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Management of Lacerations to Avoid Infection and Scarring



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Am Fam Physician. 2000 Mar 1;61(5):1501-1502.

Most lacerations heal without significant problems regardless of management, but poor management can result in wound infections, unsightly or dysfunctional scars and a prolonged healing phase. The recent development of tissue adhesives has expanded the treatment options.

Hollander and Singer reviewed the general principles of wound care. The goal of wound management is to avoid infection and obtain a functional and aesthetically acceptable scar. These goals are best achieved by reducing tissue contamination, debriding devitalized tissue, restoring perfusion on poorly perfused wounds and establishing a well-approximated skin closure.

Evaluation of a patient who has a laceration should include identification of conditions that place the patient at risk for infection or delayed wound closure. These contributing conditions include diabetes mellitus, obesity, malnutrition, chronic renal failure, advanced age and use of steroids. Allergies to anesthetics or antibiotics are also important to assess. The patient's tetanus immunization status should be evaluated, with the need for further immunization determined by U.S. Centers for Disease Control and Prevention recommendations (see accompanying table for tetanus recommendations). Determining the mechanism of injury is essential in identifying the presence of contaminants or the possible presence of a foreign body. Because of devitalization of tissue, crush injuries are more likely to develop infection than lacerations caused by shearing forces. A neurovascular examination of pulses, motor function and sensation distal to the laceration should be followed by a search for foreign bodies and nerve or tendon injury.

Recommendations for Tetanus Prophylaxis

History of tetanus prophylaxis Clean minor wounds All other wounds*
Td TIG Td TIG

Uncertain or less than 3 doses

Yes

No

Yes

Yes

3 doses or more

Last dose within 5 years

No

No

No

No

Last dose within 5 to 10 years

No

No

Yes

No

Last dose more than 10 years ago

Yes

No

Yes

No


Td = tetanus-diphtheria toxoid; TIG = tetanus immune globulin.

*—For example, contaminated wounds, puncture wounds, avulsions, burns and crush injuries.

Reprinted with permission from Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999;34:356–67.

Recommendations for Tetanus Prophylaxis

View Table

Recommendations for Tetanus Prophylaxis

History of tetanus prophylaxis Clean minor wounds All other wounds*
Td TIG Td TIG

Uncertain or less than 3 doses

Yes

No

Yes

Yes

3 doses or more

Last dose within 5 years

No

No

No

No

Last dose within 5 to 10 years

No

No

Yes

No

Last dose more than 10 years ago

Yes

No

Yes

No


Td = tetanus-diphtheria toxoid; TIG = tetanus immune globulin.

*—For example, contaminated wounds, puncture wounds, avulsions, burns and crush injuries.

Reprinted with permission from Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999;34:356–67.

Anesthesia before wound repair can be accomplished with one of the two classes of local anesthetics: esters (e.g., procaine) and amides (e.g., lidocaine). Anesthesia is usually accomplished by local infiltration; pain on administration of the injection can be decreased by buffering the solution with sodium bicarbonate. Warming the anesthetic solution also decreases pain with infiltration. Prior administration of topical anesthetics such as tetracaine 1 percent can ameliorate injection pain. Alternative methods for local anesthesia include topical and regional applications. A topical combination of tetracaine, adrenaline and cocaine (TAC) has been shown to be an effective anesthetic in children and patients with face or scalp lacerations; however, serious adverse events have been reported. Eutectic mixture of local anesthetic (EMLA) cream has been useful, but the onset of anesthesia is delayed. Local anesthetics can be administered regionally by infiltrating around a regional sensory nerve. This technique is most useful when dealing with multiple lacerations or when large areas of skin must be debrided or scrubbed.

Continuous irrigation under moderate pressure reduces wound bacterial counts. Normal saline remains the most cost-effective choice. Wounds should be closed primarily to speed healing, although wounds that pose a serious risk of infection, such as a foot puncture in a diabetic patient, should not be closed primarily. Sutures are most commonly used to close lacerations; absorbable suture is used to close structures deeper than the epidermis, and nonabsorbable suture is used to close the outermost layer of a laceration. Deep sutures relieve skin tension, decrease dead space and probably improve cosmetic outcome. Staples can be applied rapidly and are associated with a lower infection rate but can be more painful to remove. Surgical tape is rarely used for primary closure because of inadequate strength in areas subject to tension. Tissue adhesives can be applied rapidly and painlessly, and will slough off in seven to 10 days. The adhesive is painted on while manually approximating the skin edges. Adhesive in the wound or between wound margins should be avoided. A comparison of wound closure methods is provided in the accompanying table about closure techniques.

Advantages and Disadvantages of Common Wound Closure Techniques

Technique Advantages Disadvantages

Suture

Time honored Meticulous closure Greatest tensile strength Lowest dehiscence rate

Requires removal Requires anesthesia Greatest tissue reactivity Highest cost Slowest application

Staples

Rapid application Low tissue reactivity Low cost Low risk of needle stick

Less meticulous closure May interfere with some older-generation imaging techniques (computed tomography, magnetic resonance imaging)

Tissue adhesives

Rapid application Patient comfort Resistant to bacterial growth No need for removal Low cost

Lower tensile strength than sutures Dehiscence over high-tension areas (joints) Not useful on hands Cannot bathe or swim No risk of needle stick

Surgical tapes

Least reactive

Frequently falls off

Lowest infection rates

Lower tensile strength than sutures

Rapid application

Highest rate of dehiscence

Patient comfort

Requires use of toxic adjuncts

Low cost

Cannot be used in areas of hair

No risk of needle stick

Cannot get wet


Reprinted with permission from Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999;34:364.

Advantages and Disadvantages of Common Wound Closure Techniques

View Table

Advantages and Disadvantages of Common Wound Closure Techniques

Technique Advantages Disadvantages

Suture

Time honored Meticulous closure Greatest tensile strength Lowest dehiscence rate

Requires removal Requires anesthesia Greatest tissue reactivity Highest cost Slowest application

Staples

Rapid application Low tissue reactivity Low cost Low risk of needle stick

Less meticulous closure May interfere with some older-generation imaging techniques (computed tomography, magnetic resonance imaging)

Tissue adhesives

Rapid application Patient comfort Resistant to bacterial growth No need for removal Low cost

Lower tensile strength than sutures Dehiscence over high-tension areas (joints) Not useful on hands Cannot bathe or swim No risk of needle stick

Surgical tapes

Least reactive

Frequently falls off

Lowest infection rates

Lower tensile strength than sutures

Rapid application

Highest rate of dehiscence

Patient comfort

Requires use of toxic adjuncts

Low cost

Cannot be used in areas of hair

No risk of needle stick

Cannot get wet


Reprinted with permission from Hollander JE, Singer AJ. Laceration management. Ann Emerg Med 1999;34:364.

Postoperative care need not include routine use of prophylactic antibiotics unless evidence of bacterial contamination or a risk host factor is evident. Sutured or stapled lacerations should be covered with a protective, nonadherent dressing for at least 24 to 48 hours to avoid gross contamination. Patients should be instructed to observe the wound for the presence of warmth, redness, swelling or drainage. Sutures or staples should be removed after approximately seven days. Facial sutures should be removed within three to five days. Sutures in areas subject to high tension should be left in place for 10 to 14 days.

Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. September 1999;34:356–67.


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