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Shikha Kapil

Chris Bodle
2/15/16

Grady Memorial Hospital
Trauma Service Guidelines
Wound Closure Guideline for the Marcus Trauma
Center
BACKGROUND
 Improper technique during wound closure in the trauma patient
can result in infection and/or wound dehiscence contributing to
increased rates of morbidity and healthcare expenditure.
 The following guidelines will serve to aid in choosing appropriate
materials and proper technique for optimal wound closure.
 This is a guideline for lacerations that do not involve life
threatening or arterial bleeding. These lacerations would be
assessed on the secondary assessment of major trauma patients.
CLINICAL PRACTICE GUIDELINES
I. Initial Evaluation
Initial evaluation of a laceration must include thorough neurovascular
and functional exam. An abnormal exam should be addressed by
consultation of appropriate subspecialty service. Consider
consultation in:
 Flexor tendon injuries in the upper extremities
 Wounds involving joint spaces
 Wounds involving large vessels
 Wounds requiring large debridement
 Avulsion injuries of ears, nose, penis
Note that a patient request for an emergent subspecialty consult is not
an indication to consult (i.e. plastics for an uncomplicated facial
laceration)

Assessment of wound includes thorough cleaning and
exploration. Jagged wound edges, stellate shape, visible
contamination and wound depth are all increase risk of
infection.all increase risk of infection.

Materials A. Risk factors for delayed wound healing and infection include advanced age. peripheral artery disease). metal. However too much pressure causes tissue damage and increases infection risk by driving bacteria into tissue. and vascular disease (chronic venous insufficiency.2 3 o B. CT scan can detect presence of radiopaque foreign bodies in the wound  Glass. 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. Ideal pressure is 8-12 psi. teeth o Does not replace wound exploration for identification of radiolucent material  Organic material. Prolene/Nylon: Monofilament. shrapnel. Imaging o X-ray. consider 2-0 over large joints or areas of tension  Remove in 7-10 days . diabetes. Preparation A. Vicryl: Braided. subcutaneous tissue  Should not be used to close skin o Purple vicryl can tattoo skin when used in the subcutaneous tissue B. non absorbable o Indications  Skin closure. absorbable suture o Maintains tensile strength for 3-4 weeks. 1 II. tendon repair o Extremities (Arms/legs)  3-0 or 4-0. clothing III. ultrasound. fascia. Patient history is important. o Indications: preferred material for subcutaneous closure  Deep closure of muscle.

Distal extremities (hands/feet)  No smaller than 4-0  Remove in 7-10 days Chest/abdomen  3-0 or 4-0  Remove in 7-10 days Face  5-0 or 6-0  Remove in 3-5 days Tendon  2-0 or 3-0  o o o o C. small.If laceration is overlaying joint. Fast gut: Biologic o Low tensile strength. not for wounds under tension o For skin closure of a wound with significant bleeding from the skin edge . superficial wounds under no tension)  Can be re-enforced with wound tape 4 5 6 IV. Chromic Gut: Coated. o Maintains tensile strength for 10-14 days o Indications  Palms and soles  Inside the mouth o Chromic gut is not an appropriate choice for skin closure or for deep sutures D. consider orthopedic surgery consultation to ensure joint space not violated. absorbed within 4-6 days o Indications  Face on children  Face for selected adults (those unlikely to follow up. Suture technique  Buried stitches (deep stitches) for use in multi-layer closure o For subcutaneous closure in gaping wounds o For closure of fascia over muscle  Vertical mattress –This is a stitch that is meant to close wounds under significant tension o For skin closure of gaping wounds o Closure over joints  Horizontal mattress –This stitch is for hemostasis only. biologic.

o Grossly contaminated wounds should be cleaned thoroughly and left open. Wet dressing applied. The muscular layer should be closed with vicryl. for cosmesis only after deep Vicryl stitches have been applied o Use Monocryl only (4-0 or 5-0) 7 V. Avoid placing deep sutures in these wounds and consult appropriate service for follow up.  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.  Figure of eight –This stitch should be applied to an actively bleeding vessel only o Use Silk (3-0) for this stitch in an arteriolar bleed o If the bleed is truly an arterial bleed. can place retention sutures sparingly to loosely approximate skin edge. Perichondrium should be the deepest stitch. Wound type  Contaminated wounds o Copious irrigation o Lacerations or wounds over joints should be challenged with saline load to ensure no joint involvement. Need daily dressing changes and referral to follow-up with General Surgery .  Special considerations o Exposed cartilage should not be sutured. eye lid function should prompt a consult to ophthalmology . a small silk (3-0 or 40) should be used Running subcuticular –This stitch should be used to close skin. All sutures should be 5-0. 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. o Complicated facial lacerations involving the lacrimal duct. o Lip: Through and through lip lacerations often require multi-layer closure. eye lid edge. Recommend orthopedic surgery consult. Exposed cartilage needs to be covered with skin completely.

plastic surgery) o Involvement of joint space. tendon/bone exposure warrants an orthopedic surgery consult. organic material)  Higher risk of infection with poor perfusion: anatomical (scalp lower risk than extremity) and chronic disease states (PAD. muscular impairment. 8 VI. or concern for cosmetic outcome should prompt a consult to face coverage (ENT.o Facial lacerations with neurovascular compromise. o Lacerations of the hand need to be carefully examined for neurovascular status. or violation of tendon sheath. OMFS. chronic venous stasis) 10 11 References 9 . Antibiotics o Not indicated for simple lacerations o Prophylactic antibiotics for:  Human/animal bites  Extensively contaminated wounds (soil. tendon involvement. Hand consult teams are orthopedic surgery and plastic surgery.

Emerg Med Clin North Am 2003. Woods JR (1992). 8 Nicks B. Sibbald G. Ann Emerg Med 21(11):1364–1367 3 Moscati. Am J Emerg Med 1995. Singer AJ. Austin PE. Mayrose. Dunn KA. 13:396. 27:43. Del Beccaro MA. “Acute wound management: revisiting the approach to assessment. 18:785. D. Academic Emergency Medicine. Journal of cutaneous and aesthetic surgery 2013.. Reardon. 7 Moy RL. irrigation. 11 Cummings P. 6 Al-Mubarak L. Ayello E. Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Rogers K. 5 Subcuticular sutures and the rate of inflammation in noncontaminated wounds. J. 9 Eron LJ (1999) Targeting lurking pathogens in acute traumatic and chronic wounds. Hein DW. Nitzki-George D. J Dermatol Surg Oncol 1992. Shofer FS (2001) Risk factors for infection in patients with traumatic lacerations. 14: 404–409. Hollander JE. Acad Emerg Med 8(7):716–720 2 Chisholm CD. Cordell WH. F.. Bradfield JF.. Janicke. 21:205. Contaminated wounds: infection rates with subcutaneous sutures. Antibiotics to prevent infection of simple wounds: a metaanalysis of randomized studies. and closure considerations. J Emerg Med 17(1):189–195 10 Capellan O.” Nt J Emerg Med (2010) 3:399-407. M. R. A Multicenter Comparison of Tap Water versus Sterile Saline for Wound Irrigation. (2007).6:178-88. and Jehle. Cutaneous wound closure materials: an overview and update. Woo K. 4 Mehta PH. R. Al-Haddab M. Management of lacerations in the emergency department. M. D.1 Hollander JE. Valentine SM. A review of sutures and suturing techniques. V. . Waldman B. Ann Emerg Med 1996.