REPAIR OF LACERATIONS: SUTURES, STAPLES, AND DERMABOND GLUE
Indications:
Most lacerations are minor, and repairable by primary wound closure. Primary closure technique attempt to bring the wound edges together neatly and evenly, stop any bleeding, preserve function of the tissue, prevent infection, restore cosmetic appearance, and promote rapid healing. Techniques to obtain primary closure may involve steri-strip dressings, sutures, glue, or staples.
As a general rule, lacerations on any part of the body may be closed primarily for up to 12 hours following the injury. Facial wounds may be closed primarily up to 72 hours following the injury. Wounds that have been grossly contaminated, infected, or have come to medical attention late may be allowed to heal by granulation (secondary intention) after appropriate cleansing.
Contraindications
Lacerations that should be managed in an operating room under general anesthesia with a surgical consultant include wounds with:
1. Excessive length or depth, potentially requiring a toxic dose of local anesthesia to obtain adequate analgesia
2. Severe contamination requiring extensive cleansing or debridement
3. Open fractures, tendon, nerve, or major blood vessel injury
4. Complex structures requiring meticulous repair (eyelid)
Materials
1. Universal precautions materials
2. Suture set to include: needle driver, toothed forceps, suture scissors
3. Lidocaine 1% or 2% with and without epinephrine for local anesthesia
4. 10 cc syringe, and 25 gauge needle for infiltrating anesthetic
5. Sutures: absorbable or non-absorbable of appropriate size and needle type; OR Dermabond® glue OR surgical steel staples and stapler
6. Wound preparation materials: prep solution, gauze, scrub brushes
7. Wound dressings, tape
8. Tetanus immunization serum and syringe
Preprocedure patient education
1. Obtain informed consent
2. Inform patient of the major steps of the procedure, including the transient discomfort associated with local anesthesia
Procedure:
Laceration repair involves four steps:
1. Wound assessment
2. Wound preparation
3. Wound closure
4. Tetanus prophylaxis
Assessment
1. Brief history and PE
2. Potential for foreign body in wound, or fracture
3. Examine and document vascular and neurologic status
4. Radiographs, if appropriate
Preparation
1. Mechanical cleansing: surgical scrub brush, soap and water
2. Mechanical Cleansing: normal saline irrigation using a 30- or 60-cc syringe with an 18- or 20-gauge needle to develop pressure. Use 100 cc of saline for each cm of wound
3. Chemical cleansing: Betadine, Savlon, or Hibiclens
4. Freshen wound edges if necessary with scalpel or scissors
NOTE: The maximum dose of lidocaine in 4 mg/kg
Wound Closure
1. Glue: approximate edges of wound, apply glue in thin layers along wound‘s length, allow to dry between applications
2. Suturing:
Face: 1% lidocaine with epinephrine
4.0 or 5.0 nonabsorbable monofilament,
or 5.0 absorbable monofilament on cutting needle
Use interrupted or intracuticular technique, layered closure if deep
Sutures out in 3-5 days
Scalp: 1% lidocaine with epinephrine
2.0 or 3.0 nonabsorbable monofilament on cutting needle
Use interrupted or mattress technique
Sutures out in 10 days
Figure 1: A simple interrupted suture. Note the broad, even bite, and the knot tied to one side.
Ear: 1% or 2% PLAIN lidocaine, or field block
1.0 synthetic absorbable on taper needle for perichondrium, interrupted sutures
1.0 synthetic nonabsorbable monofilament on cutting needle for skin, interrupted sutures
sutures out in 5 days
Lip: 1% or 2% lidocaine with epinephrine; consider regional block
4.0 or 5.0 synthetic absorbable on taper needle for deeper layers, interrupted sutures
1.0 synthetic monofilament on cutting needle for skin, interrupted sutures
sutures out in 3-5 days
Oral cavity: lidocaine 1% with epinephrine; consider regional block if extensive laceration
4.0 absorbable gut, or synthetic absorbable on taper needle, mattress technique
allow sutures to dissolve; remove any remaining after 7 days
Neck, chest, back, abdomen:
1% lidocaine with epinephrine
4.0 or 5.0 nonabsorbable synthetic monofilament on cutting needle, interrupted or running sutures
sutures out in 10 days
Figure 2: The basic interrupted suture used to close dead space. Notice that the knot is buried in the deeper tissues.
Extremity: 1% or 2% lidocaine with epinephrine
1.0 or 4.0 absorbable synthetic on taper needle for muscle or fascia; interrupted sutures or 5.0 nonabsorbable monofilament on cutting needle for skin; interrupted or running sutures
sutures out in 10 days
Hands, feet: 1% PLAIN lidocaine, or consider regional block with bupivicaine
1.0 or 5.0 nonabsorbable synthetic monofilament on cutting needle; interrupted or running sutures
sutures out in 10-14 days
Nail beds: 2% PLAIN lidocaine, or consider regional block with bupivicaine
5.0 plain gut on taper needle; interrupted sutures
use a stent for the nail fold
allow to absorb
Figure 3: A horizontal mattress suture
Stapling
Many surgical staplers are on the market. The staple is inserted into the skin in the shape of an upside-down “U” which elevates, everts, and approximates the skin edges. Stapling is appropriate for wounds on the scalp, trunk, or extremities. They should be removed in 10 days.
Tetanus prophylaxis
Currently, a basic course of minimally three doses of tetanus vaccine with a booster dose every 10 years is current standard of care for everyone. However, patients may be deficient in one or more doses, and require tetanus prophylaxis in the ER,
1. Patients who have a clean wound, with last booster > 5 years require Td or Tetanus toxoid
2. Patients with a clean wound who have had a tetanus booster < 5 years require no vaccination
3. Patients who have not had at least three doses of tetanus vaccine as a primary course should receive Tetanus Immune Globulin, AND Td or Tetanus toxoid, and a schedule to complete their primary vaccinations
4. Patients with grossly contaminated wounds whose last tetanus booster was > 5 years ago require Tetanus Immune Globulin AND Td or Tetanus toxoid.