Laceration Trick?
I was a little disturbed by the "Tricks of the Trade" article in the latest installment of ACEP News.The authors suggest placing a couple of absorbable sutures in selected wounds under tension, followed by the use of tissue adhesive. As you can see by the pictures, the initial outcome appears to be acceptable but certainly suboptimal in my opinion. Now I'm a huge fan of Dermabond, but I fail to see the benefit in this particular application.
If you are going to go to the trouble (and cause the patient the discomfort) of anesthetizing the wound anyway, why not take the time to finish the job properly? A neat row of closely-placed 6-0 or even 5-0 sutures would even out the tension along the wound and provide for better approximation in most situations. I disagree with the authors that suture removal in children is significantly traumatic enough to justify the apparently inferior outcome of this technique.
It might be useful on a less cosmetically-significant area, primarily as a time-saver. But who the heck uses catgut anymore? Anyone?
I thought their second suggestion of using a combination of steri-strips and tissue adhesive for gaping wounds was a much better idea. That avoids the drama of the shot and allows the Dermabond to be used in situations that otherwise would require sutures.
Labels: lacerations, tips
posted by scalpel at 7:19 AM
17 Comments:
I would be really disappointed if I took a kid with that kind of wound to the ER and got a repair job like that.
I have to wonder how he received that wound in the first place - fell over and hit his Playstation? He certainly isn't doing a lot of physical activity.
But yeah, kinda bad job. Like a medical student did it ;)
Yeah, not good looking. However, it often looks much better when you see them months later for a broken wrist! Some people just heal well. Also, I use fast absorbing chromic all the time in straight, simple facial lacs. I do a subcuticular stitch and find that if the wound edges are straight and there is not too much tension, it works great. This of course is for lacs too big to easily to with Dermabond.
"If you are going to go to the trouble (and cause the patient the discomfort) of anesthetizing the wound anyway, why not take the time to finish the job properly?"
I agree. This is not a place I would use catgut (and I do still use it). I would use vicryl in the deep dermis and then a PDS subcuticular or maybe the Dermabond.
I agree - Dermabond has it's place and is a life-saver with small kids and small lacs, but it's not good for gaping/long/irregular lacs.
You can use fast absorbing chromic on the skin in place of Nylon and since it absorbs in about 7 days, you don't have to remove them unlike vicryl which takes 2-4 weeeks to fully dissolve. I know a plastic surgeon who does that almost entirely on kids and things turn out well.
I loved (chromic) catgut, but we can't get it over here anymore.
Glue and steris work well, sometimes and I trial it on a lot of wounds; if you're giving the shot and want to avoid removal, why not a subcuticualr layer, or two, and then steris and glue?
(For what its worth I closed a 7" forehead lac just so recently, with good cosmesis)
The big problem I see with the wound in question is that two sutures simply weren't enough. The tension on those two sutures is therefore excessive, and an irregular scar will likely be the result.
I would personally have done a running subcuticular with 5-0 vicryl followed by glue/strips, or simply a running 6-0 prolene removed in 4-5 days followed by strips after suture removal.
I read and thought the exact same thing. Lidocaine injections and dermabond are mutually exclusive in my mind.
Catgut? Check. Now, where do we keep the aether and carbolic acid?
I agree-- if you have gone through the trouble of opening a lac kit and suture, then just suture it all the way. From the blanching in the picture it looks like he has adequate analgesia with LET solution/local anyway. In our ED it's pretty much either dermabond or suture, both seems kind of strange. As for suture choices, I tend to only use chromic for deep/mucosal surfaces and prolene for superficial.
While it can sometimes not be fun to be up in a child's face with scissors for suture removal, I don't see how they avoided that "trauma" by doing only a halfway suture job anyway.
From the looks of the tension and the lack of approximation of the majority of the wound, i would expect a very ugly scar. I would not want such an effort associatied with my name.
What is with the dudes face in the first place. Ludwigs angina or too many Big Mac's?
And in the midst of all that, they probably missed the subcondylar mandible fracture/contusion which wil come back to haunt the kid years later.
Unfortunately, I think there are enough ER docs who are uncomfortable handling kids and facial lacerations. I've actually asked that an ER doc redo stitches that were not putting the wound edges together and/or leaving a gap/pulling. He was very accommodating. Two years later the scar is flat and barely visible.
This one would have been a redo.
I wonder if many docs do that when they are done and may realize the result is suboptimal? or do you leave it in and hope for the best if the family doesn't say anything?
My oldest son had approximately 30 VERY tiny sutures removed from his ear following plastic surgery (age 3). When it was all over, he cheerfully announced that it didn't hurt a bit.
I can't imagine that suture removal for ANY child would be more traumatic than a plastics repair or living with the scar that will result from a slovenly repair
Hope this is useful.
1. Steri strips alone do not appose deep skin edges. Nice looking repair but sunken scar!
2. Dermabond or other cyanoacrylates alone do not appose deep skin edges. Same results.
3. Chromic catgut produces intense inflammation in face, PLAIN catgut does not much, PGA even less.
On PLAIN catgut in face:
http://www.google.co.nz/url?q=http://ttuem.com/page2/page5/files/Suture%2520Type%2520Karounis%2520AEM.pdf&sa=U&ei=xvBoT5usE62aiQej4NW-Cg&ved=0CCAQFjAG&usg=AFQjCNEaVwriCrWpwTEdgH1V77ngCNS87Q
4. I try as of first importance to have deep wound edges apposed. Steristrips / cyanoacrylates fine for apposing superficial edges AFTER deep closure taken care of. Even if they come off, it will still be a narrow scar.
5. PGA, yea even Catgut, can be used for superficial edge apposition, AS LONG AS early removal is done.
- Saves you time and saves you from also unneccesarily charging patients for opening a nylon/silk suture.
Post a Comment
<< Home