Traumatic lacerations to the skin represent a fairly common reason for seeking emergency department (ED) care. Historically, nearly all lacerations were treated the same way. They were anesthetized with infiltrated lidocaine, cleaned with iodine or hydrogen peroxide, and then explored. Assuming there was no significant damage to the underlying structures, absorbable suture was used to close muscle and fascia, while the skin was sewn with nylon. A dry gauze dressing was applied and tetanus was updated. The patient was advised to return in 3–14 days for suture removal. In general, wounds older than 6 h were considered to be “contaminated” and were not closed in the ED at all. Show
Since the turn of the 21st century, there have been several incremental improvements in laceration management, such as newer and less-painful closure techniques, expanded use of tissue adhesives, new methods for anesthesia, reconsidered antibiotic recommendations, and updates in wound dressings. Although total ED volume in the United States (US) has continued to increase over the past 2 decades, the number of lacerations managed in the ED has declined. In 1992, it was estimated that 9.27 million patients were treated for lacerations in US EDs, representing 10.4% of total US ED volume (1). In 2013, there were approximately 7 million lacerations, making up only 5.2% of total ED visits (Figure 1) (2). It is unclear why lacerations are becoming less common in the ED. It may be a result of improvements in the safety of automobiles, consumer products, or industrial workplaces. Another possibility is that care of minor lacerations has shifted from EDs to urgent care centers. A final consideration is that when confronted with high costs of health care, patients are opting for more conservative management. The societal cost of lacerations can range from trivial to staggering in terms of lost wages and lost productivity. The out-of-pocket cost to a patient with health insurance can easily reach $1000 or more for a simple laceration (3). The history should begin with eliciting the time and exact mechanism of injury. Crush injuries are much more likely to destroy blood supply, which can lead to worse outcomes. Contamination of the wound with dirt or other material can increase the risk of infection. If blood or body fluids from another person or animal have entered the wound, post-exposure prophylaxis for blood-borne infection should be considered. Medical history should be reviewed for predictors of poor wound healing. Tetanus status should be recorded. If circumstances cast any doubt as to the nature of the wounding event, a social history must be sought to determine if domestic violence or another unsafe condition was responsible for the injury. The physical examination should include a meticulous search for contamination and the presence of a removable foreign body. Distal neurovascular function, including testing for two-point discrimination for finger injuries should be carefully documented as well as any other injury to nerve, tendon, bone, or other structures. The inflammatory phase of wound healing begins after hemostasis and clot formation, lasting from 24 h to several days. During this phase, granulocytes flood the wound, removing bacteria and debris. Shortly afterward, epithelial cells migrate into the wound, and the wound is considered waterproof by day 2. New growth, such as neovascularization and matrix deposition occurs during the proliferative phase. By day 3–4, macrophages reorganize the wound and remove the remnants of the inflammatory phase. By day 5–7, collagen deposition begins along with tissue remodeling. This final phase lasts 6–12 months and results in wound contraction and scar formation 4, 5. Predicting which ED wounds are likely to become infected has proven difficult. In one study of 1142 wounds seen in an academic ED, a neural network identified certain risk factors such as wound location, wound age, depth, configuration, contamination, and patient age. In this study, the clinician's estimation (“gestalt”) performed similarly to the computational model. Specific odds ratios (OR) and relative risk ratios (RR) were not provided (6). An observational study of 5521 patients with traumatic lacerations treated in the ED revealed increased risk in certain conditions, such as diabetes (RR 3.9), bite wound (RR 1.6), jagged wound margin (RR 1.7), stellate shape (RR 1.6), visible contamination (RR 1.8), injury deeper than subcutaneous tissue (RR 1.6), and presence of a foreign body (RR 2.9) (7). Another study found that diabetes (RR 2.7), lower-extremity lacerations (RR 4.1), contaminated lacerations (RR 2.0), and lacerations > 5 cm (RR 2.9) were more likely to develop an infection (8). Many surgical textbooks recommend delayed wound closure for lacerations older than 6–8 h 9, 10. The rationale for this advice is that older wounds give bacteria more time to replicate and are therefore more likely to become infected. Closure of potentially infected wounds is expected to result in a poorer outcome. In 1990, Morgan et al. showed a slight increase in wound infection in wounds that were treated more than 4 h after injury. Among those wounds, there was no significant improvement among patients that received prophylactic antibiotics (11). The American College of Emergency Physicians clinical policy of 1999 states that wounds can generally be closed if they are less than 8–12 h old, and beyond that on a case-by-case basis (12). However, it seems that the overall incidence of infection, even in contaminated wounds, is fairly low. In one Thai study, all wounds (including bites) were swabbed and cultured before closure. Potentially pathogenic bacteria were found in 7%, but the rate of clinical wound infection was only 1.2% and occurred solely in patients who were given antibiotics (13). A Dutch study of 425 patients compared infection rate in wounds sutured within 6 h of injury with those sutured more than 6 h from injury and found no correlation between infection rate and time to closure (14). In a multicenter study of 2663 ED patients treated for lacerations, patients who were treated more than 12 h after injury had rates of wound infection similar to those treated < 12 h after injury (8). Similarly, in a study of 2834 children in Philadelphia, wound infection rate was not associated with time to repair (15). Well-vascularized areas of the body are particularly resistant to infection, even in older lacerations. In one study in Kingston, Jamaica, it was found that head wounds, even up to 24 h after injury were not more likely to become infected than those treated sooner. In other body parts, however, the authors found worse outcomes in wounds older than 19 h (16). When data from multiple studies are combined, it appears that there is little evidentiary support for the existence of a golden period. A Cochrane Review in 2015 declared that there was insufficient evidence to recommend primary or delayed primary closure for wounds older than 6 h (17). Ultimately, it appears that there is little evidence for a golden period in wound closure, and the age of the wound should not be a significant factor in deciding whether or not surgical closure is safe or effective. According to Joint Commission standard UP.01.03.01, a “time-out” should be performed before any procedure, including laceration repair (18). Donning personal protective equipment protects both patients and physicians from transmission of blood-borne illness. One small study compared full sterile technique (e.g., cap, gown, face mask, gloves) to surgical clean technique, and found no difference in rates of healing or incidence of complications (19). In another study, sterile surgical gloves were compared with normal examination gloves for laceration repair. Rates of wound infection were similar between the two groups (20). Considering the seven-fold increase in cost, sterile gloves have a limited role in laceration repair. Wound irrigation removes particulate matter and potentially decreases bacterial count. In 1976, Stevenson et al. showed that high-pressure irrigation of 150 mL normal saline through a 19-gauge needle can decrease bacterial counts in experimentally created wounds 10-fold (21). In a more recent study, investigators randomized patients with open fractures to receive high, low, and very-low pressure irrigation (1–2 pounds per square inch [psi], 5–10 psi, and 20+ psi) and found no difference in rates of wound healing or reoperation (22). Because high-pressure irrigation is likely to cause splatter, the use of an appropriate splash shield is indicated. Povidone iodine has been used as an antiseptic for wound repair, but its use has been controversial because it has been linked to possible damage to fibroblasts and keratinocytes (23). In one study, authors found that the use of iodine applied to intact skin edges at least 5 cm from the wound had no effect on wound healing (24). Similarly, another study showed that soaking wounds in dilute iodine solutions does not decrease bacterial counts and is of unlikely benefit (25). Although many other irrigants have been used, a Cochrane Review found that irrigation with tap water was as safe and effective as using more expensive sterile solutions (26). In some wounds, it appears that irrigation may not be beneficial at all. For example, in clean face and scalp wounds, Hollander et al. reported that irrigation did not reduce the risk of infection (27). Retained foreign bodies impair wound healing and predispose to infection. While the majority of foreign bodies are detected by physical examination, imaging should be employed whenever there is a suspicion of foreign body, such as a wound with a depth that cannot be reliably determined or when the laceration is caused by a shattered object (28). Conventional radiography is highly sensitive for radiopaque foreign bodies as small as 1–2 mm. It is considerably less sensitive for wood, plastic, and vegetative material (29). According to one study, plain x-ray studies miss 25% of glass and 93% of wood foreign bodies (28). For radiolucent objects, such as thorns, wood, glass, and plastic, ultrasound has shown sensitivity of 97% (30). Ultrasound has also been used to detect other injuries. For example, it is highly sensitive and specific for nail-bed injuries and distal tuft fractures (31). A meta-analysis published in 2015 showed that ultrasound has high specificity, but only moderate sensitivity for detection of foreign bodies (32). One caveat of this meta-analysis is that a majority of the source articles employed traditional ultrasound instead of point-of-care ultrasound. This is especially relevant for the practicing emergency physician who may not have significant experience with bedside ultrasound. Computed tomography (CT) is superior to plain x-ray study in detection of radiopaque and radiolucent objects, but applies much more ionizing radiation. CT can be more sensitive than ultrasound if the foreign body is in an air-filled cavity, but is less sensitive if the object is near bone. Magnetic resonance imaging provides no benefit over CT, and is contraindicated if the suspected foreign body is metallic 33, 34, 35. For these reasons, CT should not be a first choice for detection of retained foreign bodies. Many patients do not know the date of their last tetanus vaccine. According to a study in the United Kingdom, even among those patients who are “sure” of their tetanus status, one third will be incorrect (36). Due to the increasing incidence of pertussis, The Advisory Committee on Immunization Practices recommends tetanus toxoid, reduced diphtheria vaccine, and acellular pertussis vaccine (Tdap) for all patients over age 10 years who require tetanus prophylaxis (Table 1, Table 2) (37). Most local anesthetics function by antagonizing the sodium pump and disrupting sensory nerve conduction. Local anesthetics are classified as either ester or amides based on their chemical structure. True allergic reactions to local anesthetics are rare. Para-aminobenzoic acid is a metabolite of ester anesthetics and can be allergenic in some patients. Less commonly, the methylparaben preservative found in amide anesthetics can cause allergic reactions. When a patient claims allergy to an ester local anesthetic, it should be safe to use an amide instead. In the case of amide allergy, there are several options: use an ester, such as procaine; try a preservative-free amide, such as cardiac lidocaine; or use a less-common anesthetic, such as diphenhydramine, benzyl alcohol, or ketamine (38) (Table 3). Lidocaine, an amide, is the most commonly used infiltrated anesthetic because of its general tolerability, safety, speed of onset, duration, and cost. Infiltrated lidocaine provides excellent anesthesia in < 2 min and typically lasts at least 30 min, which is adequate for most ED procedures. When used for nerve block, the onset is about 3 min and lasts for about 2 h (39). Bupivacaine, also an amide, is commonly used for infiltrative anesthesia. Onset of action is 10 min and duration can be 7 h (40). Bupivacaine tends to be slightly more painful on injection than lidocaine 39, 41. Given these limitations, bupivacaine alone is inferior to lidocaine for ED procedures. However, some practitioners combine bupivacaine with lidocaine in a single syringe, thereby gaining rapid onset as well as long duration. In patients with allergy to amide anesthetics (such as bupivacaine and lidocaine), procaine (an ester) may be an option. Procaine has an onset of action of 2–5 min after infiltration and has a duration of 1.5–2.5 h (42). Epinephrine functions as a vasoconstrictor, which can be very beneficial by improving visualization of the surgical field, decreasing the dose of anesthetic required and extending the duration of anesthesia. There have been concerns about using epinephrine in fingers, toes, penis, ears, and nose, as it could potentially cause ischemia. However, these fears have not been supported by evidence 43, 44. In a series of 10,201 surgical procedures using lidocaine with epinephrine in the ear and nose, there was not a single ischemic complication (45). In another study, 692 patients underwent digital block with lidocaine with epinephrine (average dose 4.3 mL). There were no ischemic complications (46). Finally, Schnabl et al. reported 95 patients who received a penile ring block with ropivacaine, lidocaine, and epinephrine (47). Again, no ischemic complications were seen. Based on these results, the authors conclude that the myth of epinephrine causing gangrene in acral parts of the body should be put to rest. In patients with true allergy to both ester and amide local anesthetics, diphenhydramine may be an alternative. It has been shown to be considerably more irritating on infiltration and produces less effective anesthesia than lidocaine and should probably be reserved for the most unusual cases 48, 49. Locally infiltrated ketamine combined with a local anesthetic has been used in patients undergoing circumcision, tonsillectomy, mastectomy, and other procedures. Compared to local anesthetic alone, ketamine patients have lower pain scores and lower requirement for rescue analgesia after the procedure 50, 51, 52, 53, 54. In one study on cleft-palate repair in children aged 1–6 years, infiltrated ketamine alone was compared to bupivacaine and found to have similar anesthetic properties. Fewer patients in the ketamine group required rescue analgesia or had disturbed sleep when compared to the bupivacaine group (55). Local anesthetics are all weak acids and can be painful on injection. Lidocaine can be buffered by mixing 9 mL lidocaine with 1 mL of 8.4% sodium bicarbonate. Buffered lidocaine is significantly less painful on injection than regular lidocaine 56, 57. Unfortunately, it is not commercially available, and must be compounded by hospital pharmacies. When stored at 5°C in a dark environment, buffered lidocaine retains 95% efficacy at 28 days (58). Warming lidocaine to body temperature reduces pain on injection, as does using a smaller (eg, 30-guage) needle 59, 60. When the solution is both warmed and buffered, the effects are synergistic (57). Injection through the wound edges is significantly less painful than injection through intact skin 61, 62. Using a slower speed of injection does not reduce pain 63, 64. If time permits, a topical anesthetic significantly reduces the pain of local infiltration (65). Topical anesthetics absorb into the skin and can produce superficial anesthesia. They can be used alone or as an adjunct to infiltrated anesthesia. The eutectic mixture of local anesthetics (EMLA) consists of prilocaine and lidocaine and was the first commercially available topical agent to provide adequate surgical anesthesia. It is applied to skin in a thick layer (1–2 g per 10 cm2). After application, it is covered with an occlusive dressing for 30–120 min, penetrating the stratum corneum to a maximum depth of 3–5 mm (66). EMLA has been shown to decrease pain on infiltration of local anesthetic, and has also been used as sole anesthesia for wound closure, although it requires supplemental injected local anesthetic in 15% of cases 65, 67. According to the package insert, EMLA should not be used on open wounds (68). Despite this warning, several studies have demonstrated safety and efficacy 65, 67, 69. Lidocaine-epinephrine-tetracaine (LET) (sometimes called lidocaine-adrenaline-tetracaine) is a widely studied topical anesthetic cocktail with efficacy similar to EMLA (69). It is not commercially produced and must be compounded locally. It does not carry any prohibition against being used in open wounds. In one small study, LET gel placed on the wound 20 min before suturing was as effective as local infiltrate of lidocaine (70). Tetracaine-adrenaline-cocaine (TAC) was one of the first commonly used topical anesthetics. TAC is equally efficacious as LET, but has fallen into disfavor because of cost, systemic toxicity, and potential for abuse. When compared to EMLA, it is useful as an adjunct to infiltrated lidocaine, but has poor efficacy as solitary anesthesia (67). Liposomes are microscopic, spherical, phospholipid-based carriers that facilitate transport of drug across the skin. A meta-analysis by Eidelman et al. compared EMLA, tetracaine, liposomal tetracaine, and liposomal lidocaine (71). They found that the liposomal agents are less expensive than EMLA and have comparable efficacy. Interestingly, a Cochrane Review by the same authors concluded that data were insufficient to make clear recommendations (72). Iontophoresis, or electromotive drug administration, is a promising technique that uses a mild electrical current to enhance topical absorption of local anesthetic. In one study, iontophoresis showed better anesthesia at 30 min than did EMLA (73). Although iontophoresis is effective, there are several major drawbacks. Firstly, it can cause skin irritation when used at modest current for prolonged periods of time. Second, the electrical sensation can be unpleasant for some people. Finally, the iontophoresis unit can be expensive and bulky (74). In summary, it seems that the overwhelming majority of adult patients are able to tolerate infiltrated lidocaine, which provides very rapid and complete anesthesia. While topical agents are painless to apply, the long time required to achieve surgical anesthesia make them unattractive for routine ED use. The ideal suture material provides excellent tensile strength, is easy to handle, resists secondary infection, has no tissue reactivity, and absorbs spontaneously when the wound is healed. Traditionally, monofilament nylon sutures have been used to close skin and absorbable sutures have been used to approximate deeper structures. Recent studies have advocated using absorbable suture material for superficial as well as deep sutures. While absorbable suture usually has less tensile strength than nonabsorbable suture, it does not require a separate visit for suture removal, making it attractive to patients who are fearful of medical intervention. In a study on pediatric facial lacerations, no cosmetic difference was found when absorbable suture was compared to nonabsorbable suture to close skin (75). In a study of 52 patients undergoing Mohs surgery, wounds were divided in half. One side was closed with absorbable sutures and the other side closed with nonabsorbable sutures. The wounds were evaluated at 1 week and again at 4 months. No cosmetic difference was seen between the two groups (76). A systematic review found that absorbable sutures had an overall lower rate of dehiscence compared to nonabsorbable sutures. This finding may be more reflective of the fact that absorbable sutures tend to remain in the skin for longer periods of time than nonabsorbable sutures (77). While absorbable sutures cannot be recommended for areas of high tension, they seem adequate for deep as well as superficial lacerations. In one study on traumatic lacerations, running sutures used less suture material and were faster to place than simple interrupted sutures. The complication rate was similar in both groups (78). Metallic surgical staples are durable, have minimal tissue reactivity, and can be placed relatively quickly. Because of their width, they are not recommended in body parts where a cosmetic closure is needed. Staples have been shown to be faster, less expensive, and possibly less painful for repair of scalp lacerations (79). Newly developed subcuticular absorbable staples (Figure 2) have shown promise in clinical studies. In one nonrandomized study of 100 patients undergoing breast surgery, the authors found comparable cosmetic outcomes between absorbable staples and traditional subcuticular sutures (80). Tissue adhesives have been commonly used in veterinary practice since the 1970s, but first gained Food and Drug Administration approval for human use in 1998 with the introduction of 2-octyl-cyanoacrylate (OCA) (Dermabond®; Ethicon, Somverville, NJ). In 2002, another adhesive, n-butyl cyanoacrylate (BCA) (Indermil™ Tissue Adhesive; United States Surgical, Norwalk, CT) was approved (81). Theoretically, because OCA has a longer side chain than BCA, it will polymerize more slowly, release less heat, cause less pain, and form a stronger, more flexible bond. In experimentally injured rats, it was shown that the amount of tension required to cause dehiscence (wound bursting strength) is significantly greater for OCA than for BCA, which is, in turn, greater than adhesive strips with tincture of benzoin (82). When studied in human lacerations, however, researchers were unable to distinguish the cyanoacrylates on the basis of cosmesis, pain, ease of procedure, time to repair, or rate of dehiscence 83, 84. It was noted, however, that the OCA took longer to dry than the BCA (54 s vs. 80 s) 84, 85. In one study of surgical pediatric groin incisions, there was a greater incidence of wound dehiscence with BCA when compared to OCA, but no difference in infection or ultimate cosmetic result (86). Not all lacerations are candidates for tissue adhesive. Cyanoacrylates are best for short, linear, low-tension wounds that can be easily approximated by hand. Areas of high tension or mobility, such as extensor surfaces or wounds located on hands or feet, must be buttressed by deep tension-relieving sutures or immobilization (87). Areas of the body that are moist or concave or covered with hair also limit adhesion. When applied, the tissue adhesive should be placed on the surface of the skin, forming a bridge over the wound. When the adhesive is placed within the cavity of the wound, it can cause an inflammatory response and prevent healing (88). Multiple studies on facial lacerations have shown cosmetic and infection rate equivalence between cyanoacrylate and subcuticular and absorbable and nonabsorbable sutures 89, 90, 91. However, a Cochrane Review found cyanoacrylates have a slightly increased risk of dehiscence when compared to sutures (92). Skin adhesives are limited by the fact that the wound must be well approximated before the adhesive can be applied. In one popular technique, the wound edges are approximated meticulously with adhesive strips and then fixed in place with skin adhesive 93, 94. A commercial device employing this principle (Dermabond Prineo; Ethicon Inc.) combines a mesh tape with liquid adhesive. The activator for the liquid adhesive is located within the tape itself, instead of in the applicator. This allows the provider to approximate the edges with tape and then apply the liquid adhesive when the wound edges are apposed. In a study of 214 traumatic lacerations closed in the ED, the tape/adhesive combination was equivalent to adhesive alone in terms of wound edge apposition and cosmetic appearance (95). This combination has been tested in many surgical applications, especially in plastic surgery, where it has been found equivalent to subcuticular sutures and up to six times faster to place 96, 97. The hair apposition technique (HAT) was described by Hock et al. in 2002 for closing scalp lacerations (98). The hair adjacent to the laceration is grasped with forceps and twisted so as to approximate the wound edges. A drop of tissue adhesive is placed on the hair and allowed to dry. HAT was shown to have better healing, less pain, less scaring, fewer complications, shorter procedure time, and was more cost-effective than standard suturing techniques 98, 99. Surgical zippers consist of two parallel strips of adhesive material joined by a reclosable connector. Although limited to linear lacerations, zippers offer painless and atraumatic closure and are generally faster than sutures. Similar to tissue adhesive, the zipper device peels off spontaneously after 7–10 days, so a return visit is not necessary. The Surgizip (MediTech Healthcare Inc., Singapore) and Medizip (Atrax Medical Group Ltd., Bermuda) are closure devices that look like traditional clothing zippers. Both have shown safety and efficacy similar to sutures for relatively low cost ($10–$13). The Surgizip can be used for lacerations up to 47 cm. Neither of these products is available in the United States at this time 100, 101, 102, 103, 104. The Zip Surgical Skin Closure (ZipLine Medical, Inc., Campbell, CA) was released in 2013. It is composed of two strips of hydrocolloid tape joined by adjustable plastic zip-ties (Figure 3). In a study of 214 children undergoing median sternotomy, cosmetic and infectious complications were comparable to subcuticular sutures, while placement time was reduced. Complications peculiar to the ZipLine device include skin discoloration (0.9%), epidermolysis (0.9%), and spontaneous detachment of the device (1.8%). In those cases where the device fell off, a new device was placed uneventfully. Skin changes were transient and treated with topical steroid creams 105, 106. In one study, pediatric facial lacerations closed with adhesive tape (Steri-Strip; 3M, Maplewood, MN) had similar cosmetic appearance to those closed with tissue adhesive (107). Some studies even question whether skin closure is beneficial at all. In one study of simple hand wounds (<2 cm; without tendon, joint, fracture, or nerve complications), the authors found no benefit in surgical wound closure when compared with wound dressing alone (108). Because most of these methods have at least one study demonstrating cosmetic and infectious equivalence (at least in linear, low-tension wounds), it may be useful to consider material cost and operator time when selecting a closure method. Traditional sutures take considerably longer to place and require the additional purchase of local anesthetic as well as a suture tray, but allow the most meticulous closure and the lowest rates of wound dehiscence (Table 4) (92). Bite wounds have a higher risk of infection because oral flora of the biter can be easily inoculated into the victim. In dogs, cats, and humans, Staphylococcus and Streptococcus contaminate most wounds (115). Dog bites are the most common type of bite wound. According to some sources, Pasturella canis is the most common infecting organism, however, this may be in dispute 115, 116, 117. Untreated, the infection rate is about 5%. According to several studies, this rate does not decrease with the introduction of prophylactic antibiotics. However, in a subgroup analysis, it was found that hand injuries are much more likely to benefit from antibiotics than other wounds 118, 119. Another study found that puncture wounds and bites that are closed surgically are at greater risk of infection (117). Therefore, it seems prudent to consider antibiotics in patients who have puncture wounds, hand injuries, and those that are closed surgically. Amoxicillin-clavulinate for 5 days is the most commonly recommended regimen. An alternative regimen for penicillin-allergic patients is ciprofloxacin+clindamycin. Trimethoprim-sulfamethoxazole may be substituted for ciprofloxacin in penicillin-allergic children. Cat bites are less common, but often more serious. The most commonly isolated organism is Pasturella multocida, which is carried by up to 90% of domesticated cats (120). It is not clear how often cat bites will become infected, and estimates vary from 15%–80%, presumably due to selection bias 118, 120, 121, 122, 123. Because there is a greater frequency of puncture wounds in cat bites, deep infections, such as flexor tenosynovitis and septic arthritis, are more common. In one small study on 12 patients with cat bites, antibiotic prophylaxis reduced infection rate from 67% to 0% (124). The majority of evidence, however, supports more judicious use of antibiotics. The Infectious Disease Society of America recommends prophylaxis in patients with immune suppression; asplenia; liver disease; edema of the affected area; injuries to the hand or face; or injuries that may have penetrated the periosteum or joint capsule (125). Human saliva contains as many as 50 species of bacteria, with almost 108 organisms/mL, which may explain why human bites are believed to be more infectious than other animal bites (126). Human bites occur as either occlusive bites, when one person deliberately bites another, or as a clenched fist injury (also called a “fight bite”), when one person punches another person in the mouth, thereby inoculating his own hand with oral flora from the victim. After Staphylococcus and Streptococcus, Eikanella corrodens has been implicated as the causative organism in most severe infections. Children tend to have less gingivitis and are therefore less likely to transmit infection when they bite (127). In one study on 48 human bites to the hand, antibiotics reduced the infection rate from 46% to 0% (128). Meanwhile, another study of 127 human bite wounds, which specifically excluded wounds to the hands, feet, or cartilaginous areas, showed only 1 patient with infection, and that was in the antibiotic group (123). Based on this information, antibiotic prophylaxis is reasonable in all patients with human bites to hands, feet, and cartilaginous areas. Traditionally, wound care instructions involved advising the patient to keep the wound clean and dry. It was believed that dry wounds were less likely to become infected and that scabs were a necessary part of healing. For this reason, absorptive, gauze-based dressings are most commonly used for lacerations in the ED. In 1990, Hutchinson and McGuckin showed that occlusive dressings (which limit dehydration) are associated with a significantly lower rate of infection (129). In addition, occlusive dressings have been shown to speed healing, reduce pain, and improve patient quality of life compared with gauze dressings (130). Other benefits of occlusive dressings include less frequent dressing changes and, because they are waterproof, patients may bathe with dressings in place. There are several types of occlusive dressings commonly in use. Films are clear, thin, nonabsorptive, adhesive plastic membranes that can be placed directly on top of a wound. The adhesive sticks to intact skin, but not the moist wound. Because films are clear, frequent visual reassessment of the wound is possible. Films are ideal for wounds with little to no exudate and may be left in place for up to 7 days. Because many ED wounds will be ready for suture removal in this time frame, dressing changes may not be required at all. Hydrocolloids are similar to films, but are thicker, somewhat absorptive, and more translucent than transparent. These dressings are more useful for wounds that are likely to have some exudate, such as wounds involving the deeper dermis. Like films, they may remain in place for up to 7 days. Foams are thicker, opaque, and more absorptive than hydrocolloids. They must be changed every 3 days and are indicated for wounds that have moderate exudate. Because acute wounds without infection tend not to have much exudate, foams have a limited role for acute lacerations treated in the ED (Table 5) (130). There are mixed data on topical antibiotics. In 1995, Dire et al. showed that topical antibiotics significantly decreased infection in ED patients with sutured wounds when compared with petrolatum gel (the control) (131). The primary weakness of this study is that the reported wound infection rate was very high (10% overall and 23% on extremities), whereas most modern studies report clinical wound infection at ≤5% (131). Other studies have failed to show a benefit of topical antibiotics. Some have argued that it is the moist wound environment, rather than the antibiotic itself that promotes wound healing. In a study comparing white petrolatum ointment to bacitracin, there was no significant difference in wound infection rate (2% vs. 0.9%; p = 0.37). There were, however, rare episodes of contact dermatitis in the bacitracin group that were not seen in the control (132). In one dermatology study, 30 patients were identified who had to have two elective, sterile excisional procedures on the same day. In each patient, one wound was covered with antibiotic and the other with white petrolatum. There was no significant difference seen in wound healing between the two groups (133). It is not clear how these data translate to the more heavily contaminated wounds seen in the ED. The routine use of prophylactic oral antibiotics has been studied in many patient populations and found to be nonbeneficial 118, 134, 135. Unfortunately, most studies have notable exclusion criteria, for example, immune deficiency, such as diabetes, cancer, chemotherapy, transplant recipients, steroids, and human immunodeficiency virus (HIV)/AIDS; perceived high-risk wounds, such as oral wounds, bite wounds, crush injuries; wounds that are grossly contaminated, especially those with a retained foreign body; and wounds that involve other structures, such as cartilage, tendons, joints, or bones. As a result, it is unclear whether or not antibiotics have a benefit in these populations. There are no high-quality studies that address this question. The conventional wisdom is that areas of higher tension mandate longer suture time. If sutures are removed too early, the risk of dehiscence rises. If sutures remain in place too long, they can result in a sinus tract or suture imprints (e.g., “traintracks”). See Table 6 4, 136. Although most wounds heal uneventfully, patients with poor follow-up or those with higher-risk wounds should be advised to have a wound check within 2 days to detect early infection. In most cases, this involves returning to the ED and potentially generating further charges. Another option is to have the patient take a photo of the wound and send it to the treating doctor. Although this option is convenient for the patient, it has not been rigorously tested for safety or reliability (137). Why is epinephrine not used in areas such as the fingers toes and nose?The conventional wisdom was clear: Epinephrine should never be used in an end-arterial field (eg, digits, pinna, nose, penis) owing to the risk for necrosis.
When assisting with suturing a laceration after bandaging the site you should remove your gloves and?When assisting with the suturing of a laceration, after bandaging the site, you should remove your gloves and ? Dispose of them in the biohazardous waste container or bag.
Which of these anesthetic agents is injected into subcutaneous tissue?Tumescent anesthesia for plastic surgical procedures such as liposuction involves the injection of extremely large volumes of lidocaine into subcutaneous tissues, usually with the addition of epinephrine for added safety.
Which of the following forceps are used to grasp tissue and in suturing?Adson Forceps: Forceps toothed at the tip used for handling dense tissue, such as in skin closures. Also called locking forceps, these are ratcheted instruments used to hold tissue or objects, or provide hemostasis.
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Local anesthetics with epinephrine are not recommended for use in suturing a finger laceration.
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