Closure of skin wounds

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29 Οκτ 2013 (πριν από 3 χρόνια και 9 μήνες)

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Closure of skin wounds

with adhesives or staples
(
UpToDate
)


G
oals of wound management :

1.

A
ssist in hemostasis

2.

A
void wound infection,

3.

P
rovide an esthetically pleasing scar


The healing process

of skin occurs in several stages

1.

Coagulation
begins immediate
ly

following the injury. Vasospasm as well as platelet
aggregation and fibrous clot formation occur. During the inflammatory phase,
proteolytic enzymes released by neutrophils and macrophages break down
damaged tissue.

2.

Epithelialization

occurs in the epid
ermis, which is the only layer capable of
regeneration. Complete bridging of the wound occurs
within 48 hours

after
suturing.

3.

New blood vessel

growth
peaks four days

after the injury.

4.

Collagen formation

is necessary to restore tensile strength to the wou
nd. The process
begins within 48 hours of the injury and
peaks in the first week
. Collagen
production and remodeling continue for up to 12 months.

5.

Wound contraction

occurs three to four days

following the injury, and the process is
poorly understood. The
full wound thickness moves toward the center of the
wound, which may affect the final appearance of the wound.


WOUND ASSESSMENT

1.

Determination of the
mechanism

of the injury

2.

Age

of the injury

3.

Identification of
possible contamination or foreign body

a.

Con
sider plain xray with glass injury (sens 90%)

4.

Assessment of
extent of the wound


a.

Fracture or tendon/nerve laceration

5.

Assessment for
neurovascular compromise

or tendon injury in the surrounding area

6.

Need for
tetanus prophylaxis


7.

Identification of
risk fact
ors

that might affect healing.

a.

DM, steroids, CRF, tendency to form keloids
, presenting beyond 18 hours





WOUND PREPARATION

1.

Wound irrigation

a.

Saline or tap water, splash guard

b.

Can use dilute betadine (1:10 Betadine/saline) for contaminated wounds.

2.

Foreign

body removal

a.

Remove splinters, glass, metal

3.

N
ecrotic tissue debridement


Indications for secondary closure

(ie, by granulation) include:

1.

Deep stab or puncture wounds that cannot be adequately irrigated

2.

Contaminated wounds

3.

Small noncosmetic animal bites


4.

Abscess cavities

5.

Presentation after a significant delay (>18h, or>24h head and neck)


Types of closure

1.

Sutures

a.

Simple interrupted commonly used

2.

Tissue adhesives

a.

cyanoacrylate polymers Dermabond (Ethicon).

3.

Staples



















A.
Tissue adhesives


http://www.aafp.org/afp/20000301/1383.html

http://www.uptodateonlin
e.com/utd/content/topic.do?topicKey=ped_proc/9347&select
edTitle=1~13&source=search_result



Physiology



Cyanoacrylate tissue adhesives are
liquid monomers

that undergo an
exothermic reaction on exposure to moisture (eg, on the skin surface),
changing to
polymers that form a strong tissue bond.

When applied to a laceration, the polymer
binds the wound edges together to allow normal healing of the underlying tissue.

Maximum bonding strength is achieved within 2.5 minutes of application

DERMABOND is 2 Octyl
cyanoacrylate


low toxicity, has addition of plasticizers which
provide increased flexibility.

Replacement for 5
-
0 or smaller sutures

Advantages



over

sutures

and staples
:

1.

Less painful application, and sometimes no need for local anesthetic injection

2.

Mor
e rapid application and repair time

3.

Cosmetically similar results at 12 months post
-
repair

4.

Waterproof barrier, no need to keep areas dry; bandages usually not required

5.

Antimicrobial properties

6.

Better acceptance by patients

7.

No need for suture

or staple
r
emoval or follow
-
up

Efficacy



Several randomized clinical trials in both children and adults have found
that there is no significant difference in outcomes when either lacerations or surgical
incisions are repaired with tissue adhesive versus standard wo
und closure (eg, sutures,
adhesive strips)

INDICATIONS
-

good wound approximation with no wound tension. The ideal
laceration is clean and linear.







CONTRAINDICATIONS
-


1.

Complex stellate lesions or crush injuries should not be closed with tissue
adhesive
s since good wound approximation is difficult to achieve.

2.

H
ands, feet, or joints
, unless immobilized

3.

O
ral mucosa or other mucosal surfaces

4.

Areas

of high moisture such as the axillae and perineum.

5.

hairline or vermilion border of the lip require more precis
ion

6.

Puncture wounds and most bites
-

increased risk of infection

7.

Patients with diabetes mellitus, chronic vascular disease, peripheral vascular
disease, decubitus ulcers, prolonged steroid use, history of keloids, bleeding
diathesis, allergy to adhesives


T
ECHNIQUE OF APPLICATION

http://www.dermabond.com/bgdisplay.jhtml?itemname=how
-
it
-
works


1.

Wound prep

2.

C
leanse

wound
,
placement of subcutaneous sutures if necessary

3.

Evert or appose

edges using the fingers or tissue forceps.

4.

Achieve hemostasis because blood interferes with adherence of the adhesive to
the skin.

5.

Remove any tissue or hair that extrudes through or overlies the wound edges

6.

Crack vial
, squeeze to saturate the foam tip, w
ipe gently over the wound edges
in a single motion, spreading a thin film

7.

Don’t press into the wound,
(may

cause a foreign body reaction that prevents
normal wound healing) .If this occurs, wipe off, using petroleum jelly or
antibiotic ointment to loosen
the polymer.

8.

allow to dry for 30 to 40 seconds
while continuing to hold the wound edges
together

to allow complete polymerization

9.

repeat three to four times in an oval pattern around the wound

10.

Wound closure strength is enhanced by extending the application

5 to 10 mm
beyond the margin of the incision

11.

Don’t touch the wound for about 5 minutes.





AFTERCARE

1.

No bandage needed

2.

No ointment

3.

May shower ;avoid long soaks

4.

No scrubbing or picking for 7
-
10 days

5.

Peels in 5
-
10 days or can use petroleum jelly to remove

6.

No follow up needed


COMPLICATIONS

Leakage, sticks to gloves/instruments

If gets in the eye or eyelids
generous amounts of ophthalmic antibiotic ointment should
be placed on the eyelid to break down the adhesive and an ophthalmologist should be
consulted

COST
-

$24/vial ($5 for suture pack), but similar in terms of time, f/u appt, suture
removal kit


























B. Staples

Pros

(
over sutures
)



Cons


1.

More rapid






2.

Avoid needle stick risk

3.

Good wound eversion

1.

More painful removal

2.

Higher risk of
scarring

3.

Less precise
-

avoid in
face/neck/hands/feet

4.

CT
-

artifact; MRI
-
avulsion






Ideal wound
-

linear with straight, sharp edges


PROCEDURE

1.

Wound assessment

2.

Anesthesia
-

regional or local

3.

Evert wound with forceps or by pinching the skin with the thumb a
nd index
finger.

4.

Place

stapler firmly on the surface but without indenting the skin; squeeze the
handle gently to eject the staple into the tissue.
Release

by pulling the wrist back.

5.

Apply antibiotic ointment (eg bacitracin)
, dressing for 24
-
48hours


Remov
al of staples (same as sutures)

1.

Neck
-

3 to 4 days

2.

Face and scalp
-

5 days

3.

Eyelids
-

3 days

4.

Trunk and upper extremities
-

7 days

5.

Lower extremities
-

8 to 10 days


Wound management and tetanus prophylaxis

Previous doses of
adsorbed tetanus
toxoid*

Cle
an and minor wound

All other wounds

Tetanus toxoid

TIG

Tetanus toxoid

TIG

<3 or unknown

Yes§

No

Yes§

Yes

3

Only if l
ast dose
given
10 years
ago

No

Only if last dose
given
5 years ago

No