impractical for small children, who may inadvertently remove them from the wound Tissue adhesives, or skin glues, such as octyl cyanoacrylate have become widely used for wound closure in the ED They allow rapid and painless closure of wounds, though if glue gets into the wound, it can cause a burning sensation or pain Anesthesia is unnecessary, unless painful irrigation or exploration of the wound are anticipated No removal is needed because adhesives slough off after to 10 days They provide an excellent cosmetic result, comparable with sutures One study using plastic surgeons blinded to the method of repair graded the wounds repaired with tissue adhesives to be cosmetically equal to sutured wounds at 2-month and 1-year follow-up visits For scalp lacerations, hair apposition technique (HAT) can be performed with skin glue A few strands of hair on either side of the scalp laceration are separated, pulled across the wound in opposite directions (pulling together the laceration), twisted together with glue applied to the twisted region, and repeated along the length of the wound HAT is a painless method of repairing scalp wounds that don’t require follow-up for stitch or staple removal Tissue adhesives act to decrease wound infections because they have antimicrobial effects against gram-positive organisms Dehiscence rates (1% to 3%) are similar to that of sutured wounds They are less expensive than sutures because less equipment is required and personnel time is reduced Studies have noted that some patients and families of small children prefer skin adhesives to sutures Routine follow-up is not needed for uncomplicated wounds, and no longterm complications have been reported Newer products such as high-viscosity octyl cyanoacrylate tissue adhesives are less likely to migrate during repair, making wound repair easier to accomplish Before application of the tissue adhesive, the wound is cleaned and hemostasis is achieved with dry gauze and pressure The wound’s edges are held together manually or with forceps while the tissue adhesive is applied along the surface of the wound The tissue adhesive should not be applied to the inside of the wound because it will act as a foreign body and inhibit healing The wound edges are held in place for about 20 to 30 additional seconds to obtain adequate bonding If poor alignment of wound edges is noted, the adhesive can be removed with forceps and reapplied without further complication The wound is then covered carefully so adhesive portions of any bandage not directly contact the skin glue, to avoid pulling off the tissue adhesive with dressing changes Avoid routine application of antibiotic ointments by parents as these will dissolve the adhesive and cause dehiscence TABLE 110.3 COMMON TECHNIQUES OF WOUND CLOSURE Technique Advantages Disadvantages Sutures Greatest tensile strength Meticulous closure Low dehiscence rate Staples Rapid application Painful Removal needed Slow application Increased tissue reaction Risk of needlestick (clinician) Not for use on face (less meticulous closure) Tissue adhesive Tape strips Low cost Low tissue reaction Rapid application Painless No removal needed Low cost No risk of needlestick (clinician) Rapid application Painless Lower tensile strength Not for use on joints Not for use on bite wounds High risk of dehiscence Not for use in moist areas, young children Low cost Low infection risk Least tissue reaction Tissue adhesives should be used only to close skin of superficial wounds For many lacerations, deep absorbable sutures will also be needed because the glue has less strength than most sutures Skin glues should not be used for wounds subject to great tension, such as on the hands or joints, or bite injuries in which occlusive closure increases the risk of infection Table 110.3 summarizes advantages and disadvantages of several techniques available for wound closure Wound Care Wound Dressing Appropriate wound aftercare is important in preventing contamination or further injury It is recommended that most sutured wounds be covered with antibiotic ointment and a dressing immediately after closure For simple lacerations, an adhesive bandage (e.g., Band-Aid) is sufficient, however larger wounds may benefit from a nonadherent sterile dressing to prevent wound edges from sticking to the dressing This nonadherent dressing should then be covered with a layer of gauze then tape This technique helps to protect and immobilize the wound For the face and trunk, a large bulky dressing is not practical Thus, for small wounds in those areas, a clear plastic adhesive (e.g., Tegaderm) should be used to secure the bandage Rolls of cotton or stretchable tube gauze can be used to wrap larger wounds to keep the sterile dressing in place This keeps the young child from touching the wound Scalp wounds are usually not dressed, though gauze and tube gauze may be applied prior to sleep to avoid staining linens with blood or drainage Patients can generally wash their hair gently after 24 hours For children who are active, it may be best to keep the wound covered until sutures are removed The original dressing should remain in place for 12 to 24 hours after which epithelialization is usually sufficient to keep the wound from gross contamination One study showed that uncovering after 12 hours with gentle washing does not increase the risk of infection After 12 to 24 hours, the bandage should be changed daily and the wound inspected Any dressing should be changed sooner if it becomes soiled, wet, or saturated with drainage because the wet dressing may become a source of infection It may be advisable to splint the wound if it overlies a joint This is most important for active children who will likely resume full activity soon after the injury Some even recommend splinting nearby joints for any large laceration of an extremity to reduce stress across the wound even if it does not involve a joint itself This should be done for no more than 72 hours to prevent muscle atrophy or joint immobility The injured extremity should be elevated to provide comfort and reduce edema Topical Antibiotics For most simple wounds, it is adequate to cover the wound with dry sterile gauze after applying topical antibacterial ointment There have been several studies looking at the different infection rates between certain topical antibiotics and petroleum ointment Overall, it has been found that a triple antibiotic ointment may be preferable in preventing Staphylococcus aureus infection although there may be a slightly increased rate of contact dermatitis with use Topical antibiotics have been noted not only to prevent infection but also to help with reepithelialization, decrease crust formation, prevent wound dehiscence, and aid in suture removal Guidelines for Systemic Antibiotics Use of prophylactic systemic antibiotics for wound management is controversial There are no data demonstrating proven benefits to the routine use of antibiotics In addition, antibiotics may lead to allergic reactions, growth of resistant organisms, altering normal gut flora, and unnecessary expense Decontamination with proper irrigation is more efficacious than routine use of antibiotics to prevent wound infection Antibiotic prophylaxis may be considered in certain high-risk wounds These include heavily contaminated wounds, wounds with devitalized tissue, bites (e.g., particularly cat, dog, and human), puncture wounds of the hand, stellate lacerations, and lacerations near joints or over open fractures Also, patients who are immunocompromised should be considered for prophylactic antibiotics Data for the role for antibiotics in intraoral wounds is conflicting There are less data supporting the use of antibiotics in dirty wounds, but may be considered in lacerations contaminated with soil or feces Wounds that result in exposed cartilage of the nose or ears or extensive facial wounds that may involve contamination from adjacent nasal passages are often treated with antibiotics It may also be reasonable to use antibiotics for wounds (other than scalp lesions) when repair takes place more than 12 hours after injury Usually, a first-generation cephalosporin or penicillinase-resistant penicillin is used to cover staphylococci and streptococci Amoxicillin–clavulanic acid is recommended for wounds created by mammalian bites (see Chapter 94 Infectious Disease Emergencies ) Additional coverage for gram-negative organisms with an aminoglycoside is recommended for open fractures (see Chapter 111 Musculoskeletal Trauma ) Methicillin-resistant Staphylococcus aureus (MRSA) in simple skin lacerations is less common, however if there is concern for high rates of MRSA in the community, then clindamycin or trimethoprimsulfamethoxazole should be considered Guidelines for Tetanus The immunization status of all injured patients should be documented in the medical record If the wound is clean and minor and the patient has received three previous doses of tetanus toxoid, a booster of tetanus toxoid is given only if 10 or more years have passed since the last dose If a patient has received three or more