot lies flat and the skin edges are apposed (Figure 93-3M)

The first half of the knot is now complete

Make the second half of the knot to complete the square knot

Raise both hands upward and uncross them until an X is formed

over the left index finger (Figure 93-3N) Close the left thumb

and index finger to entrap the suture being held with the right

hand (Figure 93-3O) Extend the left wrist to push the left thumb through the loop (Figure 93-3P) Lift the left index finger upward

FIGURE 93-3. (continued )

CHAPTER 93: Basic Wound Closure Techniques

(Figure 93-3Q) Move the right hand away from you until the suture

it holds drapes over the left thumb (Figure 93-3R) Reapply the left

index finger onto the thumb to entrap the suture held with the right

hand (Figure 93-3S) Release the suture held with the right hand

(Figure 93-3T) Flex the left wrist to push the left index finger and

suture through the loop (Figure 93-3U) Regrasp the free suture

with the right hand after it passes through the loop (Figure 93-3V)

Move the right hand upward and to the right to complete the

sec-ond half of the knot overlying the left index finger (Figure 93-3W)

Simultaneously move the left hand toward the left and move the

right hand toward the right (Figure 93-3X) Continue to pull both

halves of the suture until both halves of the knot come into contact

(Figure 93-3Y) Pull both halves of the suture to secure the knot

The square knot is now complete Continue the process to add

addi-tional knots onto the suture Cut off excess suture on both sides of

the knots

SURGEON’S KNOT

The physician may choose to use a surgeon’s knot instead of a

square knot (Figure 93-4) The square knot has one loop in the first

throw and one loop in the second throw (Figure 93-4A) The

sur-geon’s knot has two loops in the first throw and one loop in the

second throw (Figure 93-4B) The only difference between these

two knots is the two loops in the first throw The second throw and

subsequent knots are exactly the same for both knots The

advan-tage of the surgeon’s knot is that the two loops are more secure and

stay in place while the second throw is being tied The choice to use

either knot is dependent on the experience and the training of the

physician

INSTRUMENT TIE

The instrument tie is the most efficient method to complete a

sim-ple interrupted suture (Figure 93-5) It is the tie that is most

com-monly used in the Emergency Department An instrument tie is

often quicker, requires less dexterity, and is easier to perform than

the two-handed method It may be used with the square knot or the

surgeon’s knot

Place a suture through the skin on both sides of the laceration

(Figure 93-5A) Carefully grasp the needle in its midportion and pull it through the laceration (Figure 93-5B) Continue to pull

the needle until approximately 1 to 2 cm of suture on the tail end

remains outside the laceration (Figure 93-5C) A large amount of

suture will be wasted if the tail is left too long, as it will be later cut off and discarded On first learning the instrument tie, it may be best

to leave a tail of 3 to 4 cm until one is proficient with this technique.Place the needle driver over the laceration but not touching it

(Figure 93-5C) Loosely loop the needle end of the suture over (Figure 93-5D) and around (Figure 93-5E) the needle driver

Loosely loop the needle end of the suture over and around the

nee-dle driver a second time (Figures 93-5F & G) This will eventually

result in the first half of a surgeon’s knot Looping the suture once around the needle driver will result in a simple square knot Move the tip of the needle driver toward the tail of the suture without let-

ting the loops fall off the needle driver (Figure 93-5H) Grasp the tail of the suture with the needle driver (Figure 93-5I) Pull the tail

of the suture through the loop (Figure 93-5J) Pull the tail pletely through the loops (Figure 93-5K) Simultaneously move the

com-left hand toward the right and the right hand/needle driver toward

the left (Figure 93-5L) Continue to pull both sides of the suture

until the hands are opposite each other, the knot lies flat, and the

skin edges are apposed (Figure 93-5M) The first half of the knot is

needle driver Move the tip of the needle driver toward the tail

of the suture without letting the loop fall off the needle driver

(Figure 93-5Q) Grasp the tail of the suture with the needle driver (Figure 93-5R) Pull the tail of the suture completely through the loop (Figure 93-5S) Simultaneously move the left hand

toward the left and the right hand/needle driver toward the right

(Figure 93-5T) Continue to pull both sides of the suture until

both halves of the knot come into contact Pull both sides of the suture to secure the knot The knot is now complete Continue

FIGURE 93-4. The square knot (A) versus the surgeon’s knot (B) The first throw of the square knot has one loop (A), while that

of the surgeon’s knot has two loops (B) The second throw of both knots is a simple loop

FIGURE 93-5. The instrument tie.

CHAPTER 93: Basic Wound Closure Techniques

this process three or four more times, each in alternative

direc-tions, to place additional knots Cut off the excess suture on both

sides of the knots

SIMPLE INTERRUPTED STITCH

The simple interrupted stitch is the most commonly used suture

technique and is useful in many situations (Figure 93-6) One major

advantage is that each stitch is placed independent of the

oth-ers Therefore tension on each stitch can be adjusted separately

Additionally, the entire repair is not compromised if one suture

should happen to come out The other sutures will remain in place

to help assure proper wound healing The needle must enter and

exit the skin at a 90° angle to help evert the wound edges Take

equal volumes of skin from each side of the area being sutured

Drive the needle equidistantly into and out of the wound edges

and incorporate the base of the wound.

Insert the needle at a 90° angle to the skin (Figure 93-6A) Drive the needle through the tissue until the tip exits the skin

(Figure 93-6B) Grasp the needle behind the tip and pull it through the wound (Figure 93-6C) The suture should enter

and exit the skin equidistant from the wound edges (Figure 93-6D) If it does not, pull the suture out and repeat the stitch

so that it is equidistant from the wound edges Make a loop in

the suture with the two-handed tie or the instrument tie Pull the suture to appose the wound edges and cinch down the knot

(Figure 93-6E) The tissue at the base of the wound will come

into apposition before the tissue at the skin surface and thus evert the wound edge Complete the knot to one side of the laceration

(Figure 93-6F) Just prior to cinching the second throw onto

the first, pull the ends so that the knot is not directly over the wound and the edges of the wound remain in apposition Apply additional sutures equidistant from each other until the wound is

closed (Figure 93-6G).

FIGURE 93-5. (continued )

OPEN-LOOP SIMPLE INTERRUPTED STITCH

The open-loop simple interrupted stitch is a variation of the

sim-ple interrupted stitch (Figure 93-7) The same basic technique is

used except that the knot is tied differently The tie involves laying

down the first knot with an instrument tie However, the second

knot placed on the suture is not pulled all the way down Pull the

second knot only until it is just above the first knot (Figure 93-7A)

In other words, the second knot is loosely tied, leaving a loop

between the first and second knots Place a third knot as a single

knot square to the second knot (Figure 93-7B) Cinch the third

knot tightly to the second knot This “locks” the third knot onto the second knot

This knot is indicated when there is the possibility of edema ing at the suture site If edema forms, the first knot will have room

form-to open as it slides form-toward the second knot This stitch avoids sive tension on the wound and prevents the suture from cutting into the skin This stitch facilitates suture removal when numerous small stitches are placed next to a wound edge Cutting the open loop unravels the knot and allows for easy removal of the suture This stitch should not be used in areas where the skin is thin or if there

exces-is little subcutaneous texces-issue (e.g., dorsal hand and foot) In these areas, the wound edges often become unopposed while the knot is being secured

INTERLOCKING SLIP KNOT

This technique can be used in patients who will be traveling, ing, or otherwise away from their primary source of medical care

camp-(Figure 93-8) The patient can easily remove the sutures without

having to find an unfamiliar or foreign healthcare provider for tine suture removal The interlocking slip knot can be removed by hand without the use of a scissors or a scalpel This can be useful for suture removal in pediatric patients, who may find it hard to sit still for suture removal

rou-Place a suture through the skin on both sides of the laceration

(Figure 93-8A) Loop the tail end of the suture around the tip

of the needle driver (Figure 93-8A) Grasp the needle end of the suture with the needle driver (Figure 93-8B) Pull the needle end

of the suture through the loop while simultaneously pulling on the

tail end of the suture with a second needle driver (Figure 93-8C)

Continue to pull both suture halves in opposite directions until a knot is formed against the skin and the wound edges are apposed

(Figure 93-8D) Release the needle driver holding the now formed

loop Insert the needle driver through the loop and grasp the tail

end of the suture (Figure 93-8E) Grasp the needle end of the suture with the second needle driver (Figure 93-8E) Pull the

FIGURE 93-6. The simple interrupted stitch

FIGURE 93-7. The open-loop simple interrupted stitch

CHAPTER 93: Basic Wound Closure Techniques

needle drivers in opposite directions to lock and secure the knot

(Figure 93-8F) The knot is now complete (Figure 93-8G) To

remove the stitch, pull the free end of the suture to unlock the knot

Continue to pull the suture until it is free from the skin This stitch

can easily become loose or open before the wound is healed Thus,

it is recommended to cover the wound and sutures with skin

clo-sure tape (e.g., Steri-Strips)

CONTINUOUS OVER-AND-OVER

STITCH (SIMPLE RUNNING STITCH)

Continuous (simple running) sutures minimize the time required

for laceration repair Stitches can be placed very quickly, since

each individual stitch does not have to be tied This stitch provides

strength and applies equal tension on all sutures in the repair This

stitch can be used to achieve hemostasis The wound must be long

and straight Simple running stitches can effectively be used in

par-tial-thickness lacerations and wounds under minimal tension

However, there are several disadvantages to this stitch It can

be associated with significant epithelialization of the suture track

This is especially true if the suture is not removed early and

remains for a prolonged period of time Inclusion cysts may form

within a few weeks after removal of the sutures Simple running

stitches should not be used on any wound under tension If one

suture breaks, the entire wound may open This stitch should not

be used when closing a wound where there is a risk of

subse-quent hematoma formation Hematoma formation would require

the removal of all of the sutures in order to drain the hematoma

Although this suture is not commonly used in the Emergency

Department, it can be very helpful for closing bleeding scalp

wounds, as the injury will be covered with hair and cosmesis is a

secondary concern

Place the initial stitch as a simple interrupted stitch (Figure

93-9A) Do not cut the suture after the knots are securely tied

Place a second stitch 3 to 5 mm from the first stitch as if placing

another simple interrupted stitch (Figures 93-9B & C) Place a third stitch 3 to 5 mm from the second stitch (Figures 93-9D &

E) Continue to place additional stitches until the end of the

lacera-tion is reached Use care to ensure that the sutures are all lined

up with each other and equidistant from the laceration Do

not pull the last throw taut against the skin (Figure 93-9F) The

loop will act as the tail end of the suture for knot tying Loop the needle end of the suture twice around the tip of the needle driver

(Figure 93-9G) Grasp the last throw with the tips of the needle driver (Figure 93-9G) Pull the last throw through the loops until the knot is against the skin (Figure 93-9H) Perform three to five

more instrument ties to secure the knot Cut off the excess suture

closure locks each stitch after it is placed (Figure 93-10) It provides

a secure apposition of the wound edges while each subsequent stitch

is placed The main disadvantage of this stitch is the time it takes compared to a continuous over-and-over stitch

Place the initial stitch as a simple interrupted stitch (Figure

93-10A) Do not cut the suture after the knots are securely tied

Loop the tail end of the suture over the nondominant fifth

fin-ger (Figure 93-10B) Apply slight tension on the tail end of the suture while placing the second stitch (Figures 93-10C & D)

FIGURE 93-8. The interlocking slip knot

As the needle exits the skin, move the nondominant hand to bring

the suture loop down and over the needle (Figure 93-10E) Grasp

the front of the needle with the needle driver Simultaneously pull

the needle and suture through the laceration while releasing the

loop from the fifth finger (Figure 93-10F) Repeat this procedure

until the laceration is closed (Figure 93-10G) Do not pull the last

throw taut against the skin The loop will act as the tail end of

the suture for knot tying Loop the needle end of the suture twice

around the tip of the needle driver (Figure 93-10H) Grasp the last

throw with the tips of the needle driver Pull the last throw through

the loops until the knot is against the skin (Figure 93-10I) Perform

three to five more instrument ties to secure the knot Cut off the

excess suture (Figure 93-10J).

VERTICAL MATTRESS STITCH

The vertical mattress stitch is a double stitch that provides for

excel-lent wound eversion (Figure 93-11) It optimizes wound closure of

lacerations under tension This stitch is useful in areas where the skin is very lax, such as the elbow and the dorsum of the hand This

FIGURE 93-9. The continuous over-and-over or simple running stitch

CHAPTER 93: Basic Wound Closure Techniques

FIGURE 93-10. The continuous single-locked or running-locked stitch

stitch provides for both superficial as well as deep closure of

lacera-tions This stitch is contraindicated in lacerations involving the

volar aspect of the hands and feet or the face, as it requires the

blind placement of a deep suture The main disadvantage of

the vertical mattress closure is the time it takes to place it

Place the first throw much like a simple interrupted stitch with

a few noted differences The needle should enter and exit the

skin 1.0 to 1.5 cm from the wound edge The needle should

tra-verse the base of the wound and grasp a large amount of tissue

(Figures 93-11A & B) Reverse the needle The second throw

should enter and exit the skin approximately 2 to 3 mm from the

wound edge (Figures 93-11C & D) The first and second throws

must be directly over each other and parallel Tie the suture to

approximate the wound edges (Figure 93-11E) The first throw will

close the wound base and relieve the tension at the skin surface The

second throw approximates and everts the skin edges

The newer version of the classic vertical mattress is referred to as

the “shorthand” vertical mattress stitch (Figure 93-12) It provides

wound eversion in half the time as the traditional method Place the first throw close to the lacerated wound edge to approximate

the skin edges (Figures 93-12A & B) Grasp and pull the suture to elevate the wound edges (Figure 93-12C) This allows the needle to

more easily take a large bite of tissue on the second throw Place the

second throw 1.0 to 1.5 cm from the wound edge (Figures 93-12C

& D) Release the suture Tie the suture to approximate the wound

edges and evert the skin surface (Figure 93-12E) The final

prod-uct looks exactly the same as the traditional vertical mattress suture

(Figure 93-12F).

LOCKED VERTICAL MATTRESS STITCH

The locked vertical mattress stitch is useful in areas that are widely

separated and where deep sutures must be avoided (Figure 93-13)

This stitch helps to reduce the amount of tension needed to close

a wound It helps to avoid the pain and scarring that can result

if too much tension is applied to a laceration It does not put an

FIGURE 93-12. The “shortcut” vertical mattress stitch An alternative method to place the vertical mattress stitch

CHAPTER 93: Basic Wound Closure Techniques

excessive amount of tension on the deep throw, as does the vertical

mattress stitch

This is a modification of the vertical mattress stitch (Figures

93-11 & 93-12) Place the first two throws as if placing a vertical

mattress stitch (Figure 93-13A) Leave the suture lax with a loop

above the wound surface Pass the needle end of the suture through

the open loop (Figure 93-13B) This step will form the locked

por-tion of the stitch Pull the needle end of the suture taut to appose

the wound edges (Figure 93-13C) Tie and secure the suture in the

standard manner

HORIZONTAL MATTRESS STITCH

The horizontal mattress stitch is placed along the axis of the wound

and helps to eliminate tension on the wound (Figure 93-14) It is a

good closure technique for wounds with relatively poor circulation

to the wound edges because, theoretically, no suture is placed through the wound edges This helps to avoid tension on the wound edges from the suture and subsequent local necrosis This stitch

is placed more rapidly than the vertical mattress stitch It requires fewer stitches to close a wound with horizontal rather than verti-cal mattress stitches The throws are side by side rather than on top

of each other, as with the vertical mattress, and each stitch closes more tissue This closure may be used on the volar surfaces of the hands and fingers, as these delicate skin areas may swell and be cut

by simple interrupted sutures The main disadvantage of the zontal mattress stitch is that it takes more experience to properly place this stitch to achieve wound eversion than with the vertical mattress stitch

hori-Place the first throw much like a simple interrupted stitch with

a few noted differences The needle should enter and exit the skin 0.5 to 1.0 cm from the wound edge The needle should traverse the

FIGURE 93-13. The locked vertical mattress stitch

FIGURE 93-14. The horizontal mattress stitch

make a second throw 0.5 cm from the first (Figure 93-14C) The

needle must enter and exit the skin and the wound edges so that

the first and second throws are parallel to each other (Figures

93-14C & D) Pull the free ends of the suture taut to appose and

evert the wound edges (Figures 93-14E & F) Tie and secure the

suture in the standard manner

HALF-BURIED HORIZONTAL MATTRESS STITCH

This is the stitch of choice to close complex wounds with

mul-tiple flaps in a single-layer closure This stitch is ideal to close

stel-late, Y-shaped, V-shaped, and T-shaped lacerations The half-buried

horizontal mattress stitch allows a tissue flap to be reapproximated

without tension on the edges of the flap The vascular supply to a

flap is derived from its base The flaps sometimes have a limited

or poor vascular supply This stitch may be used to approximate a

flap-like laceration in which the corner has limited vascularity and/

or viability

The key to this stitch is that the needle and suture pass through

the dermis of the flap and not the epidermis (Figure 93-15) Begin

by placing the first stitch percutaneously through the skin adjacent

to the tip of the flap (Figure 93-15A) Advance the needle through

the dermal layer of the flap, the dermal layer of the skin adjacent

to the tip of the flap, and out the skin adjacent to the tip of the flap

opposite to where the stitch began (Figure 93-15A) The needle

must traverse the dermis of the flap and adjacent tissue at the

same level of the dermis to properly approximate the wound

edges Gently pull on the free ends of the suture to approximate the

flap against the adjacent skin edges Tie and secure the suture in the

usual manner Secure the edges of the flap with half-buried

horizon-tal mattress stitches (Figure 93-15A), simple interrupted stitches,

vertical mattress stitches, or horizontal mattress stitches

Stellate lacerations are often seen in the Emergency Department

They occur due to bursting of the skin from crush injuries These

lacerations are often encountered on the extremities, forehead, and

scalp Begin by inserting the needle through the skin of the largest

flap Advance the needle so that its tip exits the dermis Continue

to advance the needle through the dermis of each flap The

half-buried horizontal mattress stitch should encompass the tips of all

the flaps (Figure 93-15B) The remainder of the procedure is as

described above

CONTINUOUS (RUNNING)

HORIZONTAL MATTRESS STITCH

The running horizontal mattress stitch is indicated in areas of the

body where there is loose skin that tends to overlap or invert, such

as the skin of the upper eyelids or the dorsum of the hand This

stitch can also be used as the surface closure in a multiple-layer

clo-sure if there is a tendency for wound inversion Like the traditional

horizontal mattress stitch, it provides good apposition and can be

indicated in wounds under tension if the goal of wound closure is optimal cosmesis

This stitch begins with a simple interrupted stitch at one end of a

laceration (Figure 93-16) The needle is then run along the length

of the wound while placing horizontal mattress stitches The ence between this and the standard horizontal mattress stitch is that the suture is not tied and cut after each individual stitch Rather, the stitch is continued (running) the length of the laceration At the end

differ-of the laceration, the stitch is tied and secured in the same way as the

simple running stitch (Figure 93-9).

CONTINUOUS SUBCUTICULAR STITCH

This closure is ideal for lacerations of the face and neck It provides excellent cosmesis, leaves no suture marks on the skin, and causes minimal scarring It requires more time and skill to place than other types of stitches It may be performed for the temporary pull-out

(Figure 93-17) or permanent placement (Figure 93-18) of

subcuta-neous sutures Polypropylene or nylon sutures must be used for this stitch Polypropylene is preferred as it is stiffer, stronger, and easier

to remove than nylon

The use of this stitch is limited to lacerations that are clean, straight, have sharp edges, and are less than 6 cm in length It may

be extremely difficult to remove the suture material for the pull-out technique if the laceration is greater than 6 cm in length The lacera-tion can be longer if the permanent placement of absorbable sutures

is being used The dermis and subcutaneous tissue must be apposed before proceeding with this stitch If necessary, apply buried absorb-

able sutures to appose the dermis before applying this stitch The

superficial wound surface must be tension-free, as this stitch is for cosmesis and not strength The wound may require undermin-

ing to release the tension from the wound edges Refer to Chapter 92 for details regarding wound undermining

The pull-out technique allows the subcuticular stitch to be

removed after the laceration heals (Figure 93-17) The

subcuticu-lar suture should enter the intact skin 3 to 4 mm from one end of

FIGURE 93-16. The continuous or running horizontal mattress stitch

CHAPTER 93: Basic Wound Closure Techniques

the laceration and burrow through the dermal-epidermal

junc-tion to emerge through the skin at the other end of the lacerajunc-tion

(Figure 93-17A) The suture will continuously pass through the

subcuticular layer on alternate sides of the laceration The point

of entry of each stitch should be directly across from or slightly

behind the exit point of the previous stitch It is very important

to keep the needle at the same level of depth throughout the

wound The tension on the suture should be adjusted to ensure

that there is no puckering of the skin Tape the free suture at

both ends of the laceration to the skin (Figure 93-17B) Place

wound tape (e.g., Steri-strips) across the laceration to help

main-tain the apposition of the epidermis This stitch is easily removed

Remove the wound tape and slowly pull one end of the suture

with a needle driver

As an alternative, the continuous stitch may be placed using absorbable suture material to provide longer-lasting strength to

the wound (Figure 93-18) Suture material of choice includes

Dexon, PDS, or Vicryl The same indications, preparation, and stitch are used as with the pull-out technique The only difference

is in the starting and ending stitch Place the first stitch into the

dermis, just inside the laceration edge, as a buried knot (Figures

93-18A to C) Place the continuous suture until the opposite end

of the laceration is reached (Figure 93-18D) The final throw should be left lax with a trailing loop of suture (Figure 93-18E)

The loop should be used as the “tail end” to perform an

instru-ment tie (Figure 93-18F) Tie three or four knots in the suture

Lift the free ends of the suture and cut them just above the knot Apply wound tape across the laceration to help maintain the apposition of the wound

BURIED (SUBCUTANEOUS) KNOT STITCH

This stitch helps to decrease potential dead space underneath a eration and gives tensile support for up to 4 to 6 weeks, while the wound is still weak The loop is constructed so that the knot lies at

lac-the bottom of lac-the wound base (Figure 93-19) This helps to keep lac-the

skin surface smooth and flat The buried knot stitch is most useful

in closing subcutaneous tissue just under the skin surface

This stitch requires practice to master Insert the needle into

one side of the base of the wound (Figure 93-19A) Drive the

nee-dle from deep to superficial and exiting at the dermal-epidermal

junction (Figure 93-19A) Insert the needle through the

dermal-epidermal junction on the opposite side of the wound and drive

it through the base of the wound (Figure 93-19B) The  suture

FIGURE 93-17. The continuous subcuticular pull-out stitch

FIGURE 93-18. The continuous subcuticular permanent stitch

should exit the base of the wound across from and level with

the entrance site of the first throw Pull both free ends of the

suture up and out through the laceration (Figure 93-19C) Tie

a knot in the suture (Figure 93-19D) Pull both free ends of the

suture to lower the knot to the base of the wound and appose

the tissue (Figure 93-19E) Tie two additional knots to secure the

suture Cut off any excess suture

REINFORCING (RETENTION) SUTURES

FOR WOUNDS UNDER TENSION

Reinforcing or retention sutures are particularly useful for wounds

in which the edges are widely separated or where the skin is too

atrophic to approximate without the suture cutting through the skin

The reinforcing sutures help to decrease the tension on the wound

by providing more support for the wound edges Reinforcing sutures

can be placed using sterile buttons or rubber tubing (Figure 93-20)

Heavy sizes of nonabsorbable suture materials are used for

reinforc-ing sutures This is not for strength but to avoid the finer suture

from cutting through the tissue

Ideally, a double-swaged (needle) suture should be used to place

suture from the inside of the wound toward the outside skin to

avoid pulling potentially contaminated epithelial cells through the wound The stitch is placed like the horizontal mattress stitch and sterile buttons or rubber tubing is used to achieve approximation

to a point where the wound edges can be closed without

signifi-cant tension (Figures 93-20A & B) Do not attempt to appose the

wound edges when using retention sutures Appose the remaining

skin edges with simple interrupted, vertical mattress, or horizontal mattress stitches The reinforcing sutures should remain in place after the skin sutures are removed The reinforcing sutures should

be removed after the wound has healed and gained significant sile strength

ten-SUTURE REMOVAL TECHNIQUESRemove sutures as soon as possible to avoid the possibility of infection and prevent the formation of suture marks However,

if they are removed too early, wound dehiscence may occur Simple interrupted sutures should be cut at the end away from the knot and

then pulled out (Figure 93-21A) This helps to prevent the outer

contaminated portion of the suture from passing back through the wound In order to remove a running simple or running-locked stitch, grasp the knot at the end of the closure and cut each loop

FIGURE 93-19. The buried (subcutaneous) knot stitch

FIGURE 93-20. Reinforcing sutures for wounds under tension Sterile buttons (A) or pieces of sterile rubber tubing (B) can be used to secure the suture and prevent

injury to the soft tissues

CHAPTER 93: Basic Wound Closure Techniques

(Figures 93-21B & C) Pull out each individual suture piece

Vertical and horizontal mattress sutures can be removed in much

the same way as the simple interrupted stitch (Figures 93-21D & E).

TISSUE ADHESIVE CLOSURE (CYANOACRYLATES)

Tissue adhesives (skin glues) are best used to close low-tension,

small, straight-edged, and superficial wounds (Figure 93-22) They

should not be used for lacerations that are bleeding, lacerations

over joints, or lacerations under tension There must be adequate

hemostasis and the tissue must be as dry as possible The major

advantage to the use of tissue adhesives is speed Wounds can be

repaired quickly and without anesthesia Other contraindications to

this type of closure are angled or beveled wounds Petroleum-based

ointments or similar products will dissolve the tissue adhesive and

should be avoided on this type of closure Refer to Chapter 94 for a

more complete discussion of tissue adhesives

Tissue adhesives come in a variety of forms and applicator tips

(Figure 93-22A) Approximate the wound edges with forceps

Commercially available, disposable, single-patient-use tissue ceps can be used (Bionix Development Corp., Toledo, OH) These are specifically designed to approximate the wound edges prior to

for-using cyanoacrylates (Figure 93-22B) Apply the adhesive in two or three layers along the wound edge (Figure 93-22C) The adhesive may also be applied in spots over the laceration (Figure 93-22D) or across the laceration, like wound tape (Figure 93-22E) Droplets or

lines should be placed 0.5 cm from each other Support the wound for 30 to 60 seconds while the adhesive dries

SKIN CLOSURE TAPES

Skin closure tapes (e.g., Steri-Strips) are used to close very low tension wounds that are tidy and small They can be used as the

primary closure technique for superficial wounds (Figure 93-23)

or they can provide reinforcement after sutures have been placed

FIGURE 93-21. Suture removal techniques A. Simple interrupted stitch B Simple running stitch C. Running-locked stitch D. Vertical mattress stitch E. Horizontal mattress stitch

(Figure 93-24) Skin tapes are easy to use and can be placed

rel-atively quickly They do not leave suture marks and have no skin

reactivity

Skin closure tapes should not be used in wounds where the edges

are widely separated or on parts of the body where there is

move-ment or moisture This technique does not work well on irregularly

shaped wounds or wounds where there will be a propensity for

swelling of the wound edges Care should be taken in using these

tapes in a child If they are not secured properly, the child may

remove them prematurely

After the initial cleansing of the skin, clean the skin surface

with acetone or alcohol to remove any surface oils Allow the skin

to dry Apply benzoin solution, or gum mastic (e.g., Mastisol),

to the skin on both sides of the wound (Figure 93-23A) Allow

60 to 90 seconds for the liquid benzoin to dry and become tacky

Cut the skin closure tapes to the proper length (Figure 93-23B)

Gently tear the end-tab off the back of the card to prevent the

strips from deforming (Figure 93-23C) Remove a strip from the

card (Figure 93-23D) Firmly secure the tape to one side of the

wound (Figure 93-23E) Use the nondominant hand to appose the

wound edges as the tape is brought over and secured to the skin

on the opposite wound edge (Figure 93-23F) Place additional

tapes at 2 to 3 mm intervals until the wound edges are apposed

(Figures 93-23G & H) Place pieces of tape across the tape edges

to prevent premature removal and skin blistering from the tape

ends (Figure 93-23I).

Skin closure tapes may be placed over a sutured laceration

(Figure 93-24) The tapes will provide additional support to the

wound edge and help to prevent dehiscence This technique is cially useful in areas of cosmetic concern, such as the face

espe-The skin closure tapes should remain in place for at least as long

as the sutures They must be kept dry to prevent them from coming off prematurely and the wound from dehiscing The wound should

be observed daily for signs of infection

Skin closure tapes may be placed across a wound when sutures or staples are removed The tapes will maintain the apposition of the epidermis as the wound matures Apply benzoin solution to the skin before removing the sutures or staples Remove several sutures or staples and apply the skin closure tapes Continue this process until all the sutures or staples have been removed and the wound is cov-ered with skin closure tapes Alternatively, remove all of the sutures

or staples and then apply the skin closure tapes

Suturing lacerations in a thin-skinned individual is often cult The skin frequently tears as the wound is approximated and the suture is tied The use of skin closure tapes can facilitate wound closure, strengthening the skin edges, and allow for a more secure wound closure Clean, prep, and anesthetize the skin Apply benzoin solution to the skin adjacent to and on both sides of the laceration

diffi-Allow the benzoin to sit and become tacky Apply skin closure tapes over the benzoin on both sides of the laceration Suture the lacera-tion, ensuring that the needle enters the skin on one side of the lac-eration and exits the skin on the other side of the laceration through

A

B

FIGURE 93-22. Laceration repair with cyanoacrylate tissue adhesive A. Several examples of tissue adhesive From left to right: Dermabond ProPen, SurgiSeal, Indermil

Loctite, Liquiband Flow Control B. Commercially available wound forceps (Bionix Development Corp., Toledo, OH) C. Tissue adhesive applied continuously over the

laceration D. Tissue adhesive applied in spots over the laceration E. Tissue adhesive applied across the laceration

CHAPTER 93: Basic Wound Closure Techniques

FIGURE 93-23. Skin closure tapes to primarily close a laceration

FIGURE 93-24. Skin closure tapes can provide reinforcement for sutures

the skin closure tapes on each side Remove the skin closure tapes at the time of suture removal

Two advanced skin closure tape-based systems are the ClozeX (Clozex Medical LLC, Wellesly, MA) and the 3M Steri-Strip S Surgical Skin Closure (3M Healthcare, St Paul, MN) These are nonlatex, disposable, single patient use, transparent, adhesive-based wound closure devices for the primary closure of lacerations and wounds not under tension They align the wound edges and provide good cosmetic results They come in a variety of sizes, ranging from

10 to 100 mm

STAPLE CLOSURE

Stapling is a rapid closure technique that is useful for superficial scalp lacerations and linear lacerations of the trunk and extremi-ties Staples should not be used on the face, neck, hands, or feet These areas have little subcutaneous tissue and the staples can damage underlying structures Staples should also be avoided in any area of the body that will be exposed to computed tomogra-phy (CT) or magnetic resonance imaging (MRI) The staples are

made of an inert material, which helps to decrease tissue

reactiv-ity Staples should not be used for wounds that are crush wounds,

infected, irregular, macerated, over bony prominences, or under

tension

The skin stapler is a simple device (Figure 93-25) It is a single

patient use, sterile, disposable unit that is preloaded with staples It

is grasped and held with one hand When the handle is squeezed, a

staple is inserted into the tissue The stapler automatically loads the next staple after one staple is discharged Skin staplers typically have

10 or 35 preloaded staples

Prepare the wound for stapling Place deep sutures to close the subcutaneous tissue and, if the wound is gaping, bring the wound edges into apposition Approximate the skin edges with the domi-

nant hand (Figure 93-26A) Evert the wound edges with a forceps

FIGURE 93-25. Examples of two styles of skin staplers

FIGURE 93-26. Laceration repair with staple closure A. The wound edges are apposed and everted B. The stapler is applied over the laceration C. The stapler is applied

over the everted wound edges D. The plunger advances the staple into the wound margins E. The anvil bends the staple into shape F. The final product

CHAPTER 93: Basic Wound Closure Techniques

held in the nondominant hand (Figure 93-26A) Grasp the

sta-pler with the dominant hand Gently place the skin stasta-pler over

the laceration (Figure 93-26B) Start at one end of the

lacera-tion and work toward the opposite end Do not indent the skin

with the stapler, as this will cause the staples to be placed too

deep Align the arrow on the front of the stapler over the

lacera-tion (Figure 93-26C) Squeeze the handle of the stapler A plunger

will advance a staple into the wound margins (Figure 93-26D)

An anvil will bend the staple into a square or rectangular shape to

secure the staple (Figure 93-26E) Continue to evert the wound

edges and apply staples every 3 to 5 mm until the wound is

approxi-mated and without any gaps (Figure 93-26F) A small space will

be visible between the skin surface and the staple if it is properly

positioned If the staple is against the skin, it has been placed too

deep Remove the staple and replace it

There are a few complications associated with staple use Their

removal can be uncomfortable or difficult Minor bleeding can

occur from the holes after the staples are removed Staples placed

on the face, feet, hands, and neck can damage superficial

subcutane-ous structures (e.g., blood vessels, muscles, nerves, and tendons)

Improper wound eversion can result in wound dehiscence upon

staple removal, larger scars, and poor wound healing Staples can cause larger and more prominent skin marks and subsequent

scar-ring when compared to sutures

STAPLE REMOVAL

Staples should remain in place for approximately 5 to 10 days, the same amount of time as sutures They can remain longer if placed over a joint or in cases of slow wound healing The staple remover

is a disposable, sterile, single-patient-use device (Figure 93-27A)

It is made of metal or plastic with metal tips The lower jaw of the

stapler has two upwardly angled metal prongs (Figures 93-27B &

93-28) The upper jaw of the stapler is a flat piece of metal Insert

the prongs of the lower jaw of the staple remover between the

sta-ple and the skin (Figure 93-28A) Close the handles of the stasta-ple

remover This will cause the upper jaw to compress the center of the staple and the arms of the staple to withdraw from the skin

(Figure 93-28B) Lift the staple remover and staple off of the skin

Discard the staple and continue the process until all the staples have been removed A patient who plans to follow-up in a clinic

or office should be given a staple remover to take with them, as many clinics and offices do not routinely stock these devices

HAIR APPOSITION

Scalp wounds can be closed using hair-tying, also known as the hair apposition technique (HAT).11–15 This technique is relatively painless, does not usually require anesthesia, results in a shorter procedure time, eliminates the need for staple or suture removal,

is cost-effective, and the wound outcome is similar or superior to sutures.11,12,15 This technique should not be used on wounds under tension, wounds with ongoing hemorrhage, wounds that are grossly contaminated, or if the hair is <3 cm in length

Clean, prep, anesthetize, and dry the laceration and rounding skin Start at one end of the laceration and grasp 5 to

sur-15 hairs on each side of the laceration Twist the hair strands on each side of the laceration to form a single “rope.” Tie the two

“ropes” of hair together to close the wound and appose the edges Use a hemostat and an instrument tie to make the process sim-pler and easier Continue this process until the entire laceration

is closed with hair ties As the laceration heals, the hair know will grow away from the wound edges The hair knot can be cut off by a family member, friend, or primary care provider in 2 to

4 weeks

FIGURE 93-28. Staple removal A. The lower jaw of the staple remover is placed under the staple B. The upper jaw compresses the center of the staple and allows the staple arms to exit the skin

FIGURE 93-27. The staple remover A. Overview B. The tip with the jaws open

A

B

MISCELLANEOUS WOUND CLOSURE DEVICES V-LOC ABSORBABLE WOUND CLOSURE DEVICE

The V-Loc (Covidien, Norwalk, CT) is an absorbable,

dispos-able, single use, unidirectional barbed wound closure device The

deploys up to 20 absorbable subcutaneous staples (Figure 93-29A)

The subcutaneous staples are horse shoe-shaped (Figure 93-29B)

The device allows wound eversion with no external sutures or metal

staples that require later removal (Figures 93-29C & D) The final

cosmetic results are similar to sutures or skin staples The company also sells a reusable three-arm proprietary forceps to make wound approximation easier for one person

FIGURE 93-29. The Insorb subcuticular skin stapler A. The staple unit B. The absorbable staple resting on a fingertip C. Artist illustration of the unit in action The inset

shows the relationship of the staple to the subcutaneous tissues D. The unit closing a laceration (Photos courtesy of John L Shannon Jr., Incisive Surgical Inc.)

CHAPTER 94: Tissue Adhesives for Wound Repair

SUMMARY

There are multiple techniques available for closing wounds The

principles and techniques discussed will help to provide the most

appropriate closure for the various types of wounds that are seen in

the Emergency Department Care should be taken to provide the best

closure possible to provide good cosmesis and avoid complications

Tissue Adhesives for Wound Repair

Hagop M Afarian

INTRODUCTION

The year 1942 marked the discovery of cyanoacrylate, the

chemi-cal found in adhesives such as Superglue™.1 The use of

cyano-acrylates for wound closure has been described since the 1960s

when it was first assessed for military use It was not until 1998

that N-2-octylcyanoacrylate (Dermabond) was approved by the

FDA for use in the United States Tissue adhesives have since

redefined the overall approach to laceration repair, especially in

the Emergency Department Their ease of use, relative

painless-ness, and simplicity of aftercare make it an ideal tool for small

straight wounds and use in children.2

ANATOMY AND PATHOPHYSIOLOGY

Cyanoacrylates are a monomer liquid When activated by water,

they polymerize via an exothermic reaction to form a strong bond

Heat is released by this polymerization reaction and may cause

some discomfort Cyanoacrylates are classified as either butyl or

octyl based on the length of their side chain.20,23 Butyl

cyanoacry-lates have short and straight side chains This allows them to form

bonds that are strong, tight, and poorly flexible Unfortunately,

these bonds can become brittle and fracture Butyl cyanoacrylates

are best suited for short lacerations under no tension Examples of

butyl cyanoacrylates include Histoacryl (B Braun, Bethlehem, PA)

and Indermil (Syneture, Norwalk, CT) Octyl cyanoacrylates have

longer side chains This allows them to form bonds that are strong,

flexible, and less likely to fracture Octyl cyanoacrylates can be

used on lacerations of any length Examples of octyl cyanoacrylates

include Dermabond (Ethicon Corp., Norwood, MA) and SurgiSeal

(Adhezion Biomedical, Wyomissing, PA) Newer agents are a

com-bination of the strong and fast-setting butyl cyanoacrylates with

the flexibility of the octyl cyanoacrylates An example is LiquiBand

(MedLogic Global Ltd., Plymouth, UK)

The nonmedical and medical adhesives contain similar

ingredi-ents The differences between these two types are sterile production,

sterile packaging, and the attached alcohol chain in medical grade

tissue adhesives Converting a methyl to an octyl group reduces

the heat produced by polymerization and decreases the amount of

direct tissue inflammation caused by the breakdown products of the

adhesive.1,3

The major advantage to the use of tissue adhesives is speed

Wounds can be repaired quickly and without anesthesia Tissue

adhesives have been shown to offer similar wound closure and

cos-metic results as sutures and adhesive strips (e.g., Steri-strips).4,18,19,24

The initial tensile strength of wounds repaired with tissue

adhe-sives are not equivalent to wounds closed with sutures.5,6 Within

7 days, however, any differences in tensile strength are no longer

94

present.5,6 The cost to the patient is less for lacerations repaired with tissue adhesives compared to suturing.7,18 This takes into account physician time, procedure time, materials, and repeat vis-its for suture removal.7,24 There is less need for the painful injec-tion of local anesthetic solution The risk of a needlestick injury

is decreased when not suturing An additional benefit of tissue adhesives is that they provide an occlusive covering for wounds, keeping them moist, water tight, and providing protection from invading microbials.8 Wounds closed with tissue adhesive do not require routine follow-up like those sutured closed do for suture removal

INDICATIONS

Tissue adhesives are best used to close low-tension, small, edged, and superficial wounds Although not an absolute contra-indication, specific precautions should be taken when using tissue adhesives near the eye The liquid adhesive has a tendency to run If the eyelid margins are not protected, the tissue adhesive can cause iatrogenic sealing of the eyelids.9 Tissue adhesive may be used for wounds that are deep or under tension as a superficial closure layer only after the subcutaneous layer has been repaired to bring the wound edges together and relieve tension Most wounds on the head, neck, torso, and proximal extremities can be closed with tis-sue adhesive Flap type lacerations and lacerations of thin skin can

straight-be closed where the use of sutures can compromise the skin Long lacerations can be divided into segments and each segment closed as

if it were a small laceration.19

CONTRAINDICATIONS

Tissue adhesives should not be used on wounds which are actively infected, heavily contaminated, greater than 6 to 12 hours old, a result of a crush injury, punctures, on the eyelids or surrounding skin, or due to bites Tissue adhesives can only be used on the skin surface and not used within wounds, on mucous membranes, or on mucocutaneous junctions (e.g., the mouth and lips) Do not use tissue adhesives on patients with a known hypersensitivity to cyanoacetate and formaldehyde, as cyanoac-rylates degrade into these byproducts It is recommended that tissue adhesives not be used in areas of the body that are exposed

to heavy moisture (e.g., the perineum and axilla) and parts of the body prone to frequent movement (e.g., hands, feet, and over joints).10 Wounds must be dry Do not use tissue adhesives on wounds that are actively bleeding or oozing Tissue adhesive use in these areas may lead to wound dehiscence as the adhesive cracks and/or peels.10 Stop the bleeding with direct pressure or the injection of local anesthetic solution with epinephrine prior

to the application of tissue adhesive They may be difficult to use

in areas covered densely with hair (i.e., the scalp and axilla) since the tissue adhesive will not bond adequately to the skin They are not recommended for stellate wounds because of the difficulty of adequately approximating the many wound edges Other contra-indications to this type of closure are angled or beveled wounds, unless deep sutures are first placed to approximate the wound edges and relieve any tension

EQUIPMENT

• Povidone iodine or chlorhexidine solution

• Gloves

• Wound adhesive (Figure 94-1)

• Wound cleaning and irrigation supplies (Chapter 92)

• Forceps

Explain the procedure, its risks, and benefits to the patient and/

or their representative Obtain a signed consent for the procedure

Anesthetize the wound Cleanse the wound and surrounding skin

of any dirt and debris Irrigate the wound with normal saline or tap

water If the wound is dirty, consider the use of a wound irrigation

device as described in Chapter 92 Injuries which require

substan-tial cleaning may not be good candidates for tissue adhesive closure

Inspect the wound for any retained foreign bodies or injuries to

deep structures All bleeding must be controlled prior to the

appli-cation of the wound adhesive Repair lacerations with continued or

heavy bleeding with sutures to achieve adequate hemostasis Dry

the skin surrounding the laceration with gauze squares

TECHNIQUES GENERAL TISSUE ADHESIVE TECHNIQUE

The general technique will be described There are some differences

in the type of applicator Prepare the tissue adhesive Some only

require the removal of a twist-off plastic cap Others are supplied in

ampules that must be crushed and allowed to soak the foam tip of

the applicator Use the tissue adhesive immediately after opening the

container as it dries within minutes and may not continue to flow

freely for very long

Approximate the wound edges with forceps Commercially

available, disposable, single-patient-use tissue forceps can be used

(Bionix Development Corp., Toledo, OH) These are specifically

designed to approximate the wound edges prior to using tissue

adhesives (Figure 94-2) Alternatives to these devices are Adson

forceps or using gloved fingers Place a thin layer of tissue

adhe-sive over the wound and extending 5 to 10 mm beyond the wound

margins (Figure 94-3A) The tissue adhesive may also be applied

in spots over the laceration (Figure 94-3B) or across the

lacera-tion like wound tape (Figure 95-3C) Apply the droplets or lines

of tissue adhesive approximately 0.5 cm from each other Hold

the wound edges together for 30 to 60 seconds following the application of the first layer of tissue adhesive to allow for opti- mum polymerization.

FIGURE 94-1. Several examples of tissue adhesive From left to right: Dermabond

ProPen, SurgiSeal, Indermil Loctite, and Liquiband Flow Control

FIGURE 94-2. Commercially available wound forceps (Bionix Development Corp., Toledo, OH)

FIGURE 94-3. Laceration repair with tissue adhesive A. Tissue adhesive applied continuously over the laceration B. Tissue adhesive applied in spots over the lac-eration C. Tissue adhesive applied across the laceration