- mechanism of injury
- time of injury: clean wounds less than 12 hours old may be closed primarily; clean facial wounds may be closed up to 24 hours old with meticulous detail to irrigation and debridement.
- time of last po intake
- current meds, especially steroids
- tetanus status
- pertinent past medical history
- pertinent ROS
2. PHYSICAL EXAMINATION
- description of wound (linear, v- or y-shaped, stellate)
- length, depth and width of wound
- tendon, nerve, bone and blood vessel injury (neurovascular status)
- associated injuries
- neurologic exam if head injury
- LET: Lidocaine, Epinephrine, Tetracaine; comes from pharmacy as a liquid which is mixed with methylcellulose powder to form a gel just before applying. May also be used in the pure liquid form and put on cotton which is placed in the wound. Painless to apply, does not distort wound margins, helps with hemostasis. Best for wounds less than 4-6 cm in length. Most effective on face and scalp, which usually do not need additional anesthetic. Do not use on mucous membranes or end-arterial areas (digits, ear, etc.). Apply into wound and hold in place with tape (gauze decreases effectiveness as it absorbs the LET), leave in place for 20-30 minutes.
- lidocaine: for infiltration, can be used anywhere, including mucous membranes (unless with epi, then avoid nasal alae, penis, and pinna). Max dose 4.5mg/kg (0.45 cc/kg of 1% lidocaine); 7mg/kg if using with epi. Buffer first, with 1 part 8.4% NaHCO3 to 10 parts 1% lidocaine. Inject through wound margins, with a small needle (27 or 30 ga), and inject slowly. Takes about five minutes to take effect.
4. WOUND PREPARATION
- Wound sterility is a myth! Preservation of blood supply is of greater importance than avoidance of bacteria. Dilution of existing bacterial levels by irrigation is essential, and far more effective than surface prep.
- Clean surrounding skin with saline, Betadine, or Shurclens, either on gauze or a swabstick, making a point of scrubbing off any visible contaminants, blood, or dirt. Cleaning solutions should not be used inside the wound. Specifically, Betadine inhibits neutrophils and fibroblasts, which are vital for wound healing.
- Irrigate wound with sterile saline or water, using 100cc per centimeter of wound length. Use larger volumes for high risk (e.g. lower extremity) or dirty wounds. High pressure irrigation is required, which may be obtained by using a 35-cc syringe with a splashguard attached, which has a 19-gauge aperture. Saline is drawn up into the syringe from a basin or the plastic container the laceration tray comes in, then the splashguard is attached. The splash guard should be removed each time the syringe is refilled.
- Do not shave the site, even if it is on the scalp. Shaving (and even clipping, to some extent) increases risk of infection of a surgical site. Moistening the hair with saline or ointment, or having an assistant hold the hair out of the way will suffice.
- Debride devitalized tissue. Do not remove landmarks (eyebrows, frontal hairline, lip vermillion), but do remove crushed, torn, and non-viable edges.
5. SEDATION, RESTRAINT, AND PARENTAL PRESENCE
- Most lacerations in children can be repaired with minimal or no anxiety and pain through the use of distraction techniques, expert infiltration of local anesthetics, or the use of topical anesthetics. In children who are particularly anxious or have difficult or extensive wounds to repair, sedation with oral, intranasal, rectal or parenteral drugs is indicated. Sedation is covered in depth in another section of this manual.
- Child life should be enlisted to help whenever possible. If there is not a child life specialist in the department at the time a procedure will be performed, there is usually one on call.
- Restraints should be used to supplement other techniques to obtain patient cooperation. It is more humane, however, to use restraint effectively and complete the procedure more quickly, than to partially restrain the patient and take much longer.
- Parental presence is a matter of physician preference and controversy. Usually, both the patient and the parent prefer to have the parent stay in the room. There are some parents, however, who are more emotional or distracting, and their presence may do more harm than good.
6. WOUND CLOSURE MATERIALS
- Suture material choices include absorbable vs. nonabsorbable, monofilament vs. braided, size, needle type and size, and color. Absorbable suture is used for buried sutures, or may be used to close skin in young children in whom sutures may be difficult to remove. Braided suture tends to have a higher rate of infection in a contaminated wound than monofilament suture. Suture size helps determine strength, flexibility, and, for absorbable sutures, the rate of absorption. Suggested suture choices are listed in a table in the next section. In general, the larger the size of the suture, the smaller it is. For example, most attendings would chose to use 5-0 or 6-0 for the face and larger suture such as 3-0 or 4-0 for the extremities.
- Staples are particularly useful in scalp wounds, where they are easier and faster to apply to a hair-bearing area, and much easier to see for removal. They have a lower infection rate than sutures, but they do have some disadvantages. Accurate skin positioning is more difficult, and they can be painful to remove.
- Steri-strips are fast, easy, and painless to apply. Infection risk is lower, but only if the wound comes together with no tension and no dead space is left which can fill with serum. There are disadvantages, which include premature separation, wound edge inversion, and a slightly wider final scar.
- Dermabond is relatively painless (the bonding process is an exothermic reaction), easy to apply, and significantly reduces the time required for laceration repair. The cosmetic outcome is as good as with sutured lacerations. It is contraindicated in puncture wounds, animal or human bites, heavily contaminated wounds, infected wounds, stellate or crush wounds, wounds greater than 4-6cm, and widely gaping wounds. It cannot be used on areas of high skin tension (such as over joints), areas subjected to repetitive friction (hands or feet), areas of prolonged moisture (mucosal surfaces), and areas covered with hair.
7. WOUND CLOSURE TECHNIQUE
- Position the patient and yourself. Sit down if at all possible, and ensure good lighting. Have supplies in easy reach. An assistant in the room is also necessary.
- Obtain hemostasis. Hematoma in the wound may cause the sutures to become too tight, causing ischemia and infection. Also, hematoma in the wound is a wonderful culture medium.
- Suture deep wounds in layers: muscle-fascia-dermis/epidermis, but use deep sutures only when necessary, as the risk of infection increases with the placement of additional suture in a contaminated wound. The epidermis should not be closed with tension. Use absorbable suture for deep layers.
- Nearly all wounds can be closed with simple interrupted sutures. Using a vertical mattress as a retention stitch leads to ischemia.
- Tongue and buccal mucosa are rarely sutured. When a laceration crosses the vermillion border of the lip, the first stitch should approximate the vermillion.
- Protection: Prevention of re-injury. Especially important for hand injuries. Dressings must be of sufficient bulk to serve as a mechanical barrier to re-injury.
- Immobilization: A dressing that prevents further use of an injured area can promote healing and limit pain or discomfort. When the need for immobilization is critical, use a splint.
- Antisepsis: Overrated; remember, there is no asepsis. A dressing moist from wound exudate might serve to foster bacterial proliferation. Keep dressing fresh and dry but don't expect it to serve as a barrier to bacterial contamination. Therefore, change dressings whenever necessary. Bacitracin may be beneficial, as epithelialization occurs faster in a moist environment.
- Compression: Gentle compression limits the swelling somewhat and encourages immobilization. Zealous compression, however, can be ischemic.
- Debridement: Removing gauze from an open granulating wound will remove some devitalized surface accumulation. Don't overdo it-wet-to-wet dressings are more humane than wet-to-dry dressings.
- Appearance: Patients are usually more comfortable when a neat dressing covers an unsightly wound.
9. DISCHARGE INSTRUCTIONS
- Antibiotics: Use antibiotics therapeutically in advance of clinical infection whenever your index of suspicion is high for extraordinary contamination or whenever morbidity from infection is high.
- Pain control: Tylenol is probably a better choice than ibuprofen for pain control in someone with a fresh wound, because the first stage of healing is inflammation. It may also affect hemostasis.
- Scar formation: It can take up to a year for a scar to mature, so patients should be instructed to use sunblock (or a hat, for facial wounds) during that time. Steroids delay wound healing, but topical or systemic vitamin A is an antagonist to their anti-inflammatory activity. Vitamin E is an anti-inflammatory, which slows wound healing and may widen scar: don't use on fresh wounds!
- Follow-up: Wounds that are high risk for infection may be re-checked in two days. Sutures or staples may be removed in the emergency department, as the charge for wound closure includes the suture removal as well. Time to removal is listed in a chart at the end of this section.