Professional Documents
Culture Documents
Chris Bodle
2/15/16
II. Preparation
A. Cleaning
o Sterile saline and tap water equivalent
o Irrigation (50-100ml per cm of laceration)
o 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.2 3
o
B. Imaging
o X-ray, ultrasound, CT scan can detect presence of
radiopaque foreign bodies in the wound
Glass, metal, shrapnel, teeth
o Does not replace wound exploration for identification of
radiolucent material
Organic material, clothing
III. Materials
A. Vicryl: Braided, absorbable suture
o Maintains tensile strength for 3-4 weeks.
o Indications: preferred material for subcutaneous closure
Deep closure of muscle, fascia, subcutaneous tissue
Should not be used to close skin
o Purple vicryl can tattoo skin when used in the
subcutaneous tissue
B. Prolene/Nylon: Monofilament, non absorbable
o Indications
Skin closure, tendon repair
o Extremities (Arms/legs)
3-0 or 4-0, consider 2-0 over large joints or areas of
tension
Remove in 7-10 days
V. Wound type
Contaminated wounds
o Copious irrigation
o Lacerations or wounds over joints should be challenged
with saline load to ensure no joint involvement.
Recommend orthopedic surgery consult.
o 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
o Copious irrigation with debridement as needed
o Facial wounds may be closed up to 24 hrs after
presentation
o Wounds in the extremities may be closed up to 12 hrs after
presentation
o 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
o Exposed cartilage should not be sutured. Perichondrium
should be the deepest stitch. Exposed cartilage needs to
be covered with skin completely.
o 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.
o Complicated facial lacerations involving the lacrimal duct,
eye lid edge, eye lid function should prompt a consult to
ophthalmology
Antibiotics
o Not indicated for simple lacerations
o 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)
10 11
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):716720
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):13641367
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: 404409.
4 Mehta PH, Dunn KA, Bradfield JF, Austin PE. Contaminated wounds: infection rates with
subcutaneous sutures. Ann Emerg Med 1996; 27:43.
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):189195
11 Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a metaanalysis of randomized studies. Am J Emerg Med 1995; 13:396.