Journal Jam 21 Laceration Management – Does Timing of Closure, Irrigation, Gloves Type, Eversion Matter?

There is much dogma that has been passed on from generation to generation on how we should manage lacerations in the ED. In this Journal Jam podcast Anton and Justin welcome special guest Dr. Haley Cochrane. We dive deep into the evidence for timing of closure and infection rate, fluid choice, volume and pressure of irrigation of lacerations, glove type and infection rate, how eversion of wound edges effects cosmetic outcomes and much more. You might be surprised to discover that the evidence for many things we do for lacerations that are considered "standard of care", is either weak or non-existent. But do not fret - we deliver practical bottom line practical recommendations to help improve outcomes, save time and decrease resource utilization... Podcast production, sound design & editing by Anton Helman Written Summary and blog post by Anton Helman December, 2022 Cite this podcast as: Helman, A. Morgenstern, J. Cochrane, H. Journal Jam 21 Laceration Management - Does Timing of Closure, Irrigation, Glove Type, Eversion Matter?. Emergency Medicine Cases. December, 2022. https://emergencymedicinecases.com/laceration-management-timing-closure-irrigation-gloves-eversion. Accessed September 17, 2024 How late is too late for suturing lacerations? The timing of closure of lacerations Take home points on timing of closure of lacerations: * Whenever possible, close lacerations sooner rather than later as they are likely to heal faster with early closure. * It is unclear from the literature if delayed closure increases infection rates or not. * The most important management piece when it comes to delayed presentations for lacerations is counseling the patient who presents late after a laceration about what to expect with regards to healing, and taking into account cosmesis and patient preference in deciding whether or not to close the laceration. * The usual instructions to return if signs of infection apply regardless of when the laceration is closed. References for timing of closure of lacerations discussed in this podcast * Eliya-Masamba MC, Banda GW. Primary closure versus delayed closure for non bite traumatic wounds within 24 hours post injury. Cochrane Database Syst Rev. 2013 Oct 22;(10):CD008574. * Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014 Feb;31(2):96-100. * Hollander JE, Singer AJ, Valentine SM, Shofer FS. Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med. 2001 Jul;8(7):716-20. * Morgenstern, J. More medical dogma: The ‘golden period’ for laceration repair, First10EM, October 24, 2022. Available at: https://doi.org/10.51684/FIRS.128601 Wound irrigation: Does it improve outcomes? Fluid type, volume and pressure Take home points on wound irrigation * The evidence for any real benefit of wound irrigation for lacerations is not clear. * For visibly dirty wounds and those that were caused by a dirty implement (especially in an immunocompromised patient), irrigation makes intuitive sense and seems reasonable. * Irrigation should not be a priority in clean-appearing wounds caused by a clean implement. * There is no clinical evidence at all to guide us on the volume of irrigation fluid that is sufficient or necessary. * Data on pressure is severely limited and mixed with only one positive trial. * Based on a Cochrane Review and double blind RCT it appears that tap water irrigation of lacerations is associated with a lower infection rate compared to saline. * There is a suggestion from older literature from the 1980's that wound irrigatio...