• Haemostasis
• Wound cleansing and Irrigation
• Conservative debridement
• Local anaesthetics
• Wound closure - Choice of suture material
• Wound closure - Suturing techniques
  [ Simple interrupted suture, Vertical mattress suture ]
• Wound closure - Skin adhesives
• Wound dressings
• Follow-up

Haemostasis

Haemorrhage is stopped by firm pressure on the wound, although occasionally a tourniquet (applied for no longer than 15 minutes at a time above systolic blood pressure) may be required. Vasoconstrictors such as epinephrine can be used, avoiding areas with end organ blood supply such as fingers, nose, penis and toes.

Wound cleansing, Irrigation
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All lacerations should be considered contaminated by the time of evaluation in the Emergency Department. The rate of wound infection in sutured lacerations is 1-30%, depending on the study series.

Antibiotic administration does not substitute for the proper cleaning of wounds.

Wound cleansing is of paramount importance and cannot be overemphasised. Wound irrigation should be copious. High pressure irrigation is more effective than low-pressure irrigation in reducing bacterial wound counts and wound infection rates. Most authorities recommend impact pressures generated by a 30-60cc syringe and a 18-gauge needle.

Normal saline is the most common choice of solution and should be used until the wound appears clean. Hydrogen peroxide and poviodine should NOT be used for irrigation.

Conservative debridement

Devitalised pieces of skin and subcutaneous tissue are excised. Viable tissue should be conserved and this is especially important in the face and hands.

Local anaesthetics

Prior to the administration of local anaesthetics, check the sensory and motor nerve response, and for allergy (very rare). The pediatric literature supports the use of a topical anesthetic such as LET (a combination of lidocaine, epinephrine and tetracaine) prior to needle infiltration to reduce the pain. Slow injection by a small needle (such as a 25 Gauge) will reduce the pain of infiltration. See Medications

Picture of injecting anesthetic

Wound Closure - Choice of suture material

Absorbable suture material is utilised below the skin (except dermal sutures may be used for high tension lacerations), inside the mouth for example, or in other awkward areas where suture removal would be difficult. Plain catgut has high tissue reactivity. Chromic catgut is less problematic and is absorbed in about 10-14 days. Dexon or Vicryl last 90-120 days.

Non-absorbable suture material is used for most skin closures. The synthetics are likely best as these have less tissue reactivity. Monofilaments, for example, nylon (Ethilon, Prolene) or braided materials (Ethibond, Surgilon) may be used. Knots must be “well locked”, and there should be only minimal tension on the tissues themselves.

A suture size of 5:0 or 6:0 is used on the face, whereas 4:0 or sometimes 3:0 (if more strength is required) is used on the trunk or extremity.

Staples
The application of staples is more rapid than sutures and staples are useful for scalp, trunk, and some extremity wounds.

Wound Closure - Suturing techniques

All of the sterile equipment required for simple wound care procedures in the emergency department is available in a “suture tray”.

Picture of equipment tray and list of equipment and single shots of needle driver holding needle properly and the right tweezers to use

Simple interrupted suture
This style of suture is used most frequently in the emergency department.



In the Procedures Lab, you will be asked to repair a laceration similar to the laceration of the thigh above using simple interrupted sutures. Remember to always use universal precautions.

The laceration is 3 hours old and sustained from the clean edge of a metal shelf. You have already used lidocaine 1% to anesthetize the area, have cleaned the wound well, and have placed several subcutaneous sutures. You are now ready to place your skin sutures.

Wound examination and repair should always be conducted with good lighting conditions.
Accurate layer by layer repair is the key.

The goal is to approximate the margins of the wound as exactly as possible. The goal is a slightly elevated and everted wound closure margin that over time will flatten to a more attractive scar. For deeper lacerations, a subcuticular closure with absorbable suture will minimise tension on the skin layer itself.

Review simple knot techniques in this animation.

You can review the placement of sutures and a simple instrument tie of a simple interrupted suture in this video.

Vertical mattress suturing
Approximation and slight eversion of the wound margins is difficult in certain wounds, especially if the wound margins are already retracted or rolled inwards. A vertical mattress suture is useful in this situation.

Wound Closure - Skin adhesives

Tissue adhesives are used in small lacerations. The time to close the wound is much faster using tissue adhesives. The wound must be cleansed carefully.

Tissue adhesive should not be placed within the wound, or used on areas of high tension or repetitive movements, such as joints. Application is rapid and relatively painless. Warn the patient of an exothermic reaction as the adhesive polymerises. Tissue adhesives will slough off in 5-10 days.

Step-by-step approach on using skin adhesives

	Exact approximation of the wound margins Tissue adhesives should be applied over a bloodless field.
Exact adaptation of wound
	Application of Histoacryl Avoid placing the glue in the wound or between the wound margins. Three to four coats should be applied.
Application of Histoacryl
	Drying Hold the wound margins together for several seconds until dry.
Hold wound edges in place for 1 minute

Wound dressings and follow-up

Dressings are important to maintain sterility and absorb blood and serum. Moisture improves the rate of epithiliazation. The goal is a state of optimal hydration of the wound margins – not too wet or too dry. Sutured or stapled lacerations should be covered with a nonadherent dressing for the first 1 to 2 days to also allow sufficient epithelization to prevent gross contamination.
There is some suggestion that topical antibiotic ointments, such as Polysporin or bacitracin, are helpful in reducing infection of the wound. However, these are NOT used if a tissue adhesive is applied as the glue is weakened.

Abrasions are treated in much the same way as burns. An occlusive or semi-occlusive antibiotic or Vaseline dressing will minimize pain and help prevent infection. Some full thickness abrasions may require skin grafting, and Plastic Surgery should be consulted.

When there is a potential “dead space” in a wound, then a pressure bandage – a bolus dressing of gauze held firmly by tape, can be used to minimize serum and blood collection in the “dead space” by putting pressure on the wound area.

Most hand injuries, other than minor ones, should be splinted in a position of function following repair. Elevation of an extremity will reduce swelling for those injuries with concomitant soft tissue crush injury.

Instructions to the patient are important. The repaired laceration should be kept clean and dry. After 1 to 2 days, patients may gently clean the area with soap and water and blot the area dry. Wounds that have been closed with glue should not be kept wet for long – showering is fine but bathing and swimming should be avoided or dehiscence of the wound may occur. Again, the wound should be pat dried to avoid stress on the wound margins and dehiscence. The symptoms and signs of infection (including redness and streaking, heat, the discharge of pus, swelling, and increasing pain) must be explained to the patient and documented on the chart. A handout for wound care is available for the patient to take home but the details must be explained to the patient.

Follow-up

Sutured or stapled lacerations should be covered with a protective and nonadherent dressing for 24 to 48 hours. Thereafter, exposed wound lines should be gently washed with soap and water daily. Scrubbing or soaking is to be avoided. Topical antibiotic ointments such as Polysporin may help reduce the wound infection rate. Maintenance of a moist wound margin with such topicals also increases the rate of re-epitheliazation.

However, such topicals should not be used with tissue adhesives as the glue may slough. These patients can shower but should avoid bathes or swims. Prolonged exposure to water loosens the glue.

Patient should understand the frequency of dressing changes and also be instructed on the signs of infection and to seek medical attention if these develop. A handout for patients is useful but the handout must be explained.

The timing of suture removal is variable. As a general principle, suture marks (sinus tracts) may be permanent if the stitches are left in place for 7 days or more. The table below contains suggestions for the optimal time for suture removal. Before removing the sutures, the wound margins should appear to be healing and appear closed. A ridge of healing tissue may be felt. It may be prudent to apply “steristrips” to strengthen the wound if the area is under tension and the sutures are being removed “early” for cosmetic reasons. Coexisting illnesses, such as diabetes and renal failure, may prolong healing times and should also be considered.

The infection rate of most wounds is not decreased with the use of oral, IV or IM antibiotics. Certain exceptions exist, particularly when dealing with mammalian bites and some other situations. These wounds are seldom closed primarily. See Medications/Antibiotics and Special Situations.