Suzana Tsao, DO

Closure at the dermal level
Subcutaneous adds little strength
Complex wounds  in/below fascial layer need multi-layer closure

Initially edges retract and tissue contracts
Platelet aggregation and clotting cascade activated
Initial epithelialization 24-48 h
Peak collagen synthesis 5-7d
Strength of wound
5% at 2 weeks
35% at one month

Always start with the ABCD’s
Airway
Breathing
Circulation
Disability

Location
Active bleeding
Exposed tissue/bone/organs
Check for peripheral pulses

Where
Location, location, location
When
Golden period
How
Mechanism
Potential for foreign body

Anatomic location
Special Consideration
Mouth
Ear
Joints periorbital

Golden Hour of Wounds
Infectious inoculum 10 5 per gram
Need 3-5 hours for proliferation of bacteria
Extremities  6 hours
Face and scalp  24 hours
But wait ….

Studies show can close as late as 19 hours on extremities
ACEP clinical policy supports 8-12 hours
Depends on the clinical scenario
Consider other types of closure
Primary closure
Delayed primary closure
Healing by secondary intention

Mechanism
Assess concern for foreign body
Clean wound
Dirty wound
Contaminated wound

Open fractures
Intraoral wounds
Mamillian bites
Crush injuries/devascularized tissue
High pressure injuries
Jagged edges/stellate shape/deeper than subcutaneous layer
Foreign body
Visible contamination

Co-Morbid Conditions
Hand dominance
Occupation
Last tetanus booster

< 3 doses in primary series
Clean/minor
Tetanus toxoid
All other
Toxoid and immunoglobulin
Primary 3 series completed
< 5 years
None needed
> 5 years but < 10 years
Clean minor
None needed
All others
Give toxoid
> 10 years
Give toxoid

Give Tdap regardless of last Td to update pertussis if not updated as an adult
Replaces one of the 10 year Td booster doses
Boostrix when feasible for > 65 y/o
Tdap during each pregnancy b/w 27 and 36 weeks
CDC link http://www.cdc.gov/vaccines/vpd-vac/pertussis/recssummary.htm

Age (very young/very old)
Diabetes
Renal Failure
Malnutrition
Obesity
Immunocompromised

Type of wound
Superficial/deep
Length/shape
Bleeding/revascularization
Associated injuries
Retained foreign body
Complete neurovascular exam
2 point discrimination most accurate for sensory function in extremities

Direct pressure
BP cuff
2 hours max
Figure of 8 stitch

Assess for tendon injuries
90% lacerated tendon can still maintain normal neuro function
Assess for joint involvement
May need to inject joint
Assess for underlying fracture
X-ray if suspected before manipulating the area

Direct visualization
X-ray
May need anesthesia to fully evaluate
80-90% can be detected
Does not visualize organic material
Ultrasound
CT/MRI?

Reactive materials
Wood
Vegetative material
Contaminated materials
Clothes
Most fb in foot
Impingement on neurovascular structures
Impairment of function
Easy to remove

Nerve injury
Vascular injury
Tendon or joint involvement
Difficult to remove foreign body
High pressure injection injury

Dilution is the solution to the pollution
High pressure (5-8 psi)
30-60 cc syringe with 19 gauge angiocath or splash shield
Amount
Min 250ml
50-100ml/cm of laceration
Type of fluid
Tap water just as good as normal saline
NEVER, EVER, NEVER
Betadine or peroxide
1% Betadine may be ok, but no increased benefit

Remove necrotic tissue
May need to debride for better approximation and cosmetic results

Several trials showed no difference if final outcome
Dealer’s choice

Topical pretreatment
Consider procedural sedation
Allergies
Most are from preservative
Consider using cardiac lidocaine
1% Benadryl

Block
Large areas
When needed to avoid tissue distortion
Areas where infiltration is painful
Plantar surface of foot

Amides
Lidocaine
Max 4.5mg/kg
Duration 1-2 h
Lidocaine with epinephrine
Max 7mg/kg
Duration 2-4 h
No epi in fingers/toes, ear, nose, penis
Bupivacaine
Max 2mg/kg 0.25%
Duration 4-8 h
Esters
Procaine
Max 7mg/kg
Duration 15-45 min

Primary closure
Closure of the wound at the time of the ED visit
Delayed primary closure
Closure of wound 3-4 days after injury
Healing by secondary intention
Allow wound to heal without closure through scarring

Tape
Superficial, straight, under little tension
Skin Adhesives
Does not involve deep layers
Little tension
Staples
Linear on trunk, extremities, scalp
Sutures

Absorbable
Gut
PDS (polypropylene)
Maxon (polyglyconate)
Dexon (polyglycolic acid)
Coated Vicryl
(polyglactin)
Nonabsorbable
Dermalon or ethilon
Prolene or surgilene
(polypropylene)
Silk steel

Face
5-0 to 6-0
Scalp/Chest/Back/Abdomen
3-0 to 5-0
Extremities
4-0 to 5-0
Oral
3-0 to 5-0 (absorbable)

Prosthetic device
Endocarditis prophylaxis
Open joints and/or fractures
Mamillian bites
Intraoral lesions
Immunocompromised patients
Heavily contaminated wounds

Signs and symptoms of infection
Fever, discharge, red lines from wound, erythema, swelling
Elevation +/- splinting
When to do wound checks at one or two days
Suture removal instructions
Face 3-5 days
Scalp 5 days
Extremities 7-10 days, high tension 10-14 days
Washing - showering - avoid long baths, pools, ocean
Triple antibiotic ointment

No such thing as absolute golden hour
Tap water is as good and normal saline
Do not soak in betadine
Nonsterile gloves ok
Hand wounds less than 2cm -> big, bulky dressing as good as sutures

Always remember ABC’s
Look for associated injuries
Bone, vascular, nerve
Don’t dismiss high pressure injuries
Always assess for foreign body
Antibiotics vs. delayed primary closure for high risk wound and/or co-morbid conditions
Remember special locations
Ear, nose, vermillion border
Fight bites  do not close