Wounds ====== þ Hair Opposition for Scalp Lacs - Saves time and money and decreases pain and complications and scarring - Twist hair together and then secure with Dermabond or Indermil [Hock, M. O., S. B. Ooi, et al. (2002). "A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study)." Ann Emerg Med 40(1): 19-26.] STUDY OBJECTIVE: We evaluate a new technique of treating scalp lacerations, the hair apposition technique (HAT). After standard cleaning procedures, hair on both sides of a laceration is apposed with a single twist. This is then held with tissue adhesives. HAT was compared with standard suturing in a multicenter, randomized, prospective trial. METHODS: All linear lacerations of the scalp less than 10 cm long were included. Severely contaminated wounds, actively bleeding wounds, patients with hair strand length less than 3 cm, and hemodynamically unstable patients were excluded. Patients were randomized to receive either HAT or standard suturing, and the time to complete the wound repair was measured. All wounds were evaluated 7 days later in a nonblinded manner for satisfactory wound healing, scarring, and complications. RESULTS: There were 96 and 93 patients in the study and control groups, respectively. Wound healing trended toward being judged more satisfactory in the HAT group than standard suturing (100% versus 95.7%; P =.057; effect size 4.3%; 95% confidence interval 0.1% to 8.5%). Patients who underwent HAT had less scarring (6.3% versus 20.4%; P =.005), fewer overall complications (7.3% versus 21.5%; P =.005), significantly lower pain scores (median 2 versus 4; P <.001), and shorter procedure times (median 5 versus 15 minutes; P <.001). There was a trend toward less wound breakdown in the HAT group (0% versus 4.3%; P =.057). When patients were asked whether they were willing to have HAT performed in the future, 84% responded yes, 1% responded no, and 15% were unsure. CONCLUSION: HAT is equally acceptable and perhaps superior to standard suturing for closing suitable scalp lacerations. Advantages include fewer complications, a shorter procedure time, less pain, no need for shaving or removal of stitches, similar or superior wound healing, and high patient acceptance. HAT has become our technique of choice for suitable scalp lacerations.[Ong Eng Hock M, Ooi SBS, Saw SM, Lim SH. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). [Ong, M. E., D. Coyle, et al. (2005). "Cost-effectiveness of hair apposition technique compared with standard suturing in scalp lacerations." Ann Emerg Med 46(3): 237-242.] STUDY OBJECTIVE: We have previously described a prospective, randomized, multicenter, clinical trial comparing the hair apposition technique, a new technique of treating scalp lacerations with tissue adhesives, with standard suturing. We found the hair apposition technique to be a better technique for closing suitable scalp lacerations. In this study, we aim to compare the cost-effectiveness of the hair apposition technique and standard suturing. METHODS: All costs related to each method were calculated, including equipment and staff time. On the basis of the previous randomized controlled trial, differential costs caused by complications were also calculated. The incremental effectiveness of the hair apposition technique was assessed in terms of complications avoided. Expected values of costs and outcomes were obtained through Monte Carlo simulation. RESULTS: The hair apposition technique was dominant over standard suturing in that it was more effective and resulted in a cost savings of USD 28.50 (95% confidence interval USD 16.30 to USD 43.40) per patient compared with standard suturing because of reduced equipment needs, shorter medical staff time required, no need for another visit to remove sutures, and lower complication rates. The probability of the hair apposition technique being both cost saving and more effective was 98.9%. CONCLUSION: The hair apposition technique is more cost- effective compared with standard suturing and could lead to large cost savings, given the common occurrence of scalp lacerations in most health systems. þ Ointments for Wounds - For lacerations we repair in the ED, antibiotic ointment does decrease the wound infection rate. Petrolatum is OK for sterile surgical wounds, but antibiotic ointment is better for accidental wounds. For minor wound infections, Bactroban ointment is superior to oral Keflex, even before MRSA. [Diehr, S., A. Hamp, et al. (2007). "Clinical inquiries. Do topical antibiotics improve wound healing?" J Fam Pract 56(2): 140-144.] - No Neosporin, just bacitracin! [Epstein, E. (1966). "Allergy to dermatologic agents." Jama 198(5): 517-520.] [Gette, M. T., J. G. Marks, Jr., et al. (1992). "Frequency of postoperative allergic contact dermatitis to topical antibiotics." Arch Dermatol 128(3): 365-367. [BACKGROUND AND DESIGN: Topical antibiotics are one of the most common causes of allergic contact dermatitis and are frequently used in postoperative wound care. We prospectively followed up patients having cutaneous surgery to determine the frequency of allergic contact dermatitis to topical antibiotics used on postoperative wound care. RESULTS: Nine (4.2%) of 215 patients who had undergone surgery who were using a topical antibiotic had an eruption develop postoperatively that was consistent with an allergic contact dermatitis from the topical antibiotic. Seven of the nine patients agreed to patch testing with the standard tray and selected topical antibiotics. Five patients had a positive patch test to neomycin sulfate and four had a positive patch test to bacitracin. The frequency of allergic contact dermatitis proved by patch testing to neomycin and bacitracin is five (5.3%) of 94 and four (2%) of 198, respectively, in the patients who used these antibiotics. All proved sensitivities to bacitracin occurred in patients using a topical antibiotic that also contained neomycin and were patch tested positive to the neomycin. No patients using only pure bacitracin had allergic contact dermatitis. CONCLUSIONS: Allergic contact dermatitis to a topical antibiotic, especially neomycin, should be considered in any patient who has development of a dermatitis after cutaneous surgery. Because of the frequency of allergic contact dermatitis, neomycin-containing antibiotics should be avoided in postoperative wound care. þ Plantar Puncture Wounds IV. Plantar Puncture Wounds A. Rate of infection 2-10% a. Increased Pseudomonas if sweaty sneakers B. No evidence of benefit with prophylactic antibiotics C. Cleansing alone sufficient D. R/O Foreign body a. X-ray for radio opaque b. CT or US for non radio opaque E. No evidence to support wound coring or high pressure irrigation F. Cipro or Dicloxacillin for immune compromised or sweaty shoe Singer AJ, Dagum AB. Current Management of Acute Cutaneous Wounds. N Engl Jour Med. 2008;359:1037-46. þ Mammalian Bites A. Rate of infection a. 3-18% for Dog bites (open lacerations) b. 28-80% for Cat bites (punctures) B. Evidence suggests safe to close most bites after high pressure irrigation a. Exceptions: Puncture wounds C. Delayed primary closure may be considered for large heavily contaminated wounds D. "Fight bites" should not be closed E. Antibiotics only decrease infection rate for: a. Hand Bites b. Human Bites þ Cap and Mask? - Cap and mask doesn't make any difference [Ruthman, J. C., D. Hendricksen, et al. (1984). "Effect of cap and mask on infection rates in wounds sutured in the emergency department." IMJ Ill Med J 165(6): 397-9.] [Adam Singer, SUNY Stonybrook] þ Sterile Gloves? - Standard box gloves as good as sterile gloves for wound repair. [Perelman VS, Francis GJ, Rutledge T, Foote J, Martino F, Dranitsaris G. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med 2004;43(3):362-70.] Abstract: But may have had selection bias, leaving out high-risk wounds. þ Golden 8 hours? - Berk at all Ann 1988 17:496: Head and neck healed even if after 19 hours Trunk>Arms>Legs worse healing Even if 24 hours, face OK in kids; [Berk, W. A., D. D. Osbourne, et al. (1988). "Evaluation of the 'golden period' for wound repair: 204 cases from a Third World emergency department." Ann Emerg Med 17(5): 496-500.] Uncertainty about the existence and duration of a "golden period" for suture repair of simple wounds led us to evaluate prospectively the consequences of delayed primary closure on wound healing. Wounds were eligible for study if they were not grossly infected, and had no associated injuries to nerves, blood vessels, tendons, or bone. Three hundred seventy-two patients underwent suture repair; 204 (54.8%) returned for review seven days later. The mean time from wounding to repair for all patients was 24.2 +/- 18.8 hours. Wounds closed at up to 19 hours after wounding had a significantly higher rate of healing than those closed later: 82 of 89 (92.1%) compared with 89 of 115 (77.4%) (P less than .01). Of 23 wounds sutured 48 or more hours (mean, 65.3) after wounding, 18 (78.3%) were healing at follow-up. In contrast to wounds involving other body areas, the healing of head wounds was virtually independent of time from injury to repair: 42 of 44 (95.5%) wounds involving the head and repaired later than 19 hours after injury were healing, compared with 47 of 71 (66.2%) of all other wounds (P less than .001). On the basis of these data we conclude that there is a 19-hour "golden period" for repair of simple wounds involving body areas other than the head, after which sutured wounds are significantly less likely to heal, and the healing of clean, simple wounds involving the head is unaffected by the interval between injury and repair. þ Wound Antiseptics þ Bite Wounds þ Wound Closure þ Wound Infections þ Irrigation Notes on irrigants and wound toxicity: þ Gunshot Wounds - if in soft tissue only, prophylactic antibiotics did not seem to help in an uncontrolled retrospective trial. [Ordog GJ, et al. Infection in minor gunshot wounds. J Trauma 1993;34(3):358.] þ Tetanus Immunization Practicies þ Puncture wounds of foot: