Wound Care:
Update on Current Techniques. . .
and a Few Surprises
Michael Huey, MD
Assistant Vice President and Executive Director
Emory University Student Health and Counseling Services
With appreciation to: Menelaos Demestihas, MD
Assistant Professor - Emory Emergency Medicine
Grady Memorial Hospital
ACHA 2014 Annual Meeting
San Antonio, Texas
Thursday, May 29, 2014 @ 1:45 pm
Session TH3-180
With special thanks to:
Menelaos Demestihas, MD
Assistant Professor - Emory Emergency Medicine
Grady Memorial Hospital
Hey, this looks familiar somehow . . .


This is the exact talk we gave
at SCHA in Atlanta, March
2014
It is OK to leave now if you
want to . . . I won’t be
offended . . . There are lots of
good talks at ACHA this year:
◦ TH#-187 – “Clinical Pearls for
College Health Providers: Key
Evidence Summaries of the Last
Year’s Medical Literature”
Hey!
What’s up
with that?
Faculty Disclosure
Neither I nor my spouse
have a financial interest, arrangement or
affiliation with any organization or
business entity (including self-employment
or sole proprietorship) that could be
perceived as a conflict of interest or
source of bias in the context of this
presentation.
 My wife is the President and CEO of
The Center for the Visually Impaired of
Georgia

Diversity-Focused Presentation
SKIN IS A VERY DIVERSE
ORGAN
Time does not stand still . . .
Many of us still practice the wound care techniques
and approaches we were taught in our training.
 However, current approaches in emergency
medicine and plastic surgery settings may surprise
you.

◦ Tap water from the running faucet to cleanse/lavage
wounds?
◦ Choices for wound dressings?
◦ Epinephrine on the face and digits?
◦ Ultrasound to guide digital blocks and triangulate
foreign bodies?
◦ New suture choices?
Learning Objectives
Review the basics of wound healing.
Review current techniques for the cleansing
and lavage of traumatic wounds in emergent
and urgent settings.
3. Review options for wound dressings
4. Describe changes in the approach to local
anesthesia on the face, nose and digits.
5. Describe changes in preferred suture choices
in cosmetic and non-cosmetic wounds.
6. Review use of ultrasound in regional and
digital block anesthesia and foreign body
localization.
1.
2.
Wound Care Updates 2014
WOUND HEALING 101
Definitions and Demographics
A wound is a
disruption of the
normal structure and
function of the skin and
underlying soft tissue
(SSTI).
 11 million wounds are
treated in emergency
departments annually
in United States

Armstrong DG and Meyr AJ, UpToDate 2014

Normal wounds heal
through an orderly
sequence of
physiologic events:
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◦
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◦
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Hemostasis
Inflammation
Epithelialization
Fibroplasia
Maturation
Wound healing time line
Wound healing time line with dominant cell types and major physiologic events.
Mulholland MW, Maier RV, et al. Greenfield's Surgery Scientific Principles and Practice, 4th ed, Lippincott Williams
& Wilkins, Philadelphia 2006. Copyright © 2006 Lippincott Williams & Wilkins.
Healing time and quality


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Restoration of normal skin surface integrity
in a healthy individual takes from 2-4 weeks
Wounds can disrupt due to technical error,
infection, presence of foreign material,
underlying disease states or medications
Quality of the healed tissue depends upon:
◦ The severity of tissue trauma
◦ The suture material used in repair
◦ The presence of factors that may delay healing or reduce the
tensile strength of the final scar
Armstrong DG and Meyr AJ, UpToDate 2014
Healing time and quality (continued)

In animal models, unsutured fascial
wounds have:
◦ Minimal strength in the first week of
healing,
◦ 30% to 50% of unwounded tissue strength
after four to six weeks,
◦ 60% at six months, and
◦ Slowly continue to get stronger, but may
never achieve 100% of their previous
strength
Langer’s Lines
Avoiding wound tension
Langer (1861) developed his lines by stabbing cadavers
with a conical punch. The resulting defects were often
oval, rather than circular, because of the direction of
the underlying collagen bundles. Langer joined the long
axis of these ovals to establish his lines.
Risk factors for non-healing

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Peripheral arterial
disease
Diabetes, due to
vascular disease,
neuropathy and
impaired immunity
Chronic venous
insufficiency
Aging
Malnutrition



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

Immunosuppressive
therapy
Sickle cell disease
Cancer chemotherapy
and radiation therapy
Spinal cord disease and
immobilization
Infection
Smoking and nicotine
replacement therapy
Armstrong DG and Meyr AJ, UpToDate 2014
Re-epithelialization
Beautiful granulation tissue!
Epithelialization
of a partialthickness wound
occurs from the
wound edge.
 “Picture-framing”

Mulholland MW, Maier RV, et al. Greenfield's Surgery: Scientific Principles
and Practice, Fourth Edition. Philadelphia: Lippincott Williams & Wilkins,
2006. Copyright © 2006 Lippincott Williams & Wilkins.
Wound Re-pigmentation
Re-pigmentation of healed
wounds occurs as
melanocytes migrate from
the epidermal appendages
across the wound bed.
 Skin color in a healed wound
is difficult to predict.
 Exposure to ultraviolet
radiation can permanently
increase the pigmentation.
 Bleaching agents are
discouraged because of the
risk of further tissue damage.

Mulholland MW, Maier RV. Greenfield's Surgery: Scientific Principles
And Practice, Fourth Edition. Philadelphia: Lippincott Williams &
Wilkins, 2006. Copyright © 2006 Lippincott Williams & Wilkins.
Wound Care Updates 2014
WOUND ASSESSMENT
AND PREPARATION
Preparation of Acute Minor (“SHS-level”)
Wounds for Laceration Repair


Wounds that involve joint
spaces, nerves, tendons
(at least flexor tendons),
significantly deep muscle
or other deep underlying
structures are not “SHSlevel”
Preparation includes
assessment, adequate
hemostasis, hair and
foreign body removal,
irrigation and local
anesthesia.
Exclude
Chain Saw
Injuries!
www.photobucket.com
Wound Assessment and Preparation

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Age of injury
Mechanism of injury (e.g. cut by sharp
object, tear, bite, stab, crush)
Foreign bodies
Extent/depth of wound (e.g. joint spaces,
underlying fracture)
Neurovascular or tendon injury
Risks of poor outcome (e.g. wound
related, delayed presentation, diabetes,
keloid area)
Cosmetic significance
Type of closure (e.g. primary, delayed
primary, secondary intention)
Debridement
Hemostasis (e.g. direct pressure, lidocaine
with epi, Gel foam, careful tourniquet use)
Hair removal
2000-2011 Self Care Decisions, LLC
Age of Injury:
Berk WA et. al., Ann Emerg Med 1988

372 patients presented to ED for suture repair of
wounds not grossly contaminated or infected with
no associated injuries to nerves, major blood vessels,
tendon or bone
◦ Wounds closed at up to 19 hours after injury had
significantly higher rate of healing than those closed later
(92% v. 77%)
◦ Healing of head wounds was virtually independent of
time from injury to repair: 96% (42 of 44) head wounds
were healing when repaired > 19 hours v. 66% (47 of 71)
elsewhere on body
◦ “A facial wound can be closed up to 24 hours later with
little risk of infection if it is reasonably clean.”
Foreign Bodies
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Important to identify and remove FBs
Retained FBs increase the risk of delayed wound
healing and infection
Remove it if you can see it
Carefully remove it if you can palpate it if no risk
to underlying structures
Ultrasound replacing soft tissue x-rays!!
Location, location, location: glass and metal can be left
if not in a critical area or adjacent to a vital
structure
Wood (splinters) and other organic FBs can cause
delayed infection, including in the adjacent bone
Neurovascular or tendon injury
Careful assessment of circulation and
sensation, including two-point discrimination
in hand injuries
 Any wound overlying a tendon must be
evaluated for tendon function; base of the
wound must be carefully explored with
tourniquet and magnification loupes if
necessary
 Ends of tendon can retract from view
 Consider position of body part at time of
injury
 “REFER IF UNSURE”

Cosmetic significance
Don’t be sexist in your decisionmaking (Matthew McConaughey
could enroll in your school)
 Who has sutured an Oscar winner?
 Cosmetically sensitive areas

◦ Vermillion border of lip
◦ Tissue avulsed
◦ Orientation of wound to tension
lines (Langer, others) -perpendicular orientation leads to
worse scarring
◦ Eyelid margin (plus it is not just
cosmetic here)
◦ Stellate lacerations
www.usatoday.com
Debridement
Many/most wound experts
consider it to be equally or
more important than
irrigation in the management
of a contaminated wound
 Removes permanently
devitalized tissue that inhibits
wound’s ability to resist
infection
 However, you cannot damage
underlying structures or
make wound difficult to close
without tension

www.deadline.com
Hair removal
Hair does not need to be
removed unless it interferes
with wound closure or knot
formation
 Scalp: Lubricate to comb hair
away or snip with scissors,
don’t shave
 Shaving to skin level increases
risk of infection and can leave
small particles in wound
 Do not clip or shave
eyebrows (lose landmark; can
grow back irregularly)

www.entertainmentwallpaper.com
Wound Care Updates 2014
WOUND LAVAGE:
WHAT’S NEW. . . AND OLD . . .
AND NEW AGAIN
We clean wounds with water +/soap at home
Wound antiseptics
For years, traumatic wounds
were cleaned with antiseptic
solutions (e.g. Bactine at home,
Betadine at work) to lower
bacterial counts and promote
healing
 Published research in the
mid1980s-early 1990s using
animal models (Brennan 1985, Bergstrom
1994, others) showed evidence of
tissue damage and delayed
healing with antiseptics

Forced sterile saline lavage



“Traumatic wounds
should be cleaned
with forced lavage of
sterile saline”
Use of goggles, a
splash shield or both
How much pressure
is too much?
Cochran Review 2010
Water for Wound Cleaning (Fernandez, R et. al.)
The objective of the review was to assess
the effects of water compared with other
solutions for wound cleaning
 Literature search and looked at 10
randomized controlled trials

◦ 7 compared rates of infection and healing in
wounds cleansed with water v. normal saline
◦ 3 compared cleaning v. no cleaning
Tap water more effective than normal
saline for preventing infection in
adults (Cochran Review 2010)
For chronic wounds in adults,
Relative Risk (RR) of developing
infection was lower with tap
water cleaning than with saline
(RR 0.16, 95% CI 0.01 to 2.96)
 For acute wounds in adults, RR of
developing infection with tap
water cleaning v. saline was 0.63
(95% CI 0.40-0.99)
 In children, the difference was not
statistically significant (RR 1.07)

Wounds cleaned with tap water v.
no cleaning at all (Cochran Review 2010)
3 studies compared tap
water cleaning to no
cleaning at all.
 There was no statistically
significant difference in
infection rate (RR 1.06, 95%
CI 0.07-16.50).
 Specifically, the meta analysis
showed no difference in
healing rates postoperatively when wounds
were cleaned with tap water
(showered) and those that
were not cleaned.

Conclusions (Cochran Review 2010)
There is no evidence that using tap water to
cleanse acute wounds in adults increases infection
and some evidence that it reduces it.
 However, there is not strong evidence that
cleansing wounds per se increases healing or
reduces infection at all.
 In areas where tap water is high quality (i.e.
drinkable), it may be as effective for wound
cleaning as sterile water or saline and it is less
expensive.
 Showering with a sutured/surgically repaired
wound does not increase infection rate.

Irrigation of Clean Facial and Scalp
Lacerations
Hollander, JE et. al., Irrigation in facial
and scalp lacerations; does it alter
outcomes?, Ann Emerg Med 1998;
31(1): 73
 Is there a difference in infection
rates in clean facial and scalp
wounds irrigated v. not irrigated
before primary closure?
 1,923 consecutive patients to an
academic ED with non-bite, noncontaminated facial and scalp
lacerations presenting less than 6
hours after injury; 1,090 lavaged
with saline, 833 no lavage
Irrigation of Clean Facial and Scalp
Lacerations (2)
Hollander, JE et. al., Ann Emerg
Med 1998
 Primary outcome parameters =
incidence of wound infection
and short-term cosmetic
appearance
 Groups similar in time to
presentation to ED, frequency
of linear wound morphology,
frequency of smooth wound
margins, number of layers of
closure, number of skin and
deep sutures applied, use of
oral antibiotic prophylaxis
www.aafp.org
Irrigation of Clean Facial and Scalp
Lacerations (3)
Hollander, JE et. al., Ann Emerg Med
1998
 The incidence of wound infection was
not statistically different between the
two groups (0.9% irrigated v. 1.4% not
irrigated, P=0.28)
 The percentage of patients with
“optimal” cosmetic appearance was
similar in the two groups (75.9%
irrigated v. 81.7% not, P=0.07)
 CONCLUSION: Irrigation before
primary closure did not significantly
alter rate of infection or cosmetic
appearance with clean, noncontaminated facial and scalp
lacerations
www.theidearoom.net
Wound Care Updates 2014
WOUND DRESSINGS
Characteristics of an ideal wound
dressing (Scales 1956)
High moisture vapor permeability
 Non-adherent
 High capacity for absorption
 Provide barrier to external contaminants
 Prevents capillary loops penetrating into dressing material
 Capable of being sterilized
 Good adhesion to surrounding undamaged skin
 Hypoallergenic
 Comfortable to wear
 Cost effective

“Road Rash”
A challenging wound to dress!
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Deep, weeping abrasions from falls
onto concrete, blacktop, dirt (“base
stealer’s strawberry), grass, artificial
turf
Very painful, weeps serum heavily
Often contaminated with rocks, soil,
grass, glass and other foreign bodies
Significant risk of tattooing if not
aggressively cleaned
Risk of secondary infection
After cleaning, could use Polysporin or
Silvadene and 30 Telfa pads and several
packages of 4 x 4 gauze pads and a
huge Ace bandage or several
Cling/Conform rolls . . . Or not . . .
www.photobucket.com
Abrasion dressings

Hydrocolloid dressings
(Tegaderm, Duoderm,
others) can be very effective
in controlling pain &
reducing healing time
◦ Gelatin, pectin and/or
carboxymethylcellulose, serve
as occlusive or semi-occlusive
dressings
◦ Absorb wound exudates to
form a hydrophilic gel
◦ Waterproof, allow water vapor
and gases to cross
◦ Long wear time (up to 7 days)
can reduce visits and costs
www.organicfacts.net
Abrasion dressings (2)

Hermans, MH, Intl J
Sports Med 12(6),1991:
Hydrocolloid v. Gauze
◦ 38 racing cyclist
abrasions in 24 athletes
◦ Hydrocolloid occlusive
dressings had faster
healing times (5.6 v. 8.9
days), smaller risk of
infection (0% v. 10%), less
pain at race time (91% no
pain at race time v. 30%
with gauze dressings) +
higher overall comfort
www.firstaid.about.com
Abrasion dressings (3)

Transparent film dressings (OpSite, Comfeel, others)
◦ Adhesive, semi-permeable, polyurethane membrane dressings
◦ Waterproof, allow water vapor and gases to cross
◦ Transparent, can inspect wound without removing

Hydrogel dressings (Restore, Intrasite Gel, others)
◦ Polymers, glycerin or water-based gels, impregnated gauzes or sheet
dressings
◦ High water content of the dressing does not allow it to absorb large
volumes of exudates, so they cannot be used on heavy exuding wounds;
best suited for dry or minimal exuding wounds
◦ Gentle yet effective debriding action by rehydrating necrotic tissue and
removing it with the dressing
◦ Rehydrate the wound bed, reduce pain through a cooling effect, are nonadhesive, fill dead spaces and are easy to apply and remove
◦ They do require a secondary covering dressing.
Indian J Plast Surg 45(2), 2012
Abrasion dressings (4)
Beam, JW, J Athl Train 2008:
Occlusive dressings and the
healing of standardized abrasions
 16 healthy women (n=10)
and men (n=6)
 “Inflicted” 4 standardized,
partial thickness abrasions
 Film, hydrogel, hydrocolloid
and no dressing (control)
 Day-by-day scoring of
wound contraction, color
(chromatic red) and
luminance
www.photobucket.com
Abrasion dressings (5)
Beam, JW, J Athl Train 2008:
 Film and hydrocolloid
produced greater wound
contraction than the hydrogel
and no dressing (control) on
days 7 and 10
 Film, hydrogel and hydrocolloid
resulted in greater wound
contraction than no dressing
(control) on day 14
 Film, hydrogel and hydrocolloid
resulted in smaller measures
of color and greater measures
of luminance than no dressing
(control) on day 14
www.photobucket.com
Wound Care Updates 2014
ANESTHESIA OF FACE,
NOSE AND DIGITS
(UPDATES FROM THE EMERGENCY DEPARTMENT)
Regional Anesthesia
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Trying something new
Sensitive areas that demand best possible
cosmetic outcomes
Most of this information comes from Dental
literature
Questions
◦ 1) How to do these nerve blocks?
◦ 2) Useful for the clinic, urgent care or ED setting?
Infraorbital Nerve Block (1)

Do this for:
◦ Lower eyelid
◦ Lateral nose
◦ Medial Cheek

Technique:
◦ Topical at needle
insertion point
◦ Identify notch of
infraorbital rim
◦ Retract lip, bevel
towards foramen
◦ 1cc infiltration
Infraorbital Nerve Block (2)
Forehead Nerve Block

Not just for laceration repair
◦ Burns
◦ Foreign body removal
Digital Nerve Block
Better tolerated than local
 Palmar single injection better than double
volar injection

Cutaneous Nerve Blocks
For more extensive wounds
 Injuries proximal to fingers

Sensory Innervation of Hand
Lidocaine with Epinephrine
Mantra of “never use” in
digits, blocks, face…
deeply ingrained
 Great to debate

◦ Textbooks say no
◦ Surgical subspecialties
routinely use
◦ Good studies show is
likely safe
Digital anesthesia with epinephrine:
An old myth revisited
Krunic AL et al, J Am Acad Dermatol 2004 Nov; 51(5): 755-9
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PubMed search  total of 16 papers
50 cases of distal gangrene, most in earliest 20th
century
21 cases associated with anesthetic mixed with
epinephrine (often onsite); actual concentration
known in only 4 cases
None associated with a commercial lidocaine with
epinephrine mixture
No evidence to support the “dogma”
Epinephrine actually reduces tourniquet use and
volume of anesthetic, better pain control
Topical anesthesia: LET
LET is a combination of lidocaine (4
percent), epinephrine (0.1 percent), and
tetracaine (0.5 percent) available as an
aqueous solution or methylcellulose
based gel.
 Topical anesthetic prior to local injection
 Replaces Tetracaine-Adrenaline-Cocaine
(TAC)
 Safe down to age 2 years

Kundu (2002) Am Fam Physician 66(1):99-102
LET
Don’t Have 20 Minutes?
Topical 20%
benzocaine
 Faster onset
 Beware of sideeffects (loss of gag,
difficulty swallowing,
methemoglobinemia)

Wound Care Updates 2014
WOUND SUTURE
CHOICES AND GLUE
TIPS & TRICKS
Skin sutures haven’t changed much:
Nylon or Prolene (purple)
Suture away . . . Doc Hollywood!
6-0 Nylon
6-0 Prolene
Absorbable suture has!


Absorbable suture breaks down over time in
the body.
Absorption time depends upon:
◦
◦
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◦
◦
Suture type
Suture size
Braided v. Monofilament
Location
Host factors: Fever, nutrition status, infection
Absorbable suture breakdown times
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Vicryl Rapide – 2 weeks
Undyed Monocryl – 3 weeks
Dyed Monocryl – 4 weeks
Coated Vicryl – 4 ½ weeks
PDS (Polydioxanone) – 9 weeks
Chromic Gut – 12 weeks
Panacryl – 70 weeks (recalled for complications)
"Give me a 4-0 Vicryl on a PS-2"
Needle size and type matter
 Cutting Suture Needles

◦ FSLX - Large skin closure when a lot of
tension is present common for retention
sutures or large orthopedic use.
◦ FSL – Often used for sewing in drains or skin
closure needing higher tension closure.
◦ FS2 or PS2 - For common skin closure.
◦ P3 – Used for skin closure of small incisions
such as hand surgery or facial plastic surgery.
Skin Glue – Tips and Tricks (1)
Draw glue into a
TB syringe
 Replace needle tip
with the plastic
part of a 24 gauge
IV catheter

Skin Glue – Tips and Tricks (2)


Avoid complications
Use a hydrocolloid
dressing (Tegaderm,
others) to protect
the eye!
Elderly – Tips and Tricks
Can have friable
skin that is difficult
to suture without
tearing
 Use tape or
hydrocolloid
dressing (Tegaderm,
others) to close
wound and suture
through

Wound Care Updates 2014
USE OF ULTRASOUND IN
REGIONAL AND DIGITAL
BLOCK ANESTHESIA AND
FOREIGN BODY
EVALUATION
Why Ultrasonography?
Most ED’s have or are looking to acquire
ultrasound machines
 Common uses:

◦ Central venous placement
◦ Guiding difficult peripheral venous access

As technology becomes more affordable and
accessible will see more of these machines
Basic Ultrasonography

Transmission of sound waves and recording
what gets “bounced back”

Tips:
◦ White structures (hyperechoic) are solid/dense
◦ Dark areas (hypoechoic) are liquid & have density
approaching water
Ultrasonography for Nerve Block
Usually peripheral nerves are bundled with
an artery and vein
 Examine in cross-section

Foreign Bodies
Fifth leading cause of malpractice claims
against Emergency Medicine physicians
 Most common is glass
 Always XR if concerned, visual inspection
is not good enough
 Wood and plastic… may not show on XR

Use of US with Foreign Bodies

2 studies show, for radio-opaque objects
(Annals 1991: West JEM 2011)
◦ Sensitivity of 95-98%
◦ Specificity of 89-98%

Alternative is CT or MRI, with MRI being
significantly more sensitive
What will it look like?
Doesn’t Have to be Messy
QUESTIONS?
Bibliography
1.
2.
3.
4.
Fernandez, R and Ussia, C, Water for wound cleansing
(Review), The Cochran Collaboration 2010.
Sarabahi, S, Recent Advances in Topical Wound Care, Indian
J Plast Surg 2012 May-Aug, 45(2): 379-387.
Hermans, MH, Hydrocolloid dressing versus tulle gauze in
the treatment of abrasions in cyclists, Intl J Sports Med
1991 Dec; 12(6): 581-4
Beam, JW, Occlusive Dressings and the healing of
standardized abrasions, J Athl Train 2008 Nov-Dec; 43(6):
600-607.
Bibliography (2)
2014 UpToDate, Inc., Release: 22.2 - C22.44
6. Hollander, JE et. al., Irrigation in facial and scalp lacerations;
does it alter outcomes?, Ann Emerg Med 1998; 31(1): 73
7. Berk WA et. al., Evaluation of the “golden period” for
wound repair, Ann Emerg Med 1988; 17:496
8. Benko, Kip. Fixing Faces Painlessly: Facial Anesthesia In
Emergency Medicine, Emergency Medicine Practice Dec
2009; 11:12
9. Krunic, AL et. al., Digital anesthesia with epinephrine: an
old myth revisited, J Am Acad Dermatol 2004 Nov;
51(5):755-9
5.
Bibliography (3)
10.
11.
12.
13.
Malamed SF, Daniel L. Handbook of Local Anesthesia. 5th
ed. St Louis, MO: Mosby; 2004
Harrison B & Holland P. Diagnosis and Management Of
Hand Injuries In The ED. Emergency Medicine Practice
Feb 2005. 7; 2.
Overton DT, Uehara DT. Evaluation of the injured hand.
Emergency Medicine Clinics of North America, Aug
1993; 11(3):585-600.
Trott AT. Wounds and Lacerations: Emergency Care and
Closure. 3rd Edition. Elsevier; Feb 2005.
Thank you!
Emory University
Student Health and Counseling Services
Grady Memorial Hospital
Department of Emergency Medicine
mhuey@emory.edu
menelaos4@emory.edu