WOUND CARE AND REPAIR

1
WOUND CARE AND REPAIR

• FARAS ABUZEYAD, MD.

2
Epidemiology

• In USA gt 10,000,000 annual ER visits
• Average cost of 200 per patient
• Hollander et al Wound Registry Development and
  Validation. Ann Emerg Med, May 1995.

3
Causes of traumatic wounds
Cause of wound No. of Patients
Blunt object 42
Sharp object 34
Glass 13
Wood 4
Bite 6
Human 1
Dog 3
Others 5


4
Distribution of traumatic wounds
Location of Wound No. of Patients ()
Head and Neck 51
Trunk 2
Upper Extremities 34
Lower Extremities 13
5
Malpractice

• Karcz Malpractice claims against emergency
  physicians in Massachusetts 1975-1993. Am J
  Emerg Med 1996.
• wounds claims 19.85, and 3.15 total
  expenses (1,235,597)
• American College of Emergency Physicians.
  Foresight Issue 49, September 2000 Laceration
  mismanagement failure to diagnose a retained
  foreign body is the 2nd most common malpractice
  claims against emergency physician

6
Condition Claims Total dollars paid
1- Missed fracture 14 17
2- Wound care 12 8
3- Missed MI 10 24
4- Abdominal pain 9 4
5- Missed meningitis 3.5 8
6- Spinal cord injury 3 8
7- SAH / Stroke 3 6
8- Ectopic pregnancy 2 8
7
What patients want?

• Adam Patient Priorities With Traumatic
  Lacerations. Am J Emerg Med, October 2000.

8
Aspect of Care All Participants (n 679) Facial Lacerations (n 78) Other Lacerations (n 263)
Normal function 28 27 26
Avoiding infection 20 14 23
Cosmetic outcome 17 33 14
Least pain 17 11 18
Length of stay 10 8 10
Compassion 5 4 5
Cost 1 1 1
Days missed 2 1 3
Total 100 100 100
 
9
Evaluation

• History
• Mechanism
• Time
• FB
• Medical conditions
• Allergies
• Tetanus status

• Exam
• Size
• Location
• Contaminants
• Neurovascular
• Tendons

10
Universal Precautions

• CDC published guidelines on use of universal
  precautions.
• Use of protective barriers
• eg. Gloves/ gowns/ masks/ eyewear
• Will decrease exposure to infective material.

11
Gloves

• Use latex free gloves
• Since March 1999, FDA reported
• 2,330 latex allergic reactions
• including 21 deaths

12

• Bodiwala Surgical gloves during wound repair in
  the accident and emergency department. Lancet
  1982.
• randomized 337 patients to gloves or careful
  hand-washing, no gloves
• INFECTION GLOVES NO GLOVES
• None 167 (82.7) 170 (82.5)
• Mild 27 (13.4) 27 (13.1)
• Severe 8 (4.0) 9 (4.4)

13

• Caliendo Surgical masks during laceration
  repair. J Am Coll Emerg Phys 1976.
• Alternated face mask / no mask for 99 wound
  repairs
• Mask 1 / 47 infected
• No mask 0 / 42 infected
•  

14
Local Anesthesia 2 main groups

• 1-  Esters
• Cocaine
• Procaine (Novocain)
• Benzocaine (Cetacaine)
• Tetracaine (Pontocaine)
• Chloroprocaine (Nesacaine)

• 2-  Amides
• Lidocaine (Xylocaine)
• Mepivacaine (Polocaine, Carbocaine)
• Bupivacaine (Marcaine)
• Etidocaine (Duranest)
• Prilocaine
•   

15
Properties of commonly used local anesthetics
Agent Class Max. save dose mg/kg Onset (min) Duration (hrs)
Procaine Ester 7 2-5 0.25-0.75
Procaine Epi 9 0.5-1.5
Lidocaine Amide 5 2-5 1-2
Lidocaine Epi 7 2-4
Bupivacaine Amide 2 2-5 4-8
Bupivacaine Epi 3 8-16
16
Why Lidocaine?

• Less painful
• Rapid onset
• Less cardiotoxic
• Less expensive

17

• Morris Comparison of pain associated with
  intradermal and subcutaneous infiltration with
  various local anesthetic solutions. Anesth Analg
  1987.
• 24 volunteers
• each injected with 5 anesthetic agents and NS
• visual analog pain scale
• Etidocainegt Bupivacainegt Mepivacainegt NSgt
  Chloroprocainegt Lidocaine (least painful)
•  

18
Methods to reduce pain of Lidocaine local
infiltration

• 1-Small-bore needles
• 2-Buffered solutions
• 3-Warmed solutions
• 4-Slow rates of injection
• 5-Injection through wound edges
• 6-Subcutaneous rather than intradermal injection
• 7- Pretreatment with topical anesthetics

19
1-Small-bore needles

• Edlich, 1988
• 30-gauge hurts less than a 27-gauge
• 27-gauge hurts less than a 25-gauge, etc.

20
 2-Buffered solutions

• with sodium bicarbonate at a ratio of 110
• change in the pH of the anesthetic solution does
  not increase wound infection rates
• No compromise to anesthesia effect

21
Studies on buffered lidocaine
Study Number Pain score
McKay, 1987 24 Volunteers Reduced
Christoph, 1988 25 Volunteers Reduced
Bartfield, 1990 91 Patients No Difference
Orlinsky, 1992 61 Patients Reduced
Brogan, 1995 45 Patients Reduced
Fatovich, 1999 135 Adults 136 children No Difference
22
3-Warmed solutions
Study Number Temp. (C) Pain score
Brogan, 1995 45 Patients 20 vs 37.6 Reduced
Martin, 1996 40 Volunteers 20 vs 37 Reduced
Colaric, 1998 20 Volunteers 20 vs 37 Reduced
23
Warming and Buffering have synergistic effect

• Mader, 1994 and Bartfield, 1995 Effect of
  warming and buffering on pain of Lidocaine
  infiltration.
• Warming and Buffering have synergistic effect in
  reducing pain
• Temp. used 40 and 38.9 C vs room temp.

24
4-Slow rates of injection
Study Number Injection Rate Pain score
Krause, 1997 29 Volunteers 0.1ml/sec vs 1ml/sec Reduced with slow rate
Scarfone, 1998 42 patients 1ml/5sec vs 1ml/30sec Reduced with slow rate
25
5-Injection through wound edges
Study Number Pain score
Kelly, 1994 81 patients Reduced
Bartfield, 1998 63 patients Reduced
26
6-Subcutaneous rather than intradermal injection
27
7- Pretreatment with topical anesthetics
Study Number Agent Pain score
Bartfield, 1995 54 Patients Lidocaine Reduced
Bartfield, 1996 57 Patients Tetracaine Reduced
28
8- Digital / Regional nerve block

• A critical skill for all ED physicians
• Save time
• Decrease possibility of systemic toxicity
• Less painful than local infiltration
• Do not cause the volume-related tissue distortion

29
Topical Anesthetic instead of local

• TAC
• Tetracaine 25 cc of 2 solution
• Adrenalin 50 cc of a 11000 solution
• Cocaine 11.8 gm
• Pryor, 1980 and Hegenbarth, 1990
• topical TAC vs lidocaine infiltration, in
  laceration repair
• No significant difference in anesthetic efficacy

30
TAC

• Down sides are
• Not reliable when used below the head
• Tissue toxic, Case reports of death and seizures
• Corneal damage
• Intense vasoconstriction avoid in digits, nose,
  pinna and penis
• Must be mixed by hospital pharmacist
• Not approved by FDA
• Expensive up to 35 / dose

31
LAT, LET, or XAP

• Lidocaine 15cc of 2 viscous
• Adrenaline 7.5cc of 11000 topical
• Tetracaine 7.5cc of 2 topical
• Ernst-1995, Blackburn-1995, Ernst-1997 showed
  effective anesthesia if left in place for 15 to
  20 minutes
• Schilling-1995 and Amy-1995 As efficacious as
  TAC
• 5 / dose
• Much less potential for significant toxicity

32
Lidocaine with Epinepkrine

• In animal models, there is theoretic concern for
  increased risk of wound infection
• Tissue ischemia and necrosis if injected in
  digits

33
Skin and Wound preparation

• 1- Hair removal
• 2- Disinfecting the skin
• 3- Debridement
• 4-Wound Cleansing and Irrigation
• 5-Soaking

34
1- Hair removalTo shave or not to shave!

• Seropian, 1971
• 406 clean surgical wounds
• If shaved pre-op, 3.1 infection rate
• If depilated, 0.6 infection rate
•  
• Howell, 1988
• 68 scalp lacerations repaired without hair
  removal (93 within 3 hours of injury), no
  infection at 5-day follow-up

35
2- Disinfecting the skin

• An ideal agent does not exist either tissue
  toxic or poorly bacteriostatic
• Simple scrub water around wound should be
  sufficient
• No studies have demonstrated the impact of
  cleaning intact skin on infection rate, however
  it is important to decrease bacterial load to
  minimize ongoing wound contamination.
• Avoid mechanical scrubbing unless heavily
  contaminated (increase inflammation in animal
  data)

36
Solution Antimicrobial activity Mechanism of action Uses Tissue toxicity
N. Saline - Washing action Cleanse surrounding skin / irrigation -
Povidine-iodine 10, 1 Germicide Cleanse surrounding skin, ? Irrigation contaminated wounds
Chlorhexidine 1, 0.1 Bacteriostatic Cleanse surrounding skin
Hydrogen Peroxide Bactericidal Cleanse contaminated wounds
Hexachlorophene Bacteriostatic Cleanse surrounding skin
Nonionic detergents - Wound cleanser Wound cleanser -
37
3- Debridement

• Devitalized soft tissue acts as a culture medium
  promoting bacterial growth
• Inhibits leukocyte phagocytosis of bacteria and
  subsequent kill
• Anaerobic environment within the devitalized
  tissue may also limit leukocyte function

38

• Dhingra V Periphral Dissemination of
  Bacteria in Contaminated Wounds Role of
  Devitalized tissue Evaluation of Therapeutic
  Measures. Surgery, 1976.
• Animal study, devitalized wounds contaminated
  with 3 Bacteria, treated with NS jet irrigation
  or debridement at 2, 4, 6 hr
• Debridement more effective in reducing bacteria
  count and infection rate

39
4-Wound Cleansing and Irrigation

• Decreasing wound contamination and hence
  infection, "the solution to pollution is
  dilution."
• Indications
• Methods
• Pressure
• Solution
• Volume
• Side effects

40
1- Indications

• Any contaminated or bite wounds
• Animal and human studies demonstrate irrigation
  lowers infection rates in contaminated wounds
• Hollander JE et al Irrigation in facial and
  scalp lacerations Does it alter outcome? Ann
  Emerg Med 1998.  
• 1,923 patients 1,090 patients received saline
  irrigation, and 833 patients did not
• Nonbite, noncontaminated facial skin or scalp
  lacerations who presented less than 6 hours
• No difference in wound infection rate or
• cosmetic appearance

41
2- Methods

• Bulb syringe
• IV bag /- pressure cuff
• Syringe and needle
• Jet lavage

42
(No Transcript)
43
3- Pressure

• lack of clinical studies
• recommend irrigation pressures in the range of 5
  to 8 psi
• High-pressure irrigation is defined as more than
  8 psi (use of a 30- to 60-mL syringe and a 18-20
  gauge needle)
• Animal studies Rodeheaver, 1975 Stevenson,
  1976, high-pressure irrigation reduce both
  bacterial wound counts and wound infection rates

44
4- Solution

• Ideal solution must be
• Not toxic to tissues
• Does not increase rate of infection
• Does not delay healing
• Does not reduce tensile strength of wound healing
  
• Inexpensive

45

• Dire DJ A comparison of wound irrigation
  solutions used in the emergency department. Ann
  Emerg Med 1990.
• 531 patients were randomized into 3 groups, and
  irrigated with
• NS, 1 PI, or pluronic F-68
• No difference in wound infection rate
• NS has the lowest cost

46

• Lineaweaver Cellular and bacterial
  toxicities of topical antimicrobials. Plast
  Reconstr Surg, 1985.
• 1 povidone-iodine
• 3 hydrogen peroxide
• 0.25 acetic acid
• 0.5 sodium hypochlorite
• assayed in vitro using cultures of human
  fibroblasts and Staphylococcus aureus
• All agents tested killed 100 percent of exposed
  fibroblasts

47

• Then he looked at different dilutions
• povidone-iodine 0.01, 0.001, 0.0001
• sodium hypochlorite 0.05, 0.005, 0.0005
• hydrogen peroxide 3.0, 0.3, 0.03, 0.003
• acetic acid 0.25, 0.025, 0.0025
• ONLY antiseptic not harmful to fibroblasts yet
  still bacteriostatic was Povidone iodine 0.001

48

• Moscati Comparison of normal saline with tap
  water for wound irrigation. Am J Emerg Med 1998.
   
• lacerations were made on each animal and
  inoculated with standardized concentrations of
  Staph. aureus
• irrigation with 250 cc of either NS from a
  sterile syringe or water from a tap
• no difference in bacterial count in 2 groups

49

• LammersBacterial counts in experimental,
  contaminated crush wounds irrigated with various
  concentrations of cefazolin and penicillin.
  Richard Lammers, American Journal of Emergency
  Medicine, January 2001.
• An animal bite wound model was created
• inoculated with 0.4 mL of a standard bacterial
  solution
• each wound was scrubbed for 30 seconds with 20
  poloxamer 188 and then irrigated with 100 mL of
  one of 4 solutions NS(control) cefazolin
  penicillin G (LD) CZ PCN (ID) and CZ PCN
  (HD)
• No differences in the bacterial counts or
  infection rates

50

• Kaczmarek, 1982 Cultured open bottles of
  saline irrigating solution
• 36/169 1000cc bottles were contaminated
• 16/105 500cc bottles were contaminated
•  
• Brown, 1985 Approximately one in five of the
  opened bottles use for irrigation were
  contaminated

51
4- Volume

• Irrigation volume not studied
• use 50 mL to 100 mL of irrigant per cm of
  laceration

52
5- Side effects

• Increase tissue inflammation (very high pressure
  irrigation), but benefit outweigh risk
• Splatter (use your hand or plastic shield)

53
(No Transcript)
54
5- Soaking

• Lammers Effect of povidone-iodine and saline
  soaking on bacterial counts in acute, traumatic
  contaminated wounds. Ann Emerg Med, 1990.
• Contaminated traumatic wounds within 12 hours of
  injury
• 33 wounds randomized into
• soaking in either 1 PI, NS, or covered with
  dry gauze (control) for 10 min.
• Bacterial counts not changed in PI control
  groups, but increased in NS group
• Infection rate PI12.5 (1/8), control 12.5
  (1/8), NS71 (5/7)

55
Foreign Bodies

• Glass, metal, and gravel are Radiopaque
• Wooden objects and some aluminum products are
  radiolucent
• Glass is accurately visualized on 2-view
  radiographs if it is 2 mm or larger
• and gravel if it is 1 mm or larger

56
 Wound Closure

• Time
• Delayed primary closure
• Options
• Suturing method

57
Time

• The Golden Period the time interval from injury
  to laceration closure and the risk of subsequent
  infection, (is highly variable)
• Morgan WJ The delayed treatment of wounds of the
  hand and forearm under antibiotic cover. Br J
  Surg 1980.  
• 300 hand and forearm lacerations
• closed lt 4hr had infection rate 7
• closed gt 4hr had infection rate 21 

58

• Berk WA Evaluation of the "golden period"
  for wound repair 204 Cases from a third world
  emergency department. Ann Emerg Med 1988.
• evaluation in a third-world country - 204
  patients
• lt19 hours to repair 92 satisfactory healing
• gt19 hours to repair 77 satisfactory healing
• Exception head and face lacerations had 95.5
  satisfactory healing, regardless of time
•  

59

• Baker The management and outcome of lacerations
  in urban children. Ann Emerg Med 1990.
• 2,834 pediatric patients
• No difference in infection rate for lacerations
  closed less than or more than 6hrs

60
Delayed primary wound closure

• High risk wounds that are contaminated or contain
  devitalized tissue
• Wound is initially cleansed and debrided
• Covered with gauze and left undisturbed for 4 to
  5 days
• If the wound is uninfected at the end of the
  waiting period, it is closed with sutures or skin
  tapes

61

• Dimick, 1988 Delayed Primary Closure
• Wound left open for 4 or 5 days until edema
  subsides, no sign of infection, and all debris
  and exudates removed
• gt90 success rate in closure without infection
• Final scar as same as primary closure

62
Options

• Nonabsobable suture
• Absorbable suture
• Tissue adhesive
• Adhesive tapes
• Staples

63
Nonabsobable suture
Material Knot Security Wound Tensile Strength Tissue Reactivity Workability
Nylon (Ethilon) Good Good Minimal Good
Polypropylene (Prolene) Least Best Least Fair
Silk Best Least Most Best
64
 Absorbable suture
Material Knot Security Wound Strength Security(d) Tissue Reactivity
Surgical gut Poor Fair 5-7 Most
Chromic gut Fair Fair 10-14 Most
Polyglactin (Vicryl) Good Good 30 Minimal
Polyglycolic acid (Dexon) Best Good 30 Minimal
Polydioxanone (PDS) Fair Best 45-60 Least
Polyglyconate (Maxon) Fair Best 45-60 Least
65
Tissue adhesive

• N-butyl-2-cyanoacrylate, Histoacryl blue (HAB),
  GluStitch
• First described in 1949 and first used medically
  in 1959
• Antibacterial effect
• Cost 5 per single-use ampule
• Reduction in cost (Canadian ) per patient of
  switching from nondissolving sutures 49.60

66

• S. Mizrahi Use of Tissue Adhesives in the Repair
  of Lacerations in Children. Journal of Pediatric
  Surgery,April, 1988.
• 1500 pediatric patients with simple laceration in
  ED, closed with HAB
• Infection 1.8
• Dehiscence 0.6

67
Tissue adhesive

• Octylcyanoacrylate (OCA), or Dermabond
• Approved by FDA in 1998
• Antibacterial effect
• Cost 25 per single-use ampule
• Greater strength than HAB

68
Which laceration?

• Short (lt 6-8 cm)
• Low tension (lt 0.5 cm gap)
• Clean edged
• Straight to curvilinear wounds that do not cross
  joints or creases

69
Contraindications

• Jagged or stellate lacerations
• Bites, punctures or crush wounds
• Contaminated wounds
• Mucosal surfaces
• Axillae and perineum (high-moisture areas)
• Hands, feet and joints (unless kept dry and
  immobilized)

70
Advantages of Adhesive vs Sutures

• Faster repair time
• Less painful
• Eliminate the risk for needle sticks
• Antibacterial effect
• Does not require removal of sutures

71
Study Material No. Cosmetic outcome Time (min) Complications
Simon, 1996 HAB vs Suture 61 2 months- same 7 vs 17 1 infection (HAB)
Simon, 1997 HAB vs Suture 61 2 months/ 1yr - same _ _
Quinn, 1997 OCA vs Suture 130 3 months- same 3.6 vs 12.4 Infection 0 vs1 Dehiscence 3 vs 1
Singer, 1998 OCA vs Suture 124 3 months- same 5.9 vs 10 1 infection 2 dehiscence (OCA)
Osmond, 1999 OCA vs HAB 94 3 months- same 0 2 dehiscence (HAB)
72
Adhesive tapes

• Seldom recommended for wound closure in the ED
• Require the use of adhesive adjuncts (eg,
  tincture of benzoin)
• May be used with tissue adhesive or after suture
  removal to decrease tension

73
(No Transcript)
74
Staples

• Consider staples for linear lacerations not
  involving the face or other cosmetically
  sensitive areas
• Frequently used for scalp, trunk, or extrimities
  lacerations.
• Optimally, two operators perform this procedure
• Brickman KR Evaluation of skin stapling for
  wound closure in the emergency department. Ann
  Emerg Med 1989181122-1125.
• 87 ER patients with 87 lacerations (2/3 scalp,
  trunk, and extremities)
• 65 closed in 30 seconds using staples
• No infections

75

• John T. Kanegaye
• 88 child with scalp lacerations, nonabsorbable
  suture vs staples
• Shorter overall times for wound care and closure
  395 vs 752 sec
• Total cost based on equipment and physician time
  23.55 vs 38.51
• F/U rate 91, with no cosmetic or infectious
  complications in either group

76
Suturing methods

• Simple interrupted
• Simple running
• Horizontal mattress
• Vertical mattress
• Running subcuticular (intradermal)

77
Simple Interrupted

• Most common
• Easy to master
• Can adjust tension with each suture
• Stellate, multiple components, or directions wound

78
Simple Running

• Minimize time of suture repair
• Even distribution of tension
• Low-tension, simple linear wounds
• Removed within 7 days to avoid suture marks
• Optimal suture material is nonabsorbable

79
(No Transcript)
80
Horizontal Mattress

• Cause wound edges eversion
• Single layer closure with significant tension
• Decrease repair time, less knots required
• Need delayed suture removal, so risk of suture
  marks

81
(No Transcript)
82
Vertical Mattress

• High-tension wounds
• Prone to skin suture marks if left in too long

83
(No Transcript)
84
Running Subcuticular (Intradermal)

• Best for areas where cosmetic result is of utmost
  importance
• Time-consuming
• Difficult to master
• Low tension wounds
• Absorbable suture

85
(No Transcript)
86

• McLean, 1980
• 51 patients with continuous, running
• 54 patients with interrupted stitch
• Two infections in each group
•  

87
(No Transcript)
88
(No Transcript)
89
(No Transcript)
90
(No Transcript)
91
(No Transcript)
92
(No Transcript)
93
(No Transcript)
94
(No Transcript)
95
Topical AB

• Dire DJ Prospective evaluation of topical
  antibiotics for preventing infections in
  uncomplicated soft-tissue wounds repaired in the
  ED. Acad Emerg Med, 1995.  
• prospective, randomized, double-blinded,
  placebo-controlled (426 Lacerations)
• Bacitracin - 5.5 infection (6/109)
• Neosporin - 4.5 infection (5/110)
• Silvadene - 12.1 infection (12/99)
• Placebo 4.9 infection (5/101)

96
Dressing

• Chrintz, 1989 1202 patients with clean
  wounds
• Dressing off at 24 hours - 4.7 infection
• Dressing off at suture removal - 4.9
• Goldberg, 1981 100 patients with sutured
  scalp lacerations allowed to wash hair with no
  infection or wound disruption
• Noe, 1988 100 patients with surgical
  excision of skin lesions allowed to bathe next
  day with no infection or wound disruption

97
Tetanus

• More than 250,000 cases annually worldwide with
  50 mortality
• 100 cases annually in USA
• About 10 in patients with minor wound or chronic
  skin lesion
• In 20 of cases, no wound implicated
• 2/3 of cases in patients over age 50

98
Study Setting Age No Protective AB
Ruben, 1978 Nursing Home Elderly 49
Crossley, 1979 Urban gt 60yrs F 59, M 71
Scher, 1985 Rural Elderly 29
Pai, 1988 Urban 34-60 yrs, all Females 5
Stair, 1989 ER gt 65 yrs 9.7
Alagappan, 1996 ER gt 65 yrs 50
99
Recommendations for tetanus prophylaxis
History of Tetanus Immunization Td TIG Td TIG
Uncertain or lt3 doses Yes No Yes Yes
Last dose within 5 y No No No No
Last dose 5-10 y No No Yes No
Last dose gt10 y Yes No Yes No
3 doses
100
Infection Rate

• Galvin, 1976 4.8
• Gosnold, 1977 4.9
• Rutherford, 1980 7.0
• Buchanan, 1981 10.0
• Baker 1990 1.2

3 doses
101
Antibiotic Therapy

• Cummings P Antibiotics to prevent infection
  of simple wounds A metaanalysis of randomized
  studies. Am J Emerg Med 1995.
• 7 randomized trials (1,734 patients)
• Assigned patients to AB or control
• Patients treated with AB slightly higher
  infection rate

102
Prophylactic Antibiotics

• Bite wounds
• Contaminated or devitalized wounds
• High risk sites eg. Foot
• Immunocompromised
• Risk for infective endocarditis
• Intraoral through and through lacerations

• PVD
• DM
• Lymphedema
• Indwelling prosthetic device
• Extensive soft tissue injury
• Deep puncture wounds

103
Prophylactic Antibiotics

• Amoxicillin, Clavulin
• Keflex
• Erythromycin
• recommended course is 3 to 5 days

104
Level of Training and Rate of Infection

• Adam Level of Training, Wound Care Practices,
  and Infection Rates, American J Emerg. Med, May
  1995.
• Wounds were evaluated in 1,163 patients
• Medical students 0/60 (0)
• All resident 17/547 (3.1)
• Physician assistants 11/305 (3.6)
• Attending physicians 14/251 (5.6)

105
Level of Training and Cosmetic outcome

• Adam Association of Training level and
  Short-term Cosmetic Apperance of Repaired
  Lacerations, Academic Emerg. Med, April 1996.
• Retrospective study, 552 patients
• achieving optimal cosmetic score
• Medical student 50
• R1 54
• R2 66
• R3 68
• Physician assistance 70
• Attending physician 66

106
Points to Take Home

• Laceration mismanagement failure to Dx. FB is
  2nd most common malpractice
• Be aware of different methods to reduce pain from
  Lidocaine infiltration
• In contaminated wounds with devitalized tissues
  debride and irrigate
• You have a wide options for wound closure
• Always check tetanus status
• AB only for high risk wounds