Shikha Kapil

Chris Bodle
2/15/16

Grady Memorial Hospital

Trauma Service Guidelines
Wound Closure Guideline for the Marcus Trauma
Center
BACKGROUND
Improper technique during wound closure in the trauma patient
can result in infection and/or wound dehiscence contributing to
increased rates of morbidity and healthcare expenditure.
The following guidelines will serve to aid in choosing appropriate
materials and proper technique for optimal wound closure.
This is a guideline for lacerations that do not involve life
threatening or arterial bleeding. These lacerations would be
assessed on the secondary assessment of major trauma patients.
CLINICAL PRACTICE GUIDELINES
I. Initial Evaluation
Initial evaluation of a laceration must include thorough neurovascular
and functional exam. An abnormal exam should be addressed by
consultation of appropriate subspecialty service. Consider
consultation in:
Flexor tendon injuries in the upper extremities
Wounds involving joint spaces
Wounds involving large vessels
Wounds requiring large debridement
Avulsion injuries of ears, nose, penis
Note that a patient request for an emergent subspecialty consult is not
an indication to consult (i.e. plastics for an uncomplicated facial
laceration)

Assessment of wound includes thorough cleaning and

exploration. Jagged wound edges, stellate shape, visible
contamination and wound depth are all increase risk of
infection.all increase risk of infection.

Patient history is important. Risk factors for delayed wound

healing and infection include advanced age, diabetes, and
vascular disease (chronic venous insufficiency, peripheral artery
disease). 1

II. Preparation
A. Cleaning
o Sterile saline and tap water equivalent
o Irrigation (50-100ml per cm of laceration)
o Pressure: need to overcome bacterial adhesion to tissue.
However too much pressure causes tissue damage and
increases infection risk by driving bacteria into tissue.
Ideal pressure is 8-12 psi.2 3
o
B. Imaging
o X-ray, ultrasound, CT scan can detect presence of
radiopaque foreign bodies in the wound
Glass, metal, shrapnel, teeth
o Does not replace wound exploration for identification of
radiolucent material
Organic material, clothing
III. Materials
A. Vicryl: Braided, absorbable suture
o Maintains tensile strength for 3-4 weeks.
o Indications: preferred material for subcutaneous closure
Deep closure of muscle, fascia, subcutaneous tissue
Should not be used to close skin
o Purple vicryl can tattoo skin when used in the
subcutaneous tissue
B. Prolene/Nylon: Monofilament, non absorbable
o Indications
Skin closure, tendon repair
o Extremities (Arms/legs)
3-0 or 4-0, consider 2-0 over large joints or areas of
tension
Remove in 7-10 days

If laceration is overlaying joint, consider orthopedic

surgery consultation to ensure joint space not
violated.
Distal extremities (hands/feet)
No smaller than 4-0
Remove in 7-10 days
Chest/abdomen
3-0 or 4-0
Remove in 7-10 days
Face
5-0 or 6-0
Remove in 3-5 days
Tendon
2-0 or 3-0

C. Chromic Gut: Coated, biologic,

o Maintains tensile strength for 10-14 days
o Indications
Palms and soles
Inside the mouth
o Chromic gut is not an appropriate choice for skin closure or
for deep sutures
D. Fast gut: Biologic
o Low tensile strength, absorbed within 4-6 days
o Indications
Face on children
Face for selected adults (those unlikely to follow up,
small, superficial wounds under no tension)
Can be re-enforced with wound tape 4 5 6
IV. Suture technique
Buried stitches (deep stitches) for use in multi-layer
closure
o For subcutaneous closure in gaping wounds
o For closure of fascia over muscle
Vertical mattress This is a stitch that is meant to close
wounds under significant tension
o For skin closure of gaping wounds
o Closure over joints
Horizontal mattress This stitch is for hemostasis only, not for
wounds under tension
o For skin closure of a wound with significant bleeding from
the skin edge

Figure of eight This stitch should be applied to an actively

bleeding vessel only
o Use Silk (3-0) for this stitch in an arteriolar bleed
o If the bleed is truly an arterial bleed, a small silk (3-0 or 40) should be used
Running subcuticular This stitch should be used to close skin,
for cosmesis only after deep Vicryl stitches have been applied
o Use Monocryl only (4-0 or 5-0) 7

V. Wound type
Contaminated wounds
o Copious irrigation
o Lacerations or wounds over joints should be challenged
with saline load to ensure no joint involvement.
Recommend orthopedic surgery consult.
o Grossly contaminated wounds should be cleaned
thoroughly and left open. Wet dressing applied. Need daily
dressing changes and referral to follow-up with General
Surgery .
Delayed presentation
o Copious irrigation with debridement as needed
o Facial wounds may be closed up to 24 hrs after
presentation
o Wounds in the extremities may be closed up to 12 hrs after
presentation
o If the wound is too large to leave open or heal by
granulation, can place retention sutures sparingly to
loosely approximate skin edge. Avoid placing deep sutures
in these wounds and consult appropriate service for follow
up.

Special considerations
o Exposed cartilage should not be sutured. Perichondrium
should be the deepest stitch. Exposed cartilage needs to
be covered with skin completely.
o Lip: Through and through lip lacerations often require
multi-layer closure. The muscular layer should be closed
with vicryl, anything inside the mouth should be closed
with chromic gut and anything outside the mouth
(including the vermillion border) should be closed with
nylon or prolene. All sutures should be 5-0.
o Complicated facial lacerations involving the lacrimal duct,
eye lid edge, eye lid function should prompt a consult to
ophthalmology

o Facial lacerations with neurovascular compromise,

muscular impairment, or concern for cosmetic outcome
should prompt a consult to face coverage (ENT, OMFS,
plastic surgery)
o Involvement of joint space, tendon/bone exposure warrants
an orthopedic surgery consult.
o Lacerations of the hand need to be carefully examined for
neurovascular status, tendon involvement, or violation of
tendon sheath. Hand consult teams are orthopedic surgery
and plastic surgery. 8
VI.

Antibiotics
o Not indicated for simple lacerations
o Prophylactic antibiotics for:
Human/animal bites
Extensively contaminated wounds (soil, organic
material)
Higher risk of infection with poor perfusion:
anatomical (scalp lower risk than extremity) and
chronic disease states (PAD, chronic venous stasis)
10 11

References

1 Hollander JE, Singer AJ, Valentine SM, Shofer FS (2001) Risk factors for infection in patients with
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2 Chisholm CD, Cordell WH, Rogers K, Woods JR (1992). Comparison of a new pressurized saline
canister versus syringe irrigation for laceration cleansing in the emergency department. Ann
Emerg Med 21(11):13641367

3 Moscati, R. M., Mayrose, J., Reardon, R. F., Janicke, D. M. and Jehle, D. V. (2007), A Multicenter
Comparison of Tap Water versus Sterile Saline for Wound Irrigation. Academic Emergency
Medicine, 14: 404409.

4 Mehta PH, Dunn KA, Bradfield JF, Austin PE. Contaminated wounds: infection rates with
subcutaneous sutures. Ann Emerg Med 1996; 27:43.

5 Subcuticular sutures and the rate of inflammation in noncontaminated wounds.

6 Al-Mubarak L, Al-Haddab M. Cutaneous wound closure materials: an overview and update.
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7 Moy RL, Waldman B, Hein DW. A review of sutures and suturing techniques. J Dermatol Surg
Oncol 1992; 18:785.

8 Nicks B, Ayello E, Woo K, Nitzki-George D, Sibbald G. Acute wound management: revisiting the

approach to assessment, irrigation, and closure considerations. Nt J Emerg Med (2010) 3:399-407.

9 Eron LJ (1999) Targeting lurking pathogens in acute traumatic and chronic wounds. J Emerg Med
17(1):189195

10 Capellan O, Hollander JE. Management of lacerations in the emergency department. Emerg

Med Clin North Am 2003; 21:205.

11 Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a metaanalysis of randomized studies. Am J Emerg Med 1995; 13:396.