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Wound Care Management - Part 2

Stuart Swadron, MD and Sean Nordt, MD PharmD
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14:40

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Simple wound management controversies.

PEARLS:

  • Delayed primary closure can be considered in old, complicated wounds in immunocompromised patients.  Otherwise, the classic teaching of never closing a wound > 6 hours old no longer holds.

  • Tissue adhesives, steri-strips, absorbable sutures and non-absorbable sutures all have the same outcome.  

  • For the clean, dry, wound, prophylactic antibiotics are not necessary.  

 

Take home points from previous segment:

  • No soaking.  It increases the risk of infection.

  • No scrubbing.  It damages viable tissue and increases the infection risk.

  • Irrigation fluid - there is no difference between tap water and sterile saline.

  • Adequate pressure for irrigation is important.  At least 8 psi, which can be achieved with a 35 mL syringe with an 18 gauge catheter or commercially available device with a splash guard.  

 

Leave old wounds open?  Rarely.

Eliya MC, et al. Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury. Cochrane Database Syst Rev. 2011 Sep 7;(9):CD008574. [Free open access link]

  • Demonstrated that there seems to be no evidence to support the practice of delayed primary closure.

  • The previous teaching was to not close wounds that occurred > 6 hours ago on teh body or > 12 hours on the face.  

  • Little supporting evidence, but consider delayed primary closure in wounds very prone to infection like those that are >24 hours old, heavily contaminated or in anatomical areas prone to infection like the hand.

 

Wear sterile gloves? No.

Perelman VS, et al. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004 Mar;43(3):362-70. [PMID 14985664]

  • Looked at 816 immunocompetent patients requiring laceration repair.  Randomized the patients to be repaired by a provider wearing either sterile gloves or regular gloves.  

  • The rates of infection were higher in patients with wounds repaired by providers wearing sterile gloves (6.8% vs 4.4%).  

  • Sterile gloves are several times more expensive than regular gloves, so if they are not necessary, we should not use them.  

 

Use tissue adhesives? Yes! In the correct wound.

  • Cannot be used in a bleeding wound.

  • Wound must be dry with edges that are easily approximated.  Gaping wounds or wounds under high tension are not amenable to tissue adhesives.

 

Holger JS, et al. Cosmetic outcomes of facial lacerations repaired with tissue-adhesive, absorbable, and nonabsorbable sutures. Am J Emerg Med. 2004 Jul;22(4):254-7. [PMID 15258862]

  • A prospective study that evaluated 145 children, 5 years or older with acute facial lacerations  who were randomized to closure with either tissue adhesive or sutures.

  • No outcome difference between using tissue adhesive vs. absorbable sutures vs. non-absorbable sutures.    

  • Saves time, does not require a follow up visit for suture removal.  

 

Osmond MH, et al. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr. 1995 Jun;126(6):892-5. [PMID 7776090]

  • After analyzing initial costs, complications and necessity of return visits for suture removal, etc, this study found that tissue adhesives are more cost effective than suturing.  

 

Use Steri-Strips? Probably everywhere, at least on faces.  

Zempsky WT, et al. Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive. Pediatr Emerg Care. 2004 Aug;20(8):519-24. [PMID 15295247]

  • Used tincture of benzoin to make strips stick better.  

  • Found no significant cosmetic difference in facial lacerations on kids repaired with sutures vs. steri-strips.

  • Important to note that this study was funded by 3M, the maker of steri-strips.

 

Do nothing? Maybe.

Quinn J, et al. Suturing versus conservative management of lacerations of the hand: randomised controlled trial. BMJ. 2002 Aug 10;325(7359):299. [Free open access link]

  • Randomized controlled trial that looked at simple hand lacerations, less than 2 cm, that were not bite or puncture wounds.

  • Patients were randomized to either closure with 4-0 or 5-0 monofilament suture and covered with polymyxin B or nothing at all.

  • The stuyd found that there was no outcome difference whether the wound was closed or left open.  

 

Give prophylactic antibiotics? No.

  • The infection rate in properly handled wounds is so low to begin with that it would take a very large study to detect a difference in infection rates.  

  • Consider using antibiotics in old lacerations, or those in immunocompromised patients , but for the vast majority, antibiotics. are not indicated.  

Zehtabchi S. Evidence-based emergency medicine/critically appraised topic. The role of antibiotic prophylaxis for prevention of infection in patients with simple hand lacerations. Ann Emerg Med. 2007 May;49(5):682-9, 689.e1.  [Free open access link]

  • A meta-analysis of 4 randomized controlled trials that show there is no difference in infection rate between groups that receive antibiotics and groups that do not.  

David J. -

On the topic of closing an older-than-usual wound, at what hour range would you begin to worry about granulation tissue interfering with wound healing? I've learned that some "freshen up the wound" by trimming off the granulated edges, and then they'll proceed to close the wound as the fresh lac edges will heal together better-- but I'm finding conflicting evidence on when that "freshening" might be necessary.

Mike W., MD -

Dear David,
What a great question. I couldn't find any evidence-based, definitive answer for you--my guess is that no such study exists. My answer therefore is based on my fairly limited experience with this situation (since I personally tend to err on the side of primary closure even for "older wounds," specifics of each situation taken in to account.
There is no doubt that a wound left for delayed primary closure (or presenting at an interval of 2-3 days post injury) looks different than a fresh traumatic lac. The edges are more edematous and "puffed out" such that wound edge apposition is a trickier feat. Keep in mind this is largely due to good stuff happening--inflammatory mediators, macrophages recruited to the wound margins, helping reduce infection risk--so you don't want to trim it all away, but I certainly think it is reasonable to use a scalpel to trim the edges carefully if that's what is necessary to achieve wound edge apposition and a more effective, cosmetic closure.
I hope this is helpful and thanks again for listening!
Brian Lin, MD

David J. -

Brian, thanks for your reply!

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Mysteries of Tetanus & Influenza Full episode audio for MD edition 184:56 min - 87 MB - M4AHippo Urgent Care RAP January 2016 Summary 533 KB - PDF

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