new concepts in wound

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Many wound care techniques originate inantiquity, and despite tremendousadvances, dogma still clouds commonpractices. Recent literature has sought todisprove long-held beliefs and introducesimpler methods. Topical anastheticscontaining epinephrine may be a safeand effective adjunct to injected localanesthetics for the digits. Tap water maybe an inexpensive alternative for woundirrigation. Clean, nonsterile gloves maybe adequate for use during closure ofroutine lacerations. Tissue adhesive hasbecome a common method for woundclosure, and modifications have beenintroduced to overcome many of theproducts shortfalls. Absorbable suturemay be a cosmetically viable option forrepairing skin lacerations. Finally,evaluation of the need for tetanusprophylaxis is an important, but possiblyunderused, finish to the wound careprocess.Clin Ped Emerg Med 5:239-245. 2004 Elsevier Inc. All rights reserved.

New Concepts in Wound

Management

By Robert D. SchremmerKANSAS CITY, MISSOURI

ONE OF THE FIRST written records of wound care is includedin an ancient Egyptian papyrus thought to originate circa1600 BC. The document describes techniques for woundrepair using adhesive tape and sutures and occasionally

leaving wounds open while applying fresh meat to facilitate heal-ing.1 It seems that although some techniques have undergonetremendous advancement in the last 3,500 years, many of thefundamentals of laceration repair have endured. Control of pain

and hemorrhage and prevention of infection and unsightly scar-ring remain primary goals of wound management. Modern tech-nology often facilitates these goals through pharmaceuticals forpain relief, mechanisms for preserving sterility, and new materi-als for approximating wound edges. While these advances havebeen significant, many dogmatic views are still held with regardto the process of wound management. It is in the spirit of theancient Egyptians and their insightful approach to medicine thatwe endeavor to refute doctrine and advance efficient techniquesof wound care.

Local Anesthesia

The first step in repairing any laceration is relieving the pa-tients pain and assuring that as little pain as possible will resultfrom the treatment. Pain control for wound closure is oftenachieved through topical application or subcutaneous infiltrationof a local anesthetic. Topical anesthetics include liquids or gelscontaining 0.5% tetracaine, 0.05% epinephrine (adrenaline) and11.8% cocaine (TAC) or 4% lidocaine, 0.1% epinephrine and 0.5%tetracaine (LET). Obvious advantages of these topical agentsinclude painless application and reduced patient anxiety. Bothmixtures, however, must be applied for at least 20 to 30 minutes,potentially adding to the patients time in department. Other

From the Division of Emergency MedicalServices, Childrens Mercy Hospitals andClinics, Kansas City, MO.

Address reprint requests to Robert D.Schremmer, MD, Division of EmergencyMedical Services, Childrens MercyHospitals and Clinics, 2401 GillhamRoad, Kansas City, MO 64104. E-mail:[email protected]

1522-8401/$see front matter 2004 Elsevier Inc. All rights

reserved.doi:10.1016/j.cpem.2004.09.001

N E W C O NC E PT S I N W O UN D M A NA G EM E NT / R O BE R T D . S C HR E MM E R 239


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difficulties encountered with TAC result from the

cocaine component and include high cost, neces-

sary drug regulatory measures, and rare occur-

rences of seizures and death when applied to

mucous membranes.2 Both agents seem to be more

effective when applied to the highly vascularized,

thinner skin of the face. Conventional wisdom dic-tates that neither mixture should be applied to

digits or other areas of end-arteriolar circulation.

One study,3 however, involving digit lacerations in

63 children concluded that LET is safe and effective

for simple finger lacerations, especially those on the

dorsal surface. Seventy percent of patients with

dorsal finger lacerations needed no further anesthe-

sia, while only 43% of patients with ventral wounds

experienced complete pain control from LET. No

patient experienced signs of digital ischemia as a

result of the topical epinephrine application.

EMLA cream, a eutectic mixture of local anes-thetics, has been available for procedures involving

intact skin such as intravenous (IV) catheter inser-

tion and lumbar puncture. This emulsion of agents

containing 2.5% lidocaine and 2.5% prilocaine man-

ifests the chemical property of having a lower melt-

ing point than the component agents alone and is a

liquid at room temperature. Some research has

been done to determine if EMLA is a useful anes-

thetic for laceration repair, but the results have

been mixed. When compared with LET, EMLA was

found to provide inferior anesthesia based on a

greater proportion of patients who required addi-tional lidocaine infiltration.4 Similarly, Singer and

Stark5 found no difference in local anesthesia be-

tween LET and EMLA applied at the time of patient

presentation to triage. The mean duration of EMLA

application was only 40 minutes, however, which is

less than its recognized time required for adequate

anesthesia. Another study6 found EMLA to lend

anesthesia superior to TAC for simple extremity

lacerations, but it required a longer application

time, 26 minutes more on average.

One alternative to consider that would accom-

plish adequate pain control and improve emer-gency department (ED) efficiency is the application

of a topical anesthetic to lacerations at the time of

presentation to triage. It is common practice in

many EDs for triage nurses to administer oral an-

algesics or antipyretics, obtain rapid antigen diag-

nostic tests, and order radiographs for injured

extremities, all according to well-defined protocols.

The application of a topical anesthetic equivalent to

LET at triage has been shown to significantly re-

duce the time in the ED for repair of simple lacer-

ations.7 In this study, no complications were

experienced as the result of prolonged exposure tothe anesthetic, lasting as long as 2 hours.

Time for adequate anesthesia seems to be one ofthe greater disadvantages of EMLA, but not the onlyone. Prilocaine metabolites from EMLA applicationhave been implicated in methemoglobinemia in in-

fants younger than 3 months, with an increased riskfor premature neonates.8 Older infants and chil-dren generally tolerate the mixture well and onlyoccasionally encounter local side effects such ascontact dermatitis and temporary erythema.

L-M-X (formerly ELA-max; Ferndale Laborato-ries, Inc., Ferndale, MI) is a more recently devel-oped product. Topical 4% lidocaine delivered in aliposomal vehicle, L-M-X has the advantage ofshorter application time and longer duration of ac-tion. It has been found to be as effective as EMLAfor pain control,8 and no serious adverse effects

have been reported. Unlike EMLA, an occlusivedressing is not mandatory for application but isrecommended for patients likely to rub off thecream before completion of an adequate applica-tion time. Unfortunately, no data are available re-garding the use of L-M-X for laceration repairs. Thecream is currently approved for use in pain controlon intact or nonintact skin, such as on minor cuts,burns, and abrasions, but the manufacturer doesnot currently advocate its use in wound closure.

Local infiltration of the wound with lidocaineusually accomplishes complete anesthesia of thesite, but at the cost of increased patient anxiety andpain. The pain of injection can be reduced by usinga long, fine (27 or 30) -gauge needle; injecting at aslow rate; warming the medication to body temper-ature; and buffering with sodium bicarbonate.2 Pa-tient distraction is another effective way to reduceinjection pain. Epinephrine is frequently added tothe anesthetic to improve hemostasis and prolongthe duration of anesthesia.

Nerve blocks can be an effective alternative tolocal infiltration for prevention of pain. The mostcommon location where blocks are used is for lac-eration repairs involving the digits. Traditionally,

lidocaine without epinephrine has been advocatedfor digital blocks because of fear of ischemia fromvasoconstriction. In fact, literature reviews con-ducted by Denkler9 and Wilhelmi et al10 found noinstance where lidocaine with epinephrine was thesole cause of finger ischemia. Details from many ofthe citations of epinephrine-induced ischemia areincomplete, but factors contributing to the isch-emia include use of older anesthetics such as co-caine, hot soaks post-repair, use of tourniquets,injection of excessive volume, and presence of in-fection. Wilhelmi et al10 found in their trial of 60

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digital blocks that no complications occurred in the31 who received lidocaine with epinephrine. Simi-larly, in an unpublished study, Andrades11 con-cluded that lidocaine with epinephrine is safe fordigital blocks and offers the advantages of quickeronset of action, reduced need for subsequent doses,

improved hemostasis, and longer postoperative an-esthesia. Authors recommend using epinephrine inconcentrations of 1:200,000 or less, using no morethan 1.5 mL on each side of the digit, and using adorsal approach with a fine needle near the meta-carpal head. Lidocaine with epinephrine is discour-aged in patients with peripheral vascular disease,hyperthyroidism, severe hypertension, cardiac dis-ease, or pheochromocytoma,10 or those with infec-tion or trauma at the base of the proximal phalynx.

Irrigation and Sterile TechniqueOnce appropriate analgesia or anesthesia is

achieved, the next step in wound repair is to ensurethat contaminated material is cleaned out of thewound and surrounding skin. This goal is com-monly accomplished by irrigation of the woundwith sterile saline. Irrigation pressures in excess of8 psi recommended for adequate decontamina-tion12 can be obtained using a 35-mL syringe at-tached to a 19-guage needle or a splashguard(Zerowet, Inc., Palos Verdes, CA). Heavily contam-inated wounds can be cleaned using a nonionicsurfactant cleanser (Shur-Clens, ConvaTec, Divi-sion of E.R. Squibb and Sons, Inc., Princeton, NJ)and soft scrub brush.

The traditional choice of irrigation solution issterile saline. This is one process where dogma haspersisted because of a paucity of data. Wound in-fection is the most common severe complication oflacerations.13 Although preventing infection by ir-rigation with a sterile solution is intuitive, somestudies have shown that no greater risk of infectionis encountered when a wound is irrigated with tapwater. An animal model14 found that irrigation with

tap water eliminated more bacteria from woundsthan irrigation with normal saline from a 20-mLsyringe with splashguard. A prospective clinicaltrial in a pediatric emergency department found nodifferences in rate of infection between tap-waterirrigated wounds and those cleansed with sterilesaline.15

There are several advantages of tap water thatcontribute to its success as an irrigant. Amongthese benefits are the much larger volume of fluidused from a faucet; the constant high-pressure flowsupplied by most city water supplies; the cheap,

plentiful supply of tap water; and the elimination ofthe need for extra supplies such as syringes, splash-guards, and basins. The water supplies of most ar-eas in the United States are chlorinated andmonitored closely for pathogenic bacteria, so thereis little reason to expect that the use of tap water

would contribute to wound infection rates. Cer-tainly, many minor wounds are irrigated with tapwater daily in homes throughout the country with-out any adverse effects.

Most wounds can simply be placed under a fau-cet and irrigated for about 30 seconds. Warm orlukewarm water should be used for patient comfort.For wounds located on body parts that are awkwardto place in a sink, a length of tubing can be attachedto the faucet and used to reach the patients lacer-ation, or the more traditional water or saline in abasin may be employed.

One observational study16

questions the need forany irrigation of clean wounds on the face andscalp. These highly-vascularized areas generallyhave low rates of infection. Excluding high-risk pa-tients (those with kidney disease, diabetes, immu-nocompromised state) and high-risk wounds (thosewith fascia or muscle involvement, overlying vitalstructures, open fractures, involvement of the in-traoral mucosa, visible contamination, with foreignbodies present, with delayed presentation), the au-thors found no difference in the rate of infectionbetween those repaired with and without irrigation.

Also, wounds that were irrigated displayed a non-significant reduced likelihood of optimal cosmeticappearance at the time of suture removal. Localtrauma from the process of irrigation may, in fact,contribute to scarring. This study certainly raisesan important question about the need for vigorousirrigation of clean lacerations in areas not prone toinfection.

Another precaution commonly taken during re-pair of lacerations to minimize risk of infection isthe use of sterile surgical gloves. The rationale isthat even clean gloves may be contaminated withpathogenic bacteria. Usually packaged in boxes of

100, the gloves may have been touched by previouspersonnel removing other gloves from the box.Sterile gloves, however, are more expensive andoften necessitate an assistant to accomplish theprocedure. In fact, no data are available to supportthe use of sterile gloves during routine lacerationrepair. One recent prospective single-blindedstudy, however, reported no difference in woundinfection rates when clean, nonsterile boxed gloveswere used in wound closure.17 One caveat noted inthe report was that damp boxes containing glovesmay be more likely to contain mold and should be



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avoided. Certainly, caution should be exercisedwhen decisions about usual practice are madebased on evidence from a single study, but morework may demonstrate support for abandoning sur-gical gloves during routine laceration repair. Advan-tages would include increased convenience and

reduced cost.

Laceration Closure Techniques

In August 1998, the Food and Drug Administra-tion (FDA) approved the first tissue adhesive for usein the United States. Although cyanoacrylates havebeen used for many years in Canada and Europe,2-octylcyanoacrylate (2-OCA; Dermabond, Ethi-con, Inc., Closure Medical Corp., Raleigh, NC) is thefirst to be considered medical grade because of

improved tensile strength over the butylcyanoacry-lates and fulfillment of standards for nontoxic med-ical devices.18 The US introduction of 2-OCA wasmuch anticipated, and the demand for the productwas immediately great. In the first month and a halfof availability, $2.7 million worth of product wassold.19 Tissue adhesives were lauded as the cuttingedge of laceration repair, soon to render suturesobsolete. The advantages of rapid and painless ap-plication, increased patient convenience, relativelylow cost and ease of use were quickly recognized.

Marketing for the product was extensive, from phar-maceutical representative visits educating physi-cians and hospitals to magazine advertisements andnews releases specifically targeting parents and pa-tients. As the use of 2-OCA grew, its shortfalls be-came more familiar, causing many practitioners tolose interest and use the product more selectively.

Several studies have been conducted to evaluatethe merits of 2-OCA in laceration repair. A Co-chrane review20 analyzed 13 articles representing 9studies and concluded that tissue adhesive is anacceptable option for the repair of simple woundsand provides rapid application with less pain thanconventional wound closure. One caveat men-

tioned, however, is a small increase in the rate ofwound dehiscence. While single studies have nothad the power to show a significant complicationrate, pooled data examined by the Cochrane reviewfound a 4% risk difference versus sutures. The cos-metic outcome of wounds repaired with 2-OCA hasbeen found to be equivalent to that achieved withsutures,18 so it is unknown what clinical signifi-cance the increase in dehiscence represents. Fur-thermore, the study conducted for FDA approval of2-OCA found a trend toward an increased rate ofinfection in wounds closed with tissue adhesive.

Hollander12 postulates, however, that any increase

in likelihood of infection is due to inadequate

cleansing because local anesthetic was not applied.

In addition to thorough irrigation of wounds

closed with 2-OCA, other cautions must be heeded

to prevent complications. The wound edges should

be dry and well approximated. Any adhesive that isplaced within the wound will impair healing and

possibly produce a foreign-body reaction. Good

wound hemostasis should be assured prior to appli-

cation or blood can become sealed into the adhe-

sive, producing a displeasing appearance. Due to

the liquid nature of 2-OCA, runoff can be a com-

mon complication for the inattentive or inexperi-

enced practitioner. Anecdotes of patients eyes

glued shut, practitioners gloves attached to the

skin of patients, and tissue adhesive staining of

clothing are all too common. Ointments or acetone

may be applied to areas of unintentional runoff tospeed removal of the adhesive. For that reason,

antibacterial ointments should not be used after

laceration repair. Adhesive strips and bandages

may similarly strip the dried adhesive from the

wound, so they too should be avoided.

Since the initial release of 2-OCA for use in the

United States, several modifications have been

made in the product and packaging, especially to

reduce the problem of runoff. The first change in

the product was the addition of the chisel-tip appli-

cator. Previously, the only available applicator was

a rounded, dome-shaped tip that tended to hinderprecision in the hands of an inexperienced user.

Development of the new tip was an effort to add

accuracy to the delivery of the liquid adhesivethe

practitioner now has the choice of painting a wide

strip of adhesive for larger wounds or, by turning

the applicator 90, a narrow strip for smaller lacer-

ations. Using either applicator tip provides equiva-

lent wound approximation; it is a matter of personal

preference which is used. Both applicator tips will

continue to be available.

Another tissue adhesive innovation to correct

the problem of runoff is High Viscosity Dermabond.This product has been available since January

2003. It is another formulation of 2-OCA, differing

only in its increased viscosity. The newer product

has a syruplike viscosity, reducing the likelihood

that it will flow away from the wound.

The newest modification to counter runoff is the

Dermabond ProPen. This device contains high-vis-

cosity 2-OCA and is intended to increase the con-

trol of application. The device is held like a pencil,

and a large button on the side is pressed to release

the adhesive in a steady flow. The pen comes with



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interchangeable tips including a new narrow appli-cator for delivery of a thin line of adhesive.

Now that 2-OCA has been available for use forseveral years, its advantages and disadvantages arebecoming clearer. There is little doubt that woundclosure is more rapid with tissue adhesive than

sutures, and patients prefer the greatly reducedamount of pain involved, just as parents prefer theincreased convenience of no return visit for sutureremoval. Certainly, care must be exercised whenidentifying patients and lacerations appropriate forskin adhesive. Contraindications still include evi-dence of infection, wounds on mucosal surfaces ormucocutaneous interfaces, injury to dense hair-bearing areas, or hypersensitivity to cyanoacrylatesor formaldehyde. Relative contraindications in-clude use in areas of high tension such as joints andlikelihood that the patient (such as a child) will pick

off the adhesive before the wound heals. Ongoingdevelopments have improved the usefulness of2-OCA, so problems such as runoff do not happenas often. Further work should be done to betterelucidate the issues of wound infection and dehis-cence and see if these complications occur at aclinically significant rate.

Sutures remain as the conventional, time-honoredtechnique for repairing lacerations. This method isparticularly useful in situations where tissue-adhesiveclosure is not appropriate such as high-tension areasover joints and with lacerations that have higher riskof infection. Sutures have the advantage of greatertensile strength than tissue adhesives and, therefore,lower the rate of wound dehiscence.

Most often, nonabsorbable sutures are used toclose the skin surface, necessitating removal somedays later. Absorbable suture is used to approxi-mate the subcuticular areas in deeper lacerations.Deep sutures assist in approximating wound edgesby decreasing tension and lessening dead space inwhich transudate and blood could accumulate. Abetter cosmetic outcome is thought to result. Onerelative contraindication to deep suture placementis contamination of the laceration.

The option to close skin lacerations with absorb-able suture offers the patient increased conve-nience due to the lack of need to return for sutureremoval. A survey performed as part of a studydocumenting the efficacy of absorbable sutures inpediatric scalp lacerations showed that 79% of par-ents would prefer not to return to the ED for sutureremoval.21 This information is hardly an epiphany.Generally, the tensile strength of many absorbablesutures lasts from 2 to 4 weeks, which is adequatetime for the laceration to heal (Table 1). Tissuereactivity to absorbable materials tends to be

higher than to nonabsorbable suture, so concernabout increased scar formation has traditionally

discouraged the use of absorbable stitches for skinclosure (see Table 1).

Some work, however, has been done to shed lighton the beliefs surrounding absorbable sutures. Onestudy22 compared the use of plain gut and nylon onuncomplicated pediatric laceration repairs. No dif-ferences in a visual analog scale (VAS) or optimalwound evaluation score (WES) were found at the4-month follow-up by a plastic surgeon who did notknow which type of suture was used. These resultssuggest that cosmesis is equivalent for woundsclosed with absorbable and nonabsorbable suture.

Similarly, 44 wounds from resection of skin cancerson the head and neck areas of adult patients thatwere closed halfway with polyglactin 910 (VicrylRapide; Ethicon, Inc., Somerville, NJ) and halfwaywith polypropylene (Prolene; Ethicon, Inc.) werefound to show no difference in scarring23 This is notnew information. Studies in the 1970s and 1980sreported the use of catgut suture to close skinwounds.24,25 These papers suggest that one authorhad used absorbable material since the late 1940s.Indeed, a 1990 letter to the editor26 submits thatabsorbable sutures are commonplace in EDs in theUnited Kingdom. Perhaps the practice is also morecommon in the United States than is published orwidely known.

Tetanus Prophylaxis

The final step in wound management, after ap-propriately dressing the traumatized area, is to dou-ble-check the patients tetanus immunizationstatus. Tetanus prophylaxis has been availablesince World War II and is very safe and effective.The American Academy of Pediatrics Committee

TABLE 1. Tissue Half-Life of Absorbable Suture

Suture Material Tissue half-life (in days)

Gut 5-7

Poligecaprone 25 (Monocryl) 7

Chromic Gut 10-14

Polyglactin 910 (Vicryl) 28

Polyglyconate (Maxon) 28-36

Trott AT: Instruments and suture materials, in: Wounds and

Lacerations: Emergency Care and Closure, 2nd ed. St. Louis,

MO, Mosby, 1997, pp. 102-116.



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on Infectious Diseases has published guidelines for

tetanus prophylaxis in routine wound care.27 For

most patients with a history of at least 3 doses of

tetanus toxoid in primary immunization, protec-

tion lasts 10 years. Those patients who sustain

clean, minor wounds less than 10 years after their

last tetanus toxoid require no further prophylaxis.Tetanus-prone wounds (contaminated wounds,

punctures, bites, crushing wounds, burns, etc.) ne-

cessitate a booster tetanus toxoid vaccine if sus-

tained more than 5 years after the last dose.

Patients who were given less than 3 doses of tetanus

toxoid in primary immunization or who do not

know how many were received should receive tet-

anus toxoid at the time of wound care. If the wound

is judged to be more serious than a clean, minor

wound, tetanus immunoglobulin (TIG) should also

be given.

Although these guidelines seem relatively un-

complicated, there is evidence that they are not

well followed. A study published in 200428 exam-

ined tetanus prophylaxis practice in a general ED.

The authors found that 35% of patients were not

provided adequate prophylaxis. Surprisingly, none

of the 504 patients who had sustained tetanus-

prone wounds and had not completed primary im-

munization were given appropriate prophylaxis

(tetanus toxoid and TIG). Also, physicians failed to

give the proper booster vaccine to 21% of patients

with history of completed primary immunization

who had sustained a tetanus-prone wound more

than than 5 years after their last dose of tetanus

toxoid. On the other hand, the study also found that

many adults have sufficient protective titers despite

a history of underimmunization. Certain subpopu-

lations, however, are more likely to have low teta-

nus protection, including the elderly, immigrants,

and people with limited formal education. Although

it is unknown how often pediatric patients fail to

receive adequate prophylaxis, this data should

serve as a warning that only careful vigilance will

keep this easily preventable disease from becomingmore common.

Summary

Children with lacerations and other minor

wounds are among the most often encountered in

the ED. The steps in management of these patients

are well-known and often well-researched, but

dogma still permeates the process. Local anesthet-

ics are effective, and several choices are available.

New topical creams and expanded indications for

the currently available anesthetics will enhance pa-

tient comfort during laceration cleaning and repair.

Irrigation with tap water is a safe, effective and

economic method of cleaning wounds, and perhaps

even the use of sterile gloves is superfluous in pre-

venting wound contamination. Several alternativewound-closure materials are currently available in-

cluding tissue adhesive in an array of applicators

and formulations, adhesive strips, staples, and non-

absorbable as well as absorbable suture material.

Finally, prophylaxis for tetanus is a simple, if pos-

sibly underused, technique. Further research into

new materials and procedures will only improve our

care of patients who have sustained skin trauma.

References

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