Date: February 22, 2014
Guest Skeptic: Eve Purdy, Queens’ University
Case Scenario: An otherwise health 24-year-old man was out at the bar and got into a bit of a tussle at around 11pm. When he woke up the next morning he was surprised to see a 3cm laceration on the back of his right hand. He finally figures that he should have it checked out and makes it into the emergency department at noon the next day. This is more than 12 hours later.
Questions: Would you suture this wound?
Background: We have spoken before about the dogma of wound care on the SGEM#9. This addressed five myths about simple lacerations in the emergency department.
- Patients have priorities (function/cosmetic) and infection is not number one
- The solution is dilution and tap water is just fine
- Non-sterile gloves are fine, save the sterile gloves for sterile procedures
- Epinephrine containing local anesthetics can go in the tips of everything
- Simple hand lacerations <2cm do not always need sutures
- Dr. Chris Bond SOCMOB “Evidence-based Laceration Repair”
- Life in the Fast Lane “ Suturing Techniques”
- Eve Purdy Manu et Corde “To suture or Not to Suture”
One piece of dogma we have not addressed is the so-called “Golden Period” for laceration repair. Historically we have taught that the wounds sutured after more than 6 hours are at higher risk for infection. This time frame is based on lab and clinical studies related to the doubling time of bacterial colonization, which can progress to invasive infection. Recent reports have both supported a short suturing time window and refuted the association between wound age and infection. However, the evidence on the topic is poor quality with small sample sizes, retrospective and observational designs.
Reference: Quinn JV, Polevoi SK & Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? EMJ. 2014. 31(2): 96-100.
- Population: Multicenter prospective cohort study of 2663 consecutive patients with lacerations presenting to the ED of one of three participating hospitals (trauma center, community non-teaching hospital and city teaching hospital) between Feb 2008 and Sep 2009.
- Intervention: None
- Comparisons: 27 specific patient, laceration and treatment variables including age, sex, race, diabetes, hours from injury to presentation, length, shape, mechanism, location, contamination, repair type and closure method.
- Outcome: Primary outcome was infection at 30 days (seen by a physician and treated with antibiotics). Secondary outcome was cosmetic appearance rated by patients on a 100-point scale.
- Excluded: Animal and human bites were excluded.
Authors Conclusions: “Diabetes, wound contamination, length greater than 5 cm and location on the lower extremity are important risk factors for wound infection. Time from injury to wound closure is not as important as previously thought.”
- 3957 patients presented with lacerations
- 2663 patients completed follow-up (67%)
- 64% sutures, 24% with glue/sterile strips or both, 7% staples and 4% not closed
- 69 developed an infection or 2.6% (95% CI 2.0-3.3%)
- 2.2% (50/2248) of patients received prophylactic antibiotics
- 2342/2663 (88%) had documented time to injury
- No association between infection and closure/repair before or after 12hrs
- Also, no association between age, sex, race or tetanus status
- Infected wounds received a worse cosmetic rating (70 vs. 87)
- Infected wounds more likely to consider scar revision (24.6% vs. 9.6%)
- Multivariate model for predictors of infection showed lower extremities, diabetes, length >5cm and moderate/heavy contamination
BEEM Commentary: This is a prospective cohort study looking at an important issue.
- Large sample size, consecutive lacerations, standardized data collection forms
- Three different sites (Level 1 Trauma centre, teaching and non-teaching community hospital)
- Subjective variables were given explicit definitions
- The sample size calculation was deliberate and appropriate
- Statistical analysis seemed appropriate
- Asked patient oriented outcome of cosmetic result
- 2.6% infection rate consistent with other data
- Not randomize but this is a limitation of evidence based medicine
- Follow-up was only 67% and they were excluded from analysis
- Doctors who diagnosed infection were not blinded to the time from suture to infection or any other mechanism/wound factors
- Patient records were not used to confirm infection
- #1 patient oriented outcome (function) was not recorded
- Only 85 patients (2.1%) presented >12hrs with only 1 getting infected
- 13/85 (15.3%) were treated without initial closure leaving only 72 patients repaired >12hrs post injury
- This was five times (15% vs. 3%) higher rate than those presenting <12hrs after injury
- Heavy or moderate contamination, identified in the multivariate model as associated with infection, included time in the description
- Unclear about whether people with comorbidities were less likely to have wounds sutured in the first place
- Not very impressive odds ratio (OR 1.9-3.1)
The Bottom Line: The overall rate of infection is low in simple lacerations. There is no good evidence to show that there is an association between infection and time from injury to repair. There is some evidence to suggest wounds on the lower extremities, diabetic patients, size >5cm or those with moderate to heavy contamination are more likely to become infected. Clinicians should consider using prophylactic antibiotics in these high-risk situations.
Case Resolution: After examining the wound you determine that it is a simple laceration with no involvement of tendons, nerves or major blood vessels. You take a good history and learn that the patient does not have diabetes. You discuss the evidence with the patient and despite the long time from injury to presentation you both decide to go for sutures. You clean the wound thoroughly with tap water and use clean but non-sterile gloves for the repair. You inform him of about a 3% risk of infection and advise him of what to watch for and return if concerned.
KEENER KONTEST: Last week’s winner was a repeat winner Constant Coolsma from the Netherlands. He knew that the Nobel Prizes awarded every year on December 10th.
Listen to this weeks episode of the SGEM for the Keener Kontest? If you know the answer send an email to THESGEM@gmail.com with keener in the subject line. The first person will receive a skeptical prize.
BEEM Conferences: SweetBEEM and PrairieBEEM