Laceration repair technique

[rowan]

I have a quick question about laceration repair that didn’t occur to me while watching other people do them, but only when I started doing them myself. The wound needs to be appropriately anesthetized for proper irrigation and exploration. The irrigation (saline bottle, syringe, etc.) is normally nonsterile, but the lidocaine and anesthetizing syringe/needle is in the lac kit, which is sterile. So, if you need to anesthetize first (with sterile gloves to get the lido/syringe from the lac kit) and then irrigate (which would make your gloves nonsterile), do you use two sets of gloves? One to anesthetize, then another when you are ready to sew? Or do you use nonsterile lido/syringe/needle that are not from the lac kit? This is probably an incredibly stupid question, but one that I don’t have a good answer to. Thanks.

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[GatorEM]

I usually use a separate (not in the lac tray) syringe and lido to anesthetize. I guess this is pretty wasteful as the supplies from the lac tray are usually discarded unused. I also poke holes in the top of the sterile water bottle using a sterile 18 or so gauge syringe and use it as a squirt bottle to irrigate. This is a trick I picked up from the ortho guys. It saves you the hassle of using the tume or large syringe for irrigation. I haven't quite figured out the best way to take the little cups out of the lac tray without wasting a pair of sterile gloves so that I can us it for betadine. I usually just ask someone to squirt it into the cup for me once I'm sterile and ready to work.

 

[kungfufishing]

For most lacerations, it does not matter if you are "sterile" when you sew it. Clean gloves are fine.

Poking holes in a saline bottle probably is not as good as a syringe (or even a well running tap) in terms of PSI for irrigation.

 

[southerndoc]

The Canadians studied this and demonstrated that sterility is overrated.

Here's a trick to get the cups, syringes, etc. out and still be able to draw things up. Glove only one hand. Use that gloved hand to move things around from the lac tray, move the small cups out, put the 18 g needle onto the syringe to draw up the lidocaine, etc.

Use the non-gloved hand to hold the lidocaine as you draw it up, pour the betadine, pour the water, etc.

Takes a little practice, but once you get used to it, you can do it pretty easily.

 

[DOrk]

I never put on sterile gloves until just before I pick up the needle driver. As the above poster commented, sterile technique is overrated, at least for most lacs we sew in the ED. These lacs are contaminated already-you're not going to make them any worse by wearing clean, nonsterile gloves. That being said, I still change over to sterile gloves before starting the repair-force of habit, I guess.

 

[deleted109597]

Our kits come with the needles on top inside the first fold, so they aren't sterile.
That being said, I rarely use OR technique with sutures. Just like trauma lines, they get a combo of speed and clean.
Now, elective lines, I make them pretty clean. Don't want to risk an infection cancelling out Medicare money.

 

[roja]

ditto what has been said here. Our lac kits don't have needles in them so it doesn't really matter. What will matter is irrigation, no using sterile gloves.

One thing that I changed in my practice once I was an attending (more fast track type shifts and it speeds up moving patients) is alot more digital and other various nerve blocks for feet/hands.

 

[Capgras]

Great topic! I go through the same thought process every time I suture someone up. First off most of the sources say that betadine is not necessary just irrigation with normal saline. Now if I don't use betadine then the area isn't sterile anyways so why do I have to use sterile gloves (I will agree that sterile gloves fit better than regular gloves). Still there is something ingrained (probably from surgery) that the suture kit is sterile and should remain that way throughout the whole procedure. Now if I decide to be a rebel and not worry about sterility I run into a problem when I write my procedure not that usually starts with "Under strict sterile precautions ... "

Its hard to get past old habits.

 

[drewpydog]

Two words: tap water.

I've been using tap water and clean, nonsterile gloves since after residency and I haven't had an infected lac (at least, that I know of). What I usually do is have the patient place his/her lac under warm running tap water x 5 minutes, then irrigate with the small amount of saline the techs put in my suture tray. I feel like the volume of water from the tap (at less pressure) is better than high-pressure, small volume irrigation from sterile saline. There is literature to support this, but I am too lazy and tired to look it up.

 

[GeneralVeers]

I have a witch doctor shake rattles over the lac for 5 minutes.

 

[docB]

I have a witch doctor shake rattles over the lac for 5 minutes.

I probably should have done that. I got a complaint from the mother of a little girl who had a dog bite to the face. Don't let your daughter climb over your neighbor's fence if you know they have pitbulls. Anyway the PA and I irrigated them out and closed them and started antibiotics. Kid still got a small area of infection. Some idiot pediatrician told the mom it happened because we didn't scrub the lacs out with betadine. Not sure what decade he trained in but there you go.

 

[AmoryBlaine]

Great topic! I go through the same thought process every time I suture someone up. First off most of the sources say that betadine is not necessary just irrigation with normal saline. Now if I don't use betadine then the area isn't sterile anyways so why do I have to use sterile gloves (I will agree that sterile gloves fit better than regular gloves). Still there is something ingrained (probably from surgery) that the suture kit is sterile and should remain that way throughout the whole procedure. Now if I decide to be a rebel and not worry about sterility I run into a problem when I write my procedure not that usually starts with "Under strict sterile precautions ... "

Its hard to get past old habits.

There is no reason to ever use betadine when closing a lac. The only possible thing would be to paint skin edges and this is not necessary. I've seen attendings splash full strength betadine into clean wounds before closing them -- all it's going to do is impair healing.

I think if you watched even careful people do lac closures you'd see that they are rarely sterile like an elective line is. You have a suture with a tail on it that is probably longer than your little fen. drape and so the chances of a piece of that never touching outside the field is not great. You also have a relatively small field. Are people swabbing the entire surrounding skin with CHG before starting? I kind of doubt it.

Great line I recently heard from an attending, "the literature doesn't support the use of sterile gloves but I still want you to use them."

 

[southerndoc]

Our kits include one paper drape (that doesn't have a hole in it) and 3 sterile cloth drapes (1 with a hole in it). So you can drape a large area so that the tail of the suture material never gets contaminated.

Even though the literature doesn't support it, patients still expect it because they've always seen it done in a sterile fashion. If it gets infected and the patient ends up suing you, the jury won't care what the research shows, they'll only relate to anecdotal stuff. "Doc X in my hometown sutured cousin Susie using sterile technique, so that must be the standard." Someone with an 8th grade education is not going to understand the evidence.

 

[DogFaceMedic]

A good general review of wound care is in Emergency Medicine Practice, March 2005, vol 7 no 3, empractice.net. IV bag or NS bottle for irrigation are not enough PSI. 30-60cc Syringe with NS or tap water are the preferred method.

Or, we can have a séance to create a delicate balance between science and paganism calling on the spirit of Galen, Osler, Marcus Welby, and Hawkeye Pierce, to give us the power to heal…

 

[southerndoc]

A good general review of wound care is in Emergency Medicine Practice, March 2005, vol 7 no 3, empractice.net. IV bag or NS bottle for irrigation are not enough PSI. 30-60cc Syringe with NS or tap water are the preferred method.

Or, we can have a séance to create a delicate balance between science and paganism calling on the spirit of Galen, Osler, Marcus Welby, and Hawkeye Pierce, to give us the power to heal…

A hole poked in the bottom of a bottle of saline generates more pressure than a water tap. Seriously, I can blast away debris with this technique. A syringe is useless for irrigation if you do not attach an IV catheter (the actual catheter, not the needle) to generate pressure. The blunt end of the syringe doesn't generate enough pressure.

 

[brainfailure]

The Canadians studied this and demonstrated that sterility is overrated.

Really? Where can I get that study? I love the Canadians. No x-rays for foot/ankle/knee pain, no sterile gloves. What will they think of next?

 

[GatorEM]

Really? Where can I get that study? I love the Canadians. No x-rays for foot/ankle/knee pain, no sterile gloves. What will they think of next?

Gloves? Who the heck needs gloves? 😉

 

[droliver]

The Canadians studied this and demonstrated that sterility is overrated.

Nonsterile technique for an elective wound closure would not be standard of care. If this became an issue in a lawsuit you do not want to be defending yourself against the consensus body of literature re this.

 

[kungfufishing]

Ah, the elective department.

 

[GeneralVeers]

Really? Where can I get that study? I love the Canadians. No x-rays for foot/ankle/knee pain, no sterile gloves. What will they think of next?

They have to provide evidence for not providing medical care, as the wait for sterile gloves in some rural Canadian hospitals is 6-8 months due to rationing.

 

[deleted109597]

Someone with an 8th grade education is not going to understand the evidence.

Where are you cherry picking your patients from? Here they couldn't hit that if you spotted them the middle school part.
I can tell the sick patients because they aren't breathing from their mouths.

 

[southerndoc]

Where are you cherry picking your patients from? Here they couldn't hit that if you spotted them the middle school part.
I can tell the sick patients because they aren't breathing from their mouths.

I'm speaking of jurors, where the average juror has the equivalent of an 8th grade education.

 

[Jeff698]

I use sterile gloves for any procedure that requires fine finger movements. They're the only gloves in the department that fit my fingers well.

I hate stumbling trying to "pull up" gloves that are too large for my fingers.

Take care,
Jeff

 

[EctopicFetus]

a few items..

1) a study done in michigan (im not gonna find the cite) shows that even young strong college kids (who i presume werent hung over) could not generate enough psi to clean a wound.properly. We have those little dome things in our ED which do generate enough psi alternatively you could use an angiocath.

2) Betadine is toxic to skin and should never be used to clean a wound.

3) While I agree with others that there is no literature to support using sterile gloves for lacs I think why not use it? you are a bit "cleaner" in theory.

 

[DogFaceMedic]

Who has some good techniques to clean the skin around the lac of a mechanic that has not been adequately scrubbed for years? I sewed up the lac using a vertical mattress and had to go through some skin I just could not get very clean without de-gloving the whole foot. For those who have been doing this for years, do these types come back infected more than others?

 

[EctopicFetus]

feet tend to get infected IMO esp if the pt continues to wear shoes. A nice warm moist environment is a bacterias friend.

 

[napster]

in regards to betadine being toxic to viable tissue, why do orthopedists like soaking lacs in betadine /sterile H2O solutions prior to their arrival?

 

[DogFaceMedic]

in regards to betadine being toxic to viable tissue, why do orthopedists like soaking lacs in betadine /sterile H2O solutions prior to their arrival?

Pagan Ritual? Perhaps they can hire GeneralVeers witchdoctor, or maybe franchise witchdoctors for lacs.

I saw an older well-respected surgeon soak a wound with betadyne before inserting hardware in the OR. At least the other surgeon knew it was baseless and made fun of it with pagan dances in the OR in front of the students.

 

[GeneralVeers]

Pagan Ritual? Perhaps they can hire GeneralVeers witchdoctor, or maybe franchise witchdoctors for lacs.

I saw an older well-respected surgeon soak a wound with betadyne before inserting hardware in the OR. At least the other surgeon knew it was baseless and made fun of it with pagan dances in the OR in front of the students.

Betadyne is about as useful as giving antibiotics for simple lacs.

I had one peds attending tell a patient's family (after sewing up a small head lac) that "scalp lacs have a high incidence of infection and always get antibiotics". I rolled my eyes but kept my mouth shut, as I just wanted to finish the damned peds em rotation.

 

[nymbarra]

On top of being cytotoxic, iodine-based solutions have been linked to Pseudomonas infections in several studies, especially after surgical procedures.

One main reason may be that those bottles in the OR or ED are usually refilled, so unless they are changed regularly Pseudomonas can actually colonize that solution--and live over a year in those bottles! 😱

http://www.cdc.gov/mmwr/preview/mmwrhtml/00001358.htm

http://www.ncbi.nlm.nih.gov/pubmed/1865100

 

[AmoryBlaine]

Betadyne is about as useful as giving antibiotics for simple lacs.

I had one peds attending tell a patient's family (after sewing up a small head lac) that "scalp lacs have a high incidence of infection and always get antibiotics". I rolled my eyes but kept my mouth shut, as I just wanted to finish the damned peds em rotation.

Wow. Just, wow.

 

[southerndoc]

On top of being cytotoxic, iodine-based solutions have been linked to Pseudomonas infections in several studies, especially after surgical procedures.

One main reason may be that those bottles in the OR or ED are usually refilled, so unless they are changed regularly Pseudomonas can actually colonize that solution--and live over a year in those bottles! 😱

http://www.cdc.gov/mmwr/preview/mmwrhtml/00001358.htm

http://www.ncbi.nlm.nih.gov/pubmed/1865100

We actually discard our bottles after each use. Seriously, everytime I open up a lac tray and go to throw some betadine in there, I always have to take the seal off the new bottle.

On another note, I find that lacs that I was timid to repair during residency I now do without hesitation as an attending. Lacs through the vermilion border (not a biggie, but was always nervous when doing them as a resident for some reason), and even plastics closures. Today I closed a guy's ear that was nearly torn off.

 

[GeneralVeers]

On another note, I find that lacs that I was timid to repair during residency I now do without hesitation as an attending. Lacs through the vermilion border (not a biggie, but was always nervous when doing them as a resident for some reason), and even plastics closures. Today I closed a guy's ear that was nearly torn off.

I always warn patients that they will have a scar, that way they can't sue later claiming that they were never warned. F

 

[droliver]

I saw an older well-respected surgeon soak a wound with betadyne before inserting hardware in the OR. At least the other surgeon knew it was baseless and made fun of it with pagan dances in the OR in front of the students.

Actually there is a good deal of literature supporting preparing implants and the wound they're to be inserted into with antimicrobial solutions prior to insertion. In plastic surgery for instance, preparing breast implants with betadine or with triple antibiotic solutions (ancef-gent-bacitracin) have both been established to signifigantly lower capsular contracture rates around breast implants, presumably attributable to bacterial colonization.

 

[BKN]

a few items..



2) Betadine is toxic to skin and should never be used to clean a wound.

You sure about that fetus? I thought it was mildly toxic to sub-q tissue but not to skin surface.

 

[AmoryBlaine]

I always warn patients that they will have a scar, that way they can't sue later claiming that they were never warned. F

It is sort of funny when people come in with jagged, nasty lacs and then say "am I going to have a scar?"