Skin Laceration and Abrasion Care - Curbside
Skin Laceration and Abrasion Care
Editors: Dan Imler, MD
Inclusion Criteria  (Any one criteria present)
  • Simple skin laceration or abrasion
Exclusion Criteria
  • Complex anatomical location (auricle, intraoral, eyelid involvement, genital or rectal involvement)
  • Deep muscle, tendon or neurovascular involvement
  • Deep puncture wounds
  • Animal or human bites
  • High tension skin areas
  • Active signs of infection
  • Complex nature of wound
Consult advanced provider in wound repair

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Evidence
Total Notes: 19
Evidence

1 Goals of care

Lacerations and abrasions represent millions of visits to emergency and urgent care centers throughout the world. Although new techniques and technologies constantly appear, the primary goals of care have remained unchanged:

  1. Assure hemostasis
  2. Avoid infection
  3. Achieve a functional and aesthetically pleasing scar


References:
  1. Laceration management.
    Hollander JE, Singer AJ
    Ann Emerg Med. 1999;34(3):356.

2 Skin wound care

Goals of Care

Lacerations and abrasions represent millions of visits to emergency and urgent care centers throughout the world. Although new techniques and technologies constantly appear, the primary goals of care have remained unchanged:

  1. Assure hemostasis
  2. Avoid infection
  3. Achieve a functional and aesthetically pleasing scar

Wound healing

Skin wounds heal in a standard pattern, which is important to understand when determining the proper treatment of these injuries.

  1. Coagulation and vasospasm producing a fibrin clot and hemostasis
  2. Inflammatory phase with neutrophil/macrophage breakdown of injured tissue
  3. Epithelialization of epidermal tissue and wound bridging over 48 hours (no regeneration of deep structures)
  4. Blood vessel growth (peak 4 days after injury)
  5. Collagen production restores tensile strength (begins within 48 hours, peaks at 1 week, continues for up to 12 months)
  6. Wound contraction (starts 3 days post injury)


References:
  1. Laceration repair. In: Textbook of pediatric emergency procedures
    McNamara, RN, Loiselle, J
    Williams and Wilkins, Baltimore 1997. p.1141.
  2. Laceration management.
    Hollander JE, Singer AJ,
    Ann Emerg Med 1999 Sep;34(3):356-67.

3 Risks for poor outcomes

Many patients have host-specific risk factors for skin wound repair which are usually related to underlying chronic disease processes (DM, collagen vascular diseases, obesity, chemotherapy, renal disease, nutritional deficiencies, etc.). These host factors may alter the risk of the patient for certain techniques of wound management and should be identified early on.

In addition, the nature of the wound should be evaluated closely as alterations in temperature, risk of ischemia and risk of infection should modify wound management.

Wounds that involve tendons, nerves, major blood vessels, joints or other concerning structures often require surgical exploration prior to primary closure.



References:
  1. Disturbances of wound healing.
    Robson MC
    Ann Emerg Med. 1988;17(12):1274.
  2. Laceration management.
    Hollander JE, Singer AJ
    Ann Emerg Med. 1999;34(3):356.
  3. Risk factors for infection in patients with traumatic lacerations.
    Hollander JE, Singer AJ, Valentine SM, Shofer FS
    Acad Emerg Med. 2001;8(7):716.
  4. Determinants of poor outcome after laceration and surgical incision repair.
    Singer AJ, Quinn JV, Thode HC Jr, Hollander JE
    Plast Reconstr Surg. 2002;110(2):429.

4 Achieving hemostasis

A majority of simple wounds will achieve hemostasis with constant pressure for 10-15 min. If there is persistent bleeding the injection of 1% lidocaine with epinephrine into the local area may be effective. In addition, the use of absorbable gelatin foam may be used in clean wounds to attenuate bleeding. Additional techniques are:

  • Use of a BP cuff at 10 mmHg above systolic pressure applied to proximal end of extremity with wound after elevating the extremity for 1 min to allow venous drainage.
  • Large extremity tourniquets (30-60 min)
  • Digital tourniquets (20-30 min)


References:
  1. Wounds and Lacerations
    Trott, AT
    Mosby-Year Book, St. Louis 1997.p.122.

5 Tetanus prophylaxis

Any open wound increasing the risk of tetanus. If a patient is not adequately vaccinated against tetanus they should receive the tetanus vaccine immediately. This should include the diphtheria vaccine (Td) or the pertussis as well if indicated (Tdap).



References:
  1. Advisory committee on immunization practices recommended immunization schedule for adults aged 19 years or older: United States, 2014.
    Bridges CB, Coyne-Beasley T, Advisory Committee on Immunization Practices
    Ann Intern Med. 2014;160(3):190.
  2. Serologic immunity to diphtheria and tetanus in the United States.
    McQuillan GM, Kruszon-Moran D, Deforest A, Chu SY, Wharton M
    Ann Intern Med. 2002;136(9):660.

6 Issues affecting primary closure

  • The time of injury to repair of a wound impacts the rate of healing. Wounds older than 19 hours are at higher risk of worse outcomes/infections; however wounds on the face may be closed up to 24 hours if the wound site is clean.
  • Stellate or wounds with irregular borders increase the risk of infection and poor cosmetic outcome.
  • Crush wounds may cause local tissue ischemia that can increase the risk of infection if not properly debrided
  • Stabbing or penetrating wounds may need surgical consultation for concern of deeper structural damage prior to primary closure


References:
  1. Evaluation of the 'golden period' for wound repair: 204 cases from a Third World emergency department.
    Berk WA, Osbourne DD, Taylor DD
    Ann Emerg Med. 1988;17(5):496.
  2. Wound infections after minor limb lacerations: risk factors and the role of antimicrobial agents.
    Stamou SC, Maltezou HC, Psaltopoulou T, Tsaroucha A, Kaseta M, Skondras C, Asimacopoulos PJ, Kafetzis DA
    J Trauma. 1999;46(6):1078.

7 Secondary and delayed closure

Secondary closure (granulation) of wounds may be indicated in some situations. Delayed presentation, contamination, deep wounds that cannot be irrigated, non-cosmetic animal bites and abscess cavities may cause the clinician to abort primary closure.

In some cases, delaying closure of the wound may be optimal either allowing the patient's own immune system or antibiotics to take effect prior to the closure of a wound.

In each case, including abrasions, cleaning of the wound and giving follow up advice is necessary.



References:
  1. Evaluation of the 'golden period' for wound repair: 204 cases from a Third World emergency department.
    Berk WA, Osbourne DD, Taylor DD
    Ann Emerg Med. 1988;17(5):496.
  2. Minor Wound Care. In: Pediastat
    Brancato JC, Babl FE, Vinci RJ.
    CMC ReSearch, Portland, OR1998.
  3. Debridement: an essential component of traumatic wound care.
    Haury B, Rodeheaver G, Vensko J, Edgerton MT, Edlich RF
    Am J Surg. 1978;135(2):238.

8 Procedural sedation

Sedation has been shown to improve the provider’s ability to adequately perform procedures in patients who otherwise would not be able to tolerate the procedure. There are no hard and fast indications for the use of procedural sedation. The providers should assess the patient's level of anxiety, behavioral status and ability to tolerate the procedure and weigh this against the risks inherent in sedation.



References:
  1. Procedural sedation and analgesia in children.
    Krauss B, Green SM
    Lancet. 2006;367(9512):766.
  2. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update.
    American Academy of Pediatrics, American Academy of Pediatric Dentistry, CotéCJ, Wilson S, Work Group on Sedation
    Pediatrics. 2006;118(6):2587.
  3. Relief of pain and anxiety in pediatric patients in emergency medical systems.
    Zempsky WT, Cravero JP, American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine
    Pediatrics. 2004;114(5):1348.

9 Anxiolysis

Laceration repair can be a scary event, especially for young children. In appropriate cases, the use of anxiolysis can improve the provider’s ability to perform the procedure and maximize cosmetic outcome. If initial non-pharmalogic methods are ineffective the use of nitrous oxide or midazolam can be helpful.

Evidence suggests that the use of nitrous oxide may be more effective and have a shorter recovery time than midazolam for short, minimally painful procedures (digital blocks, laceration repair, skin biopsy, etc.). Pediatric patients below 4 years of age are less likely to have successful anxiolysis with nitrous oxide.

Midazolam’s onset is 20 – 30 minutes, so the provider should wait this length of time minimum before starting the procedure (duration 30 – 60 min).



References:
  1. Fixed 50% nitrous oxide oxygen mixture for painful procedures: A French survey.
    Annequin D, Carbajal R, Chauvin P, Gall O, Tourniaire B, Murat I
    Pediatrics. 2000 Apr;105(4):E47.
  2. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair.
    Luhmann JD, Kennedy RM, Porter FL, Miller JP, Jaffe DM
    Ann Emerg Med. 2001;37(1):20.
  3. Efficient intravenous access without distress: a double-blind randomized study of midazolam and nitrous oxide in children and adolescents.
    Ekbom K, Kalman S, Jakobsson J, Marcus C
    Arch Pediatr Adolesc Med. 2011;165(9):785.
  4. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases.
    Zier JL, Liu M
    Pediatr Emerg Care. 2011 Dec;27(12):1107-12.
  5. High-concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation.
    Babl FE, Oakley E, Seaman C, Barnett P, Sharwood LN
    Pediatrics. 2008 Mar;121(3):e528-32.
  6. Procedural sedation and analgesia in children.
    Krauss B, Green SM
    Lancet. 2006;367(9512):766.

10 Foreign body

Any foreign body in a wound increases the likelihood of infection and should be removed if reasonable. If an object is identified in a non-critical anatomic area and will likely not cause irritation (glass, metal) if may be left in place if very difficult to remove. Objects that contain irritant material (wood splinters) or are near vital structures should be removed.

Although direct inspection reveals a majority of foreign bodies, many objects may remain hidden, especially in a large or puncture wound. Radiographs have been shown to improve the provider’s ability to identify glass and should be considered in most cases. A cadaver study showed a sensitivity of 90 percent for glass fragments (although the rate was affected by size and type of glass).



References:
  1. Risk factors for infection in patients with traumatic lacerations.
    Hollander JE, Singer AJ, Valentine SM, Shofer FS
    Acad Emerg Med. 2001;8(7):716.
  2. Side-effects of high pressure irrigation.
    Wheeler CB, Rodeheaver GT, Thacker JG, Edgerton MT, Edilich RF
    Surg Gynecol Obstet. 1976;143(5):775.
  3. Foreign body retention in glass-caused wounds.
    Montano JB, Steele MT, Watson WA
    Ann Emerg Med. 1992;21(11):1360.
  4. Retained glass foreign bodies in wounds: predictive value of wound characteristics, patient perception, and wound exploration.
    Steele MT, Tran LV, Watson WA, Muelleman RL
    Am J Emerg Med. 1998;16(7):627.
  5. Detection of foreign bodies in the hand.
    Russell RC, Williamson DA, Sullivan JW, Suchy H, Suliman O
    J Hand Surg Am. 1991;16(1):2.
  6. Radiographic imaging of foreign bodies in the hand.
    Donaldson JS
    Hand Clin. 1991;7(1):125.

11 L.E.T.

LET = Lidocaine (4%) - Epinephrine (0.1%) - Tetracaine (0.5%). It has been shown to provide adequate anesthesia in 75-90 percent of patients. On lower extremities and trunchel wounds LET has less efficacy. Even if supplemental lidocaine is required, the pain from the injection has been shown lower than if LET was not used.

LET is not recommended to be used on the digits, penis, nose, and ears due to risk of vasoconstriction. The lidocaine from the preparation can be absorbed systemically so placement in large wounds or on mucus membranes is also not recommended. In addition, large wounds are less likely to achieve adequate anesthesia from LET alone. Using LET in neonates < 1 month should be done so with caution as they have higher topical absorption and would be at risk from the tetracaine component. A dose of 3ml usually is successful in most small wounds and has been shown to have no serious toxicity.

LET gels have advantages over solution in several respects in a study of 200 children with suturing of uncomplicated scalp and facial lacerations.

  • More patients had complete anesthesia (85 percent compared to 76 percent)
  • Less had partial anesthesia (5 percent compared to 21 percent)
  • Less accidental contact with mucous membranes
  • Less loss of volume from drainage
  • Easier application of the gel

However, more of these patients have incomplete anesthesia compared to solution (9 percent compared to 3 percent).

Of note, LET was shown also shown to improve analgesia in patients receiving tissue adhesives alone.



References:
  1. Toxicity of local anesthetics in infants and children.
    Berde CB
    J Pediatr. 1993;122(5 Pt 2):S14.
  2. The "ouchless emergency department". Getting closer: advances in decreasing distress during painful procedures in the emergency department.
    Kennedy RM, Luhmann JD
    Pediatr Clin North Am. 1999;46(6):1215.
  3. Tetracaine, epinephrine (adrenalin), and cocaine (TAC) versus lidocaine, epinephrine, and tetracaine (LET) for anesthesia of lacerations in children.
    Schilling CG, Bank DE, Borchert BA, Klatzko MD, Uden DL
    Ann Emerg Med. 1995;25(2):203.
  4. Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years.
    Ernst AA, Marvez E, Nick TG, Chin E, Wood E, Gonzaba WT
    Pediatrics. 1995;95(2):255.
  5. Topical anesthesia for pediatric lacerations: a randomized trial of lidocaine-epinephrine-tetracaine solution versus gel.
    Resch K, Schilling C, Borchert BD, Klatzko M, Uden D
    Ann Emerg Med. 1998;32(6):693.
  6. Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: a randomized double-blind trial.
    Singer AJ, Stark MJ
    Acad Emerg Med. 2000;7(7):751.
  7. Topical anaesthetics for repair of dermal laceration.
    Eidelman A, Weiss JM, Baldwin CL, Enu IK, McNicol ED, Carr DB
    Cochrane Database Syst Rev. 2011;Jun 15;(6)
  8. Relief of pain and anxiety in pediatric patients in emergency medical systems.
    Zempsky WT, Cravero JP, American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine
    Pediatrics. 2004;114(5):1348.
  9. Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial.
    Harman S, Zemek R, Duncan MJ, Ying Y, Petrcich W
    CMAJ. 2013;185(13):E629.

12 Local anesthetic infiltration

1 percent lidocaine is the infiltration anesthetic of choice. Concentrations greater than 1 percent have not been shown to improve the onset or duration of analgesia and increase the risk of toxicity. Onset time is usually 2 - 5 min and the duration lasts 30 - 120 minutes. Buffering lidocaine with sodium bicarbonate has been shown to decrease pain and may shorten the onset time.

The use of epinephrine has the benefit of decreasing local bleeding, decreasing systemic absorption of lidocaine and extending the duration of action up to 180 minutes. In the past, warnings existed for using epinephrine in the injection of the nose and ear, digit, or penis. However, reviews of the literatures have shown no major reports of ischemic complications with epinephrine. 

Max doses are 4mg/kg for lidocaine WITHOUT epinephrine and 7mg/kg for lidocaine WITH epinephrine.



References:
  1. Local and topical anesthesia. In: Clinical Procedures In Emergency Medicine, 5th edition
    McGee, DL.
    Saunders Elsevier, Philadelphia 2010.p.481.
  2. Toxicity of local anesthetics in infants and children.
    Berde CB
    J Pediatr. 1993;122(5 Pt 2):S14.
  3. Sedation and analgesia. In: Textbook of Pediatric Emergency Medicine, 5th
    Selbst SM, Fein JA
    Lippincott Williams and Wilkins, Philadelphia 2006.p.69.
  4. The ouchless emergency department. Getting closer: advances in decreasing distress during painful procedures in the emergency department.
    Kennedy RM, Luhmann JD
    Pediatr Clin North Am. 1999;46(6):1215.
  5. Anesthesia. In: Dermatology, Volume 2, 2nd
    Hruza, GJ
    Mosby Elsevier, Spain 2008.p.2173.
  6. Digital anesthesia with epinephrine: an old myth revisited.
    Krunic AL, Wang LC, Soltani K, Weitzul S, Taylor RS
    J Am Acad Dermatol. 2004;51(5):755.
  7. Six years of epinephrine digital injections: absence of significant local or systemic effects.
    Muck AE, Bebarta VS, Borys DJ, Morgan DL
    Ann Emerg Med. 2010;56(3):270.
  8. Do not use epinephrine in digital blocks: myth or truth? Part II. A retrospective review of 1111 cases.
    Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ
    Plast Reconstr Surg. 2010;126(6):2031.
  9. A critical look at the evidence for and against elective epinephrine use in the finger.
    Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ
    Plast Reconstr Surg. 2007;119(1):260.

13 Wound preperation

Debridement of the wound to remove de-vascularized tissue improves the body's ability to heal and prevents infection. This should be done with care to ensure cosmetic outcome and if excision is required, it should be done along the relaxed skin tension lines.

Irrigation is one of the most important steps of wound management as it removes contaminated material that can serve as a nidus for infection. In multiple studies, tap water (where water quality is assured) has been shown equivalent to sterile water and isotonic saline. Solutions containing betadine, chlorhexidine, hydrogen peroxide etc. are sometimes used for dirty or bite wounds although have little evidence to improve outcomes and may be toxic to the wound tissue.

Optimal irrigation pressures are unknown although pressures of 5 to 8 lbs per square inch (PSI) have been recommended. This can be obtained with syringe or pressure bag irrigation. Highly contaminated wounds may benefit from very high pressure irrigation if deemed necessary. The volume of irrigation is also unknown and depends on the degree of contamination and anatomical area (highly vascularized areas need less).



References:
  1. Debridement: an essential component of traumatic wound care.
    Haury B, Rodeheaver G, Vensko J, Edgerton MT, Edlich RF
    Am J Surg. 1978;135(2):238.
  2. Laceration repair. In: Textbook of pediatric emergency procedures
    McNamara, RN, Loiselle, J
    Williams and Wilkins, Baltimore 1997.p.1141.
  3. Cleansing the traumatic wound by high pressure syringe irrigation.
    Stevenson TR, Thacker JG, Rodeheaver GT, Bacchetta C, Edgerton MT, Edlich RF
    JACEP. 1976;5(1):17.
  4. Identification of the wound infection-potentiating factors in soil.
    Rodeheaver G, Pettry D, Turnbull V, Edgerton MT, Edlich RF
    Am J Surg. 1974;128(1):8.
  5. Laceration management.
    Hollander JE, Singer AJ
    Ann Emerg Med. 1999;34(3):356.
  6. Water for wound cleansing.
    Fernandez R, Griffiths R
    Cochrane Database Syst Rev. 2012;2:CD003861.
  7. Wound irrigation with tap water.
    Moscati RM, Reardon RF, Lerner EB, Mayrose J
    Acad Emerg Med. 1998;5(11):1076.
  8. Principles of emergency wound management.
    Edlich RF, Rodeheaver GT, Morgan RF, Berman DE, Thacker JG
    Ann Emerg Med. 1988;17(12):1284.
  9. Does bacteremia occur during high pressure lavage of contaminated wounds?
    Tabor OB Jr, Bosse MJ, Hudson MC, Greene KG, Nousiainen MT, Meyer RA Jr, Sims SH, Kellam JF
    Clin Orthop Relat Res. 1998;(347):117-21.
  10. Wound infection rate and irrigation pressure of two potential new wound irrigation devices: the port and the cap.
    Morse JW, Babson T, Camasso C, Bush AC, Blythe PA
    Am J Emerg Med. 1998;16(1):37.

14 Wound closure tapes

Wound closure tapes (Steri-Strips©) can be used for linear, low tension lacerations. They are also beneficial in patients with fragile skin. 



References:
  1. Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive.
    Zempsky WT, Parrotti D, Grem C, Nichols J.
    Pediatr Emerg Care. 2004 Aug;20(8):519-24.
  2. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair
    Mattick A, Clegg G, Beattie T, Ahmad, T
    Emerg Med J. Sep 2002;19(5): 405–407.

15 Hair Apposition

Instead of using staples or sutures for scalp lacerations, crossing the hair over the laceration and then applying a drop of tissue adhesive has been shown to be cost-effective, faster and less painful. In addition, patients do not need to return for staple or suture removal. This technique can be done with patients with relatively short hair as well.



References:
  1. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study).
    Hock MO, Ooi SB, Saw SM, Lim SH.
    Ann Emerg Med. 2002 Jul;40(1):19-26.
  2. Modified hair apposition technique as the primary closure method for scalp lacerations.
    Karaduman S, Yürüktümen A, Güryay SM, Bengi F, Fowler JR Jr.
    Am J Emerg Med. 2009 Nov;27(9):1050-5.
  3. Hair apposition technique for scalp laceration repair: a randomized controlled trial comparing physicians and nurses (HAT 2 study).
    Ong ME, Chan YH, Teo J, Saroja S, Yap S, Ang PH, Lim SH.
    Am J Emerg Med. 2008 May;26(4):433-8.
  4. Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations.
    Ong ME, Coyle D, Lim SH, Stiell I.
    Ann Emerg Med. 2005 Sep;46(3):237-42.

16 Staples

Staples are appropriate for linear wounds in non-cosmetic areas (especially scalp) or in wounds that need rapid closure (difficulty with hemostasis, mass casualty situations). Staples will leave scars so using them in cosmetic areas (face, neck) is usually not indicated.

Recommended removal times:

  • Scalp:7 to 14 days
  • Trunk and upper extremities: 7 to 10 days
  • Lower extremities: 10 to 14 days


References:
  1. Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits.
    Kanegaye JT, Vance CW, Chan L, Schonfeld N
    J Pediatr. 1997;130(5):808.
  2. Skin stapling of wounds in the accident department.
    MacGregor FB, McCombe AW, King PM, Macleod DA
    Injury. 1989;20(6):347.
  3. Revolutionary advances in the management of traumatic wounds in the emergency department during the last 40 years: part II.
    Edlich RF, Rodeheaver GT, Thacker JG, Lin KY, Drake DB, Mason SS, Wack CA, Chase ME, Tribble C, Long WB 3rd, Vissers RJ
    J Emerg Med. 2010;38(2):201.
  4. Essentials of skin laceration repair.
    Forsch RT
    Am Fam Physician. 2008;78(8):945.
  5. Skin closure using staples and nylon sutures: a comparison of results.
    Stockley I, Elson RA
    Ann R Coll Surg Engl. 1987;69(2):76.

17 Tissue adhesives

Tissue adhesives, n-butyl-2-cyanoacrylate (eg, Histoacryl or PeriAcryl) or 2-octyl-cyanoacrylate (eg, Dermabond or Surgiseal), are liquids which undergo a reaction when exposed to moisture forming polymers and a strong bond (max strength within 2 1/2 min). Compounds that contain petroleum jelly will weaken these bonds making it unstable for wound closure, but provides the ability to remove the adhesive. Compared to other wound closure techniques, the initial tensile strength is initially less secure, but becomes equivalent at one week.

Tissue adhesives are likely the best option for small (< 5cm) linear lacerations in places of low tension (eg forehead). They have been shown to require less closure time, improved patient satisfaction and equivocal cosmetic outcome compared to sutures under these circumstances. Some studies also point towards cost-effectiveness over sutures.

In studies looking at adding wound closure tape to tissue adhesive closures, there was no improvement in wound dehiscence, although it may be helpful if used for longer incisions (>5cm).

The use of LET with tissue adhesives was shown to improve the number of pediatric patients who reported no pain with procedure. Using lidocaine injections is unlikely to improve pain outcomes with the use of tissue adhesives given that the pain reported during the procedure is likely to be mild.



References:
  1. Management of lacerations in the emergency department.
    Capellan O, Hollander JE
    Emerg Med Clin North Am. 2003;21(1):205.
  2. Using tissue adhesive for wound repair: a practical guide to dermabond.
    Bruns TB, Worthington JM
    Am Fam Physician. 2000;61(5):1383.
  3. Management of skin trauma.
    Pearson AS, Wolford RW
    Prim Care. 2000;27(2):475.
  4. The cyanoacrylate topical skin adhesives.
    Singer AJ, Quinn JV, Hollander JE
    Am J Emerg Med. 2008 May;26(4):490-6.
  5. Tissue adhesives for traumatic lacerations in children and adults.
    Farion K, Osmond MH, Hartling L, Russell K, Klassen T, Crumley E, Wiebe N
    Cochrane Database Syst Rev. 2002;(3):CD003326.
  6. A randomized, clinical trial comparing butylcyanoacrylate with octylcyanoacrylate in the management of selected pediatric facial lacerations.
    Osmond MH, Quinn JV, Sutcliffe T, Jarmuske M, Klassen TP
    Acad Emerg Med. 1999;6(3):171.
  7. Evaluation of a new high-viscosity octylcyanoacrylate tissue adhesive for laceration repair: a randomized, clinical trial.
    Singer AJ, Giordano P, Fitch JL, Gulla J, Ryker D, Chale S
    Acad Emerg Med. 2003 Oct;10(10):1134-7.
  8. Cost-consequence analysis comparing 2-octyl cyanoacrylate tissue adhesive and suture for closure of simple lacerations: a randomized controlled trial.
    Man SY, Wong EM, Ng YC, Lau PF, Chan MS, Lopez V, Mak PS, Graham CA, Rainer TH
    Ann Emerg Med. 2009 Feb;53(2):189-97.
  9. Evaluation of a novel wound closure device: a multicenter randomized controlled trial.
    Singer AJ, Chale S, Giardano P, Hocker M, Cairns C, Hamilton R, Nadkarni M, Mills AM, Hollander JE
    Acad Emerg Med. 2011 Oct;18(10):1060-4.
  10. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations.
    Osmond MH, Klassen TP, Quinn JV
    J Pediatr. 1995;126(6):892.
  11. Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial.
    Harman S, Zemek R, Duncan MJ, Ying Y, Petrcich W
    CMAJ. 2013;185(13):E629.

18 Sutures

Absorbable sutures

  • Simple facial lacerations: Fast-absorbing gut allows for easy percutaneous closure without the need for suture removal. Especially useful in children. May need absorbable subcutaneous sutures to provide support after gut dissolved (4 - 6 days)
  • Deep facial lacerations: Monocryl (7 - 10 days) or Vicryl (30 days)
  • Percutaneous lacerations under casts/splints: Vicryl Rapide (5 - 7 days) or Chromic Gut (10 - 14 days)
  • Nail bed lacerations: Chromic Gut (10 - 14 days) or Vicryl (30 days)
  • Tongue & oral mucosa lacerations: Chromic Gut (10 - 14 days) or Vicryl (30 days)

Non-absorbable sutures

  • Holding objects (lines, drains) in skin: Silk (high amount of tissue reactivity, but easiest to tie
  • General skin closure: Nylon (Dermalon, Ethilon)
  • Skin closure in areas where suture will be difficulty to identify for removal (dark-skinned patients, hair line, eyebrows): Polypropylene (Prolene)

Needle choice

  • Scalp, trunk, and extremities: Standard skin needles
  • Palms & soles (thick skin): Reverse cutting needles
  • Small structures or face: Finely sharpened needle

Suture technique

  • Uncomplicated percutaneous wound: Interrupted suture
  • Dermal closure: Inverted buried suture (must be absorbable sutures, does not increase risk of wound infection in uncontaminated, irrigated wounds)

When placing sutures the distance between sutures should be equal to the bite distance from the wound edge.



References:
  1. Suture materials for closing the skin and subcutaneous tissues.
    Lober CW, Fenske NA
    Aesthetic Plast Surg. 1986;10(4):245.
  2. A comparison of absorbable and nonabsorbable suture materials for skin repair.
    Guyuron B, Vaughan C
    Plast Reconstr Surg. 1992;89(2):234.
  3. Emergency department repair of hand lacerations using absorbable vicryl sutures.
    Shetty PC, Dicksheet S, Scalea TM
    J Emerg Med. 1997;15(5):673.
  4. Skin wound approximation with new absorbable suture material.
    Webster RC, McCollough EG, Giandello PR, Smith RC
    Arch Otolaryngol. 1985;111(8):517.
  5. The use of chromic catgut in the primary closure of scalp wounds in children.
    Start NJ, Armstrong AM, Robson WJ
    Arch Emerg Med. 1989;6(3):216.
  6. A review of sutures and suturing techniques.
    Moy RL, Waldman B, Hein DW
    J Dermatol Surg Oncol. 1992;18(9):785.
  7. Special anatomic sites. In: Wounds And Lacerations: Emergency Care and Closure, 3rd edition
    Trott, AT
    Elsevier Mosby, Philadelphia 2005.p.153.
  8. Subcuticular sutures and the rate of inflammation in noncontaminated wounds.
    Austin PE, Dunn KA, Eily-Cofield K, Brown CK, Wooden WA, Bradfield JF
    Ann Emerg Med. 1995;25(3):328.

19 Hair removal

Nothing more than combing or trimming the edge of hair around a wound is necessary and only if it impairs closure of the wound edges. Shaving can lead to increased risk of infection and can leave particulate matter within the wound. Eyebrows especially should not be trimmed or shaved as they may have abnormal regrowth.



References:
  1. Scalp laceration repair without prior hair removal.
    Howell JM, Morgan JA
    Am J Emerg Med. 1988;6(1):7.
  2. The Influence of hair shave on the infection rate in neurosurgery. A prospective study.
    Tang K, Yeh JS, Sgouros S
    Pediatr Neurosurg. 2001;35(1):13.
  3. Shaving of the scalp may increase the rate of infection in CSF shunt surgery.
    Horgan MA, Piatt JH Jr
    Pediatr Neurosurg. 1997;26(4):180.
  4. Evaluation and management of traumatic lacerations.
    Singer AJ, Hollander JE, Quinn JV
    N Engl J Med. 1997;337(16):1142.