Weekly Report – Seeking Closure

You are working a busy trauma shift when a 19 year old male comes in after a dirt bike accident. Fortunately for him he has no significant injuries, but he does have a number of lacerations that require closure including a scalp lac, full thickness lip lac, eyelid lac, and multiple extremity lacs. As you ponder your wound care approach you remember that the trauma committee just recently posted their Wound Closure Guidelines:

BACKGROUND

• Improper technique during wound closure in the trauma patient can result in infection and/or wound dehiscence contributing to increased rates of morbidity and healthcare expenditure.
• The following guidelines will serve to aid in choosing appropriate materials and proper technique for optimal wound closure.
• This is a guideline for lacerations that do not involve life threatening or arterial bleeding. These lacerations would be assessed on the secondary assessment of major trauma patients.

CLINICAL PRACTICE GUIDELINES

I. Initial Evaluation

• Initial evaluation of a laceration must include thorough neurovascular and functional exam. An abnormal exam should be addressed by consultation of appropriate subspecialty service. Consider consultation in:
  • Flexor tendon injuries in the upper extremities
  • Wounds involving joint spaces
  • Wounds involving large vessels
  • Wounds requiring large debridement
  • Avulsion injuries of ears, nose, penis
• Note that a patient request for an emergent subspecialty consult is not an indication to consult (i.e. plastics for an uncomplicated facial laceration)
• Assessment of wound includes thorough cleaning and exploration. Jagged wound edges, stellate shape, visible contamination and wound depth all increase risk of infection.
• Patient history is important. Risk factors for delayed wound healing and infection include advanced age, diabetes, and vascular disease (chronic venous insufficiency, peripheral artery disease).

II. Preparation

A. Cleaning

• Sterile saline and tap water equivalent
• Irrigation (50-100ml per cm of laceration)
• Pressure: need to overcome bacterial adhesion to tissue. However too much pressure causes tissue damage and increases infection risk by driving bacteria into tissue.  Ideal pressure is 8-12 psi.

B. Imaging

• X-ray, ultrasound, CT scan can detect presence of radiopaque foreign bodies in the wound
  • Glass, metal, shrapnel, teeth
• Does not replace wound exploration for identification of radiolucent material
  • Organic material, clothing

III. Materials

A. Vicryl: Braided, absorbable suture

• Maintains tensile strength for 3-4 weeks.
• Indications: preferred material for subcutaneous closure
  • Deep closure of muscle, fascia, subcutaneous tissue
  • Should not be used to close skin
• Purple vicryl can tattoo skin when used in the subcutaneous tissue

B. Prolene/Nylon: Monofilament, non absorbable

• Indications
  • Skin closure, tendon repair
• Extremities (Arms/legs)
  • 3-0 or 4-0, consider 2-0 over large joints or areas of tension
  • Remove in 7-10 days
  • If laceration is overlaying joint, consider orthopedic surgery consultation to ensure joint space not violated.
• Distal extremities (hands/feet)
  • No smaller than 4-0
  • Remove in 7-10 days
• Chest/abdomen
  • 3-0 or 4-0
  • Remove in 7-10 days
• Face
  • 5-0 or 6-0
  • Remove in 3-5 days
• Tendon
  • 2-0 or 3-0

C. Chromic Gut: Coated, biologic,

• Maintains tensile strength for 10-14 days
• Indications
  • Palms and soles
  • Inside the mouth
• Chromic gut is not an appropriate choice for skin closure or for deep sutures

D. Fast gut: Biologic

• Low tensile strength, absorbed within 4-6 days
• Indications
  • Face on children
  • Face for selected adults (those unlikely to follow up, small, superficial wounds under no tension)
  • Can be re-enforced with wound tape

IV. Suture technique

• Buried stitches (deep stitches) for use in multi-layer closure
  • For subcutaneous closure in gaping wounds
  • For closure of fascia over muscle
• Vertical mattress –This is a stitch that is meant to close wounds under significant tension
  • For skin closure of gaping wounds
  • Closure over joints
• Horizontal mattress –This stitch is for hemostasis only, not for wounds under tension
  • For skin closure of a wound with significant bleeding from the skin edge
• Figure of eight –This stitch should be applied to an actively bleeding vessel only o Use Silk (3-0) for this stitch in an arteriolar bleed
  • If the bleed is truly an arterial bleed, a small silk (3-0 or 4-0) should be used
• Running subcuticular –This stitch should be used to close skin, for cosmesis only after deep Vicryl stitches have been applied
  • Use Monocryl only (4-0 or 5-0)

V. Wound type

• Contaminated wounds
  • Copious irrigation
  • Lacerations or wounds over joints should be challenged with saline load to ensure no joint involvement. Recommend orthopedic surgery consult.
  • Grossly contaminated wounds should be cleaned thoroughly and left open. Wet dressing applied. Need daily dressing changes and referral to follow-up with General Surgery
• Delayed presentation
  • Copious irrigation with debridement as needed
  • Facial wounds may be closed up to 24 hrs after presentation
  • Wounds in the extremities may be closed up to 12 hrs after presentation
  • If the wound is too large to leave open or heal by granulation, can place retention sutures sparingly to loosely approximate skin edge. Avoid placing deep sutures in these wounds and consult appropriate service for follow up.
• Special considerations
  • Exposed cartilage should not be sutured. Perichondrium should be the deepest stitch. Exposed cartilage needs to be covered with skin completely.
  • Lip: Through and through lip lacerations often require multi-layer closure. The muscular layer should be closed with vicryl, anything inside the mouth should be closed with chromic gut and anything outside the mouth (including the vermillion border) should be closed with nylon or prolene. All sutures should be 5-0.
  • Complicated facial lacerations involving the lacrimal duct, eye lid edge, eye lid function should prompt a consult to ophthalmology
  • Facial lacerations with neurovascular compromise, muscular impairment, or concern for cosmetic outcome should prompt a consult to face coverage (ENT, OMFS, plastic surgery)
  • Involvement of joint space, tendon/bone exposure warrants an orthopedic surgery consult.
  • Lacerations of the hand need to be carefully examined for neurovascular status, tendon involvement, or violation of tendon sheath. Hand consult teams are orthopedic surgery and plastic surgery.

VI. Antibiotics

• Not indicated for simple lacerations
• Prophylactic antibiotics for:
  • Human/animal bites
  • Extensively contaminated wounds (soil, organic material)
  • Higher risk of infection with poor perfusion: anatomical (scalp lower risk than extremity) and chronic disease states (PAD, chronic venous stasis)

References

1 Hollander JE, Singer AJ, Valentine SM, Shofer FS (2001) Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med 8(7):716–720

2 Chisholm CD, Cordell WH, Rogers K, Woods JR (1992). Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Ann Emerg Med 21(11):1364–1367

3 Moscati, R. M., Mayrose, J., Reardon, R. F., Janicke, D. M. and Jehle, D. V. (2007), A Multicenter Comparison of Tap Water versus Sterile Saline for Wound Irrigation. Academic Emergency Medicine, 14: 404–409.

4 Mehta PH, Dunn KA, Bradfield JF, Austin PE. Contaminated wounds: infection rates with subcutaneous sutures. Ann Emerg Med 1996; 27:43.

5 Subcuticular sutures and the rate of inflammation in noncontaminated wounds.

6 Al-Mubarak L, Al-Haddab M. Cutaneous wound closure materials: an overview and update. Journal of cutaneous and aesthetic surgery 2013;6:178-88.

7 Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg Oncol 1992; 18:785.

8 Nicks B, Ayello E, Woo K, Nitzki-George D, Sibbald G. “Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations.” Nt J Emerg Med (2010) 3:399-407.

9 Eron LJ (1999) Targeting lurking pathogens in acute traumatic and chronic wounds. J Emerg Med 17(1):189–195

10 Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg Med Clin North Am 2003; 21:205.

11 Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med 1995; 13:396.