principles of spacing as above.

Tissue adhesive is applied using 4-5 layers on a hemostatic, cleaned, dry wound, which the provider approximates while applying the adhesive. Avoid getting the

adhesive into the wound itself. Wound tape may be applied

to the wound before placing the adhesive to provide

improved approximation.

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.A. Figure 6-4. Horizonta l mattress.

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LACERATION REPAIR

Figure 6-5. Deep dermal stitch. On the first pass,

the needle enters at the depth of the wou nd so that

the knot wi ll end up at the bottom of the wound.

..... Wound Aftercare

Topical antibiotic ointments provide a moist environment

that assists epithelization and reduces the rate of infection.

They should not be used after the use of tissue adhesive.

Prophylactic oral antibiotics are r ecommended for heavily

contaminated wounds, significant animal or human bites,

areas prone to infection (mouth, plantar aspect of the

foot), open fractures, tendon or joint involvement, immunocompromised patients, a prosthetic heart valve, or deep

puncture wounds.

In patients with full childhood immunizations, tetanus

toxoid, given with diphtheria toxoid (Td 0.5 mL administered intramuscularly [IM) ), is administered after a minor,

clean wound if the last booster was > 10 years ago. In all

other wounds (contaminated, puncture, crush), tetanus

toxoid is given if the last booster was >5 years ago. Tetanus

immune globulin (TIG) 3,000-5,000U IM and around the

wound is administered to patients with a history of <3

immunizations and a contaminated wound.

Apply a topical ointment ( eg, bacitracin) and then a

sterile dressing. The dressing may be removed in 24 hours

and the wound can be gendy cleansed with soap and water,

using caution to blot the sutures dry.

Suture removal is recommended in 3-5 days for face

and neck; 7-10 days for upper extremity, chest, legs, and

scalp; and 10-14 days for hand, back, buttocks, foot, and

overlying joints.

COMPLICATIONS

Complications may include infection and scarring. Despite

all efforts to reduce the risk of infection, this complication

can still occur. The patient should be instructed to return

at the first signs of infection (ie, fever, purulent drainage,

or erythema). Patients with high-risk wounds should be

asked to return to their physician or the emergency department within 24-48 hours to have the wound reexamined

by a physician. Patients should also be instructed that a

scar will form with healing. Scarring is more significant

after deeper wounds, or those that do not run parallel to

natural skin lines, and when absorbable sutures are used.

There are insufficient data to recommend routine use of

topical healing creams such as vitamin E, aloe vera, or

other commercially available products.

SUGGESTED READING

Desai S, Stone SC, Carter WA. Wound preparation. In:

Tintinalli JE, Stapczynski JS, Ma OJ, Clince DM, Cydulka,

RK, Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1,

pp. 301-306.

Singer AJ, Hollander JE. Methods for wound closure. In:

Tintinalli )E, Stapczynski JS, Ma OJ, Clince DM, Cydulka, RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 20 1 1,

pp. 306-3 15.

Singer AJ, Hollander JE, Quinn JV. Evaluation and management

of traumatic lacerations. N Eng! J Med. 1997;337:1 142-1 148.