SGEM #9: Who Let the Dogs Out? (Wound Care)

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Date: 28 October 2012

Case Presentation: A 45-year-old man presents to the emergency department (ED) with a laceration to his finger. He was washing the dishes and a glass broke. There is a 1cm full thickness laceration on the pad of his index finger. The bleeding has stopped, skin edges look good, tetanus is up-to-date and he wants to know does he need stitches?

Dogma Taught in Medical School: There are over seven million lacerations a year in the USA. Close to five million animal bits/yr and 1.5 million skin tears in the elderly. Open wounds and lacerations are the third most common presenting problems in the ED (Singer and Dagum NEJM 2008). Most of what we know has been based on observations from animal studies and practices in the operating room (OR). However, most of our ED patients are not animals and do not end up in the OR. So it is time to challenge some of the dogma of wound care.

Dogma #1: Top priority for patients is infection

Interestingly when you ask patients about their priorities infection is not their top concern. Singer et al published a study called Patient Priorities With Traumatic Lacerations. It surveyed 724 adult ED patients in 2000 attempt to find the “clinically relevant outcome” for future wound research. Function was number one concern for non-facial lacerations and cosmetic appearance was #1 priority for facial lacerations. This is something we should keep in mind when addressing these injuries.

The risk for infection in adults with traumatic lacerations is 3.5% according Hollander. He did a cross sectional study looking at 5,521 patients over 4 years. Two things really increased the Odds Ratio (EBM Teaching Point) of developing an infection and that was diabetes (OR 6.7 [95%CI; 1.7-26.4]) and a foreign body (OR 2.6 [95%CI; 1.3-5.2]).

Bottom Line: Infection is very important to us but patients have priorities too. They are more concerned about function for non-facial lacerations and cosmetic outcome on the face. We should make sure we acknowledge and address both sets of priorities.

Dogma #2: All wounds need to be cleaned with fancy solutions

What is the best solution to prevent wound infection? Luckily there is a Cochrane Systematic Review on the subject. Fernandez and Griffith searched the various databases for randomized controlled trials.

Tap water vs. no cleansing
Tap water vs. sterile normal saline (NS)
Water (distilled or cooled, boiled water) vs. sterile NS
Tap water vs. cooled, boiled water
Tap water vs. any other solution

Bottom Line: There was not a significant difference between all these solutions so clean tap water is fine and less costly than using all the fancy solutions to prevent infection.

Dogma #3: Sterile gloves must be used for simple laceration treatment

Believe it or not there was a study done on gloves v. no gloves! Maitra and Adams did a single blinded, non-RCT of 242 sutured hand wounds. There was an increase in late purulent infections in those treated without gloves. The conclusion was “we recommend wearing of sterile gloves to suture all wounds”.

This brings up the issue of whether sterile gloves are necessary or will clean non-sterile gloves be fine? Perelman et al published a multicentre RCT in 2004 with 816 patients. They compared infection rates using sterile gloves v. clean non-sterile gloves.

Sterile gloves group: 6.1% (95% CI; 3.8% – 8.4%)
Non-Sterile group: 4.4% (95% CI; 2.4% – 6.4%)

The relative risk (RR) was 1.37 (95% CI; 0.75 – 2.52) with the confidence interval crossing 1.0 indicating no statistical difference.

Bottom Line: This study demonstrated that there is no clinically important difference in infection rates between using clean non-sterile gloves and sterile gloves during the repair of uncomplicated traumatic lacerations.

Dogma #4: No epinephrine in the tips of things or they will fall off

Epinephrine activates alpha adrenergic receptors in the vascular endothelium. It causes peripheral vascular endothelial vasoconstriction. Several of the prominent emergency medical textbooks still say don’t use local anesthetic containing epinephrine in fingers, toes, nose or other appendages.

Katis P addressed this issue with a systematic review published in the CJEM 2003. The article was called Epinephrine in digital blocks: refuting dogma.

Dr. Katis searched 120 years of the literature and only found four papers met inclusion criteria There were historical cases in context of epinephrine using older anesthetics (cocaine). Other studies used un-standardized epinephrine concentrations or other conditions including infection or tourniquet use. There were no modern-day reports to suggest epinephrine in commercial lidocaine preparations cause finger gangrene. In addition, there are ample case studies of post-amputation digit re-implantation after up to 42 hours of warm ischemia suggesting significant digital resistance to ischemic insult

Bottom Line: This means that epinephrine is safe to use with local anesthetic in the tips of things without the fear of those tips falling off.

Dogma#5: All lacerations must be sutured

The dogma here is that sutures lead to better wound approximation and thus better wound outcome. Quinn et al (BMJ 2002) investigated that question in their paper Suturing vs. conservative management of lacerations of the hand: randomised controlled trial.

They looked at whether or not simple lacerations needed sutures. Single centre randomized control trial (RCT) with 95 full thickness lacerations to the hand which would normally require sutures. These were uncomplicated (no tendon, joint, fracture, nail bed or nerve complications) lacerations of <2cm.

Outcome:

Cosmetic appearance after three months – No statistical difference
Time for patients to resume normal activities (function) – No statistical difference
Pain during treatment – Significantly better favouring conservative management

Bottom Line: The conclusion of this small RCT was you can achieve similar cosmetic and functional outcomes with either conservative managment or suture repair of small uncomplicated hand lacerations. But conservative managment is less painful, quicker and likely less costly. No sutures required.

Busted: Dogma of Simple Laceration in the ED

Patients have priorities and infection is not their number one priority
The solution is dilution and tap water is just fine
Non-sterile gloves are fine, save the sterile gloves for sterile procedures
Epinephrine can go in the tips of everything without fear of the appendage falling off
Simple hand lacerations less than 2cm don’t need sutures

Keener Kontest: Can epinephrine be safely used in the tips of things (fingers, toes, noses, etc) without the fear of them gettign ischemic and falling off?

Email your answer to TheSGEM@gmail.com or go to the “Contact Us” link at the top of the home page. Use “Keener Kontest” in the subject line. First one to email me the correct answer will win a cool skeptical prize.