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When can traumatic lacerations be closed?
Background: When are you happy to suture a traumatic laceration closed? 6 hours? 12? Longer? The 'Golden Period' used to be 6 hours, but many clinicians have moved away from this, particularly for wounds on the face or neck. A literature search of this topic turns up many papers, but most are quite small, observational and retrospective in approach. Still, the collective force of these has been to push back the 'golden period' beyond 6 hours, but no one really knows what the magic number should be. What we are most interested in, of course, is the risk of infection. This paper has some answers for us.
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;31(2):96-100.
The paper: This was the largest multicentre prospective cohort study of consecutive lacerations in the ED. From an initial group of 3,957, a total of 2,663 patients completed follow up (which is pretty good for a wound care study). In each case, data on 27 variables were collected at the time of treatment. The patients were reviewed or spoken to after 30 days to determine whether an infection had developed and whether they were happy with the cosmetic result. The authors suggested that it would become cost effective to give prophylactic antibiotics when there was a greater than 5% chance of infection. Those variables associated with a significantly increased infection rate (>5%) were diabetes, lower extremity lacerations, contaminated wounds and lacerations greater than 5cm. Interestingly, time from injury to wound closure made no difference to infection rate in this study (3% if under 12 hours, 1.2% if over 12 hours - numbers were not sufficiently high to make this significant).
The bottom line: This large study found no evidence that closing older wounds increases the risk of infection. Infections were commoner in diabetic patients, those with leg wounds, large wounds (>5cm) and contaminated wounds.
Expert commentary:"This is useful and hopefully diminishes the incorrect belief that antibiotics are always required - they should be prescribed only to high risk patients or for high risk wounds. Also, giving antibiotics should not replace proper cleaning and if required debridement (to fresh edges) of the wound."
(Dr Dwynwen Roberts, ED consultant)
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By Barrie StevensonBackground: When are you happy to suture a traumatic laceration closed? 6 hours? 12? Longer? The 'Golden Period' used to be 6 hours, but many clinicians have moved away from this, particularly for wounds on the face or neck. A literature search of this topic turns up many papers, but most are quite small, observational and retrospective in approach. Still, the collective force of these has been to push back the 'golden period' beyond 6 hours, but no one really knows what the magic number should be. What we are most interested in, of course, is the risk of infection. This paper has some answers for us.
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;31(2):96-100.
The paper: This was the largest multicentre prospective cohort study of consecutive lacerations in the ED. From an initial group of 3,957, a total of 2,663 patients completed follow up (which is pretty good for a wound care study). In each case, data on 27 variables were collected at the time of treatment. The patients were reviewed or spoken to after 30 days to determine whether an infection had developed and whether they were happy with the cosmetic result. The authors suggested that it would become cost effective to give prophylactic antibiotics when there was a greater than 5% chance of infection. Those variables associated with a significantly increased infection rate (>5%) were diabetes, lower extremity lacerations, contaminated wounds and lacerations greater than 5cm. Interestingly, time from injury to wound closure made no difference to infection rate in this study (3% if under 12 hours, 1.2% if over 12 hours - numbers were not sufficiently high to make this significant).
The bottom line: This large study found no evidence that closing older wounds increases the risk of infection. Infections were commoner in diabetic patients, those with leg wounds, large wounds (>5cm) and contaminated wounds.
Expert commentary:"This is useful and hopefully diminishes the incorrect belief that antibiotics are always required - they should be prescribed only to high risk patients or for high risk wounds. Also, giving antibiotics should not replace proper cleaning and if required debridement (to fresh edges) of the wound."
(Dr Dwynwen Roberts, ED consultant)