RESUMEN
BACKGROUND: Minor abrasions and skin tears are usually treated with gauze dressings and topical antibiotics requiring frequent and messy dressing changes. OBJECTIVE: We describe our experience with a low-cost, cyanoacrylate-based liquid dressing applied only once for minor abrasions and skin tears. METHODS: We conducted a single-center, prospective, noncomparative study in adult emergency department (ED) patients with minor nonbleeding skin abrasions and class I and II skin tears. After cleaning the wound and achieving hemostasis, the wounds were covered with a single layer of a cyanoacrylate liquid dressing. Patients were followed every 1-2 days until healing. RESULTS: We enrolled 40 patients with 50 wounds including 39 abrasions and 11 skin tears. Mean (standard deviation) age was 54.5 (21.9) years and 57.5% were male. Wounds were located on the face (n = 16), hands (n = 14), legs (n = 11), and arms (n = 9). Pain scores (0 to 10 from none to worst) after application of the liquid dressing were 0 in 62% and 1-3 in the remaining patients. Follow-up was available on 36 patients and 46 wounds. No wounds re-bled and there were no wound infections. Only one wound required an additional dressing. Median (interquartile range [IQR]) time to complete sloughing of the adhesive was 7 (5.5-8) days. Median (IQR) time to complete healing and sloughing of the overlying scab was 10 (7.4-14) days. CONCLUSIONS: Our study suggests that a single application of a low-cost cyanoacrylate-based liquid adhesive is a safe and effective treatment for superficial nonbleeding abrasions and class I and II skin tears that eliminates the need for topical antibiotics and dressings.
Asunto(s)
Cianoacrilatos/uso terapéutico , Servicio de Urgencia en Hospital , Apósitos Oclusivos , Piel/lesiones , Heridas y Lesiones/terapia , Administración Tópica , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Cicatrización de Heridas , Adulto JovenRESUMEN
OBJECTIVES: Cutaneous abscesses have traditionally been treated with incision and drainage (I&D) and left to heal by secondary closure. The objective was to compare the healing rates of cutaneous abscesses following I&D after primary or secondary closure. METHODS: This was a randomized, controlled, trial, balanced by center, with blocked randomization created by a random-number generator. One urban and one suburban academic emergency department (ED) participated. Subjects were randomized to primary or secondary wound closure following I&D of the abscess. Main outcome measures were the percentage of healed wounds (wound was completely closed by visual inspection; a 40% difference in wound healing was sought) and overall failure rate (need for additional intervention including suture removal, additional drainage, antibiotics, or admission within 7 days after drainage). RESULTS: Fifty-six adult patients with simple localized cutaneous abscesses were included; 29 were randomized to primary closure, and 27 were randomized to secondary closure. Healing rates at 7 days were similar between the primary and secondary closure groups (69.6%, 95% confidence interval [CI] = 49.1% to 84.4% vs. 59.3%, 95% CI = 40.7% to 75.5%; difference 10.3%, 95% CI = -15.8% to 34.1%). Overall failure rates at 7 days were also similar between the primary and secondary closure groups (30.4%, 95% CI = 15.6% to 50.9% vs. 28.6%, 95% CI = 15.2% to 47.1%; difference 1.8%, 95% CI = -24.2% to 28.8%). CONCLUSIONS: The rates of wound healing and treatment failure following I&D of simple abscesses in the ED are similar after primary or secondary closure. The authors did not detect a difference of at least 40% in healing rates between primary and secondary closure.
Asunto(s)
Absceso/cirugía , Drenaje/métodos , Servicio de Urgencia en Hospital , Enfermedades de la Piel/cirugía , Técnicas de Cierre de Heridas , Absceso/diagnóstico , Adulto , Intervalos de Confianza , Tratamiento de Urgencia/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Medición de Riesgo , Enfermedades de la Piel/diagnóstico , Estadísticas no Paramétricas , Resultado del Tratamiento , Cicatrización de Heridas/fisiología , Adulto JovenRESUMEN
OBJECTIVES: A novel wound closure device combining a mesh tape and octylcyanoacrylate (OCA) topical skin adhesive (TSA) was developed to facilitate wound closure and enhance the adhesive's strength. The objective of this study was to determine whether the incidence of wound dehiscence after laceration repair with the new device was equivalent to that after use of a high-viscosity OCA. We hypothesized that the rate of complete wound edge apposition would be equivalent for the two closure devices. METHODS: This was a multicenter, randomized clinical trial in nine academic and community emergency departments (EDs) and urgent care centers. Patients with simple traumatic lacerations were included. Lacerations were randomly closed with a high-viscosity OCA or mesh tape-OCA combination. The rate of complete wound edge apposition at 14 days, rates of wound infection at 14 and 30 days, and the percentage of optimally appearing scars at 30 days after closure were assessed. Assuming a maximal clinically acceptable difference for equivalence of 8% in the rate of completely apposed wound edges, a sample of at least 138 patients in the tape-OCA group and at least 69 in the OCA-only group would give 80% power and a one-sided significance level of 5%. RESULTS: During the study period the investigators enrolled 216 subjects, of whom 143 were randomized to the tape-OCA combination and 73 to the OCA-only group. Most wounds were located on the face and the upper extremities. Mean laceration length was similar in patients in both groups (tape-OCA 2.1 cm vs. OCA-only 2.0 cm; difference 0.1 cm, 95% confidence interval [CI] = -0.45 to 0.58 cm). The rate of complete wound edge apposition at 14 days was higher in wounds treated with the tape-OCA combination than in wounds treated with OCA alone (86.0% vs. 78.1%). The upper bound of the one-sided CI was 1.0% for the intention-to-treat population, which was less than the predetermined acceptable difference of less than 8%. There were no between-group differences in rates of infection and optimally appearing scars. CONCLUSIONS: When compared with OCA alone, the novel tape-OCA combination is equivalent with regard to complete wound edge apposition and cosmetic appearance.
Asunto(s)
Cianoacrilatos/uso terapéutico , Servicio de Urgencia en Hospital , Mallas Quirúrgicas , Dehiscencia de la Herida Operatoria/prevención & control , Adhesivos Tisulares/uso terapéutico , Adolescente , Adulto , Distribución de Chi-Cuadrado , Femenino , Humanos , Masculino , Poliésteres , Resultado del TratamientoRESUMEN
BACKGROUND: Cutaneous abscesses have traditionally been treated with incision and drainage followed by secondary healing. Primary closure after incision and drainage is an alternative mode of therapy practiced in some parts of the world. The current study reviews the experience with primary closure of abscesses. METHODS: A systematic literature review was conducted using search terms abscess and primary closure. The databases searched included MEDLINE, PubMED, EMBASE, CINHAL, and the Cochrane Library between 1950 and 2009. The reference lists of the retrieved studies were also manually searched for additional studies. We performed a meta-analysis of all randomized clinical trials in which patients were randomized to either primary or secondary closure of incised and drained abscesses using Review Manager software. RESULTS: Of 33 articles retrieved, there were 7 randomized controlled trials in which 915 patients were randomized to primary (n = 455) or secondary (n = 460) closure. Many abscesses were located in the anogenital region and drained by surgeons. The time to healing after primary closure (7.8 days [95% confidence interval {CI}, 7.3-8.3]) was significantly shorter than that after secondary closure (15.0 days [95% CI, 14.3-15.7]; absolute difference, 7.3 days [95% CI, 6.9-7.6]). The rates of abscess recurrence after primary closure (7.6% [95% CI, 4.6-10.6]) were similar to those after secondary closure (11.1 days [95% CI, 7.5-14.7]; odds ratio, 0.66 [95% CI, 0.35-1.15]). CONCLUSIONS: Studies from 4 countries suggest that primary closure of incised and drained abscesses results in faster healing and similar low abscess recurrence rates than after secondary closure. These studies provide a foundation for which clinical trials can be conducted in the United States.
Asunto(s)
Absceso/cirugía , Drenaje , Enfermedades Cutáneas Bacterianas/cirugía , Técnicas de Sutura , Infección de Heridas/cirugía , Absceso/tratamiento farmacológico , Absceso/etiología , Antibacterianos/uso terapéutico , Humanos , Enfermedades Cutáneas Bacterianas/tratamiento farmacológico , Enfermedades Cutáneas Bacterianas/etiología , Suturas , Cicatrización de Heridas , Infección de Heridas/tratamiento farmacológico , Infección de Heridas/etiologíaRESUMEN
OBJECTIVES: The objective of our study was to evaluate the efficacy of the observation option for the treatment of acute otitis media (AOM) in the emergency department (ED). METHODS: The study was designed as a prospective case series. It was conducted in a suburban academic emergency department, with pediatric patients 2 years or older as participants. INTERVENTIONS AND OUTCOMES: The patient population consisted of children 2 years or older with conditions diagnosed as AOM. Patients were excluded if they had a history of any potentially immunocompromising conditions or a history of recurrent AOM. Patients were treated with ibuprofen or acetaminophen in the ED. The parents were given a prescription for antibiotics but were asked not to fill the prescription immediately. Parents were contacted by phone for follow-up. RESULTS: One hundred forty-four patients were enrolled in the study. One hundred five (73%) recovered uneventfully without ever requiring antibiotics. Thirty-nine patients were treated with antibiotics. Of the 39 patients who were started on antibiotics, 11 patients had at least 1 episode of vomiting or diarrhea, and 5 of these patients had their antibiotic changed because of it. CONCLUSIONS: Our study demonstrates that the observation option as defined by the New York Otitis Project Committee can be safely implemented in the ED and prevented the administration of antibiotics in more than 70% of the patients in our group. This suggests that if the observation option became the standard of care for the treatment of AOM, antibiotic administration for this disease could be significantly reduced.
Asunto(s)
Antibacterianos/uso terapéutico , Prescripciones de Medicamentos/estadística & datos numéricos , Unidades de Cuidado Intensivo Pediátrico , Observación/métodos , Otitis Media/terapia , Enfermedad Aguda , Adolescente , Niño , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Incidencia , Masculino , New York/epidemiología , Otitis Media/epidemiología , Estudios Prospectivos , Población Rural , Resultado del TratamientoRESUMEN
OBJECTIVES: To compare the pain of needle insertion, anesthesia, and suturing in finger lacerations after local anesthesia with prior topical anesthesia with that experienced after digital anesthesia. METHODS: This was a randomized controlled trial in a university-based emergency department (ED), with an annual census of 75,000 patient visits. ED patients aged > or = 8 years with finger lacerations were enrolled. After standard wound preparation and 15-minute topical application of lidocaine-epinephrine-tetracaine (LET) in all wounds, lacerations were randomized to anesthesia with either local or digital infiltration of 1% lidocaine. Pain of needle insertion, anesthetic infiltration, and suturing were recorded on a validated 100-mm visual analog scale (VAS) from 0 (none) to 100 (worst); also recorded were percentage of wounds requiring rescue anesthesia; time until anesthesia; percentage of wounds with infection or numbness at day 7. Outcomes were compared by using Mann-Whitney U and chi-square tests. A sample of 52 patients had 80% power to detect a 15-mm difference in pain scores. RESULTS: Fifty-five patients were randomized to digital (n = 28) or local (n = 27) anesthesia. Mean age (+/-SD) was 38.1 (+/-16.8) years, 29% were female. Mean (+/-SD) laceration length and width were 1.7 (+/-0.7) cm and 2.0 (+/-1.0) mm, respectively. Groups were similar in baseline patient and wound characteristics. There were no between-group differences in pain of needle insertion (mean difference, 1.3 mm; 95% confidence interval [CI] = -17.0 to 14.3 mm); anesthetic infiltration (mean difference, 2.3 mm; 95% CI = -19.7 to 4.4 mm), or suturing (mean difference, 7.6 mm; 95% CI = -3.3 to 21.1 mm). Only one patient in the digital anesthesia group required rescue anesthesia. There were no wound infections or persistent numbness in either group. CONCLUSIONS: Digital and local anesthesia of finger lacerations with prior application of LET to all wounds results in similar pain of needle insertion, anesthetic infiltration, and pain of suturing.
Asunto(s)
Analgésicos/administración & dosificación , Anestesia Local/métodos , Traumatismos de los Dedos , Adolescente , Adulto , Niño , Medicina de Emergencia , Femenino , Humanos , MasculinoRESUMEN
BACKGROUND: The objective of this study was to compare the cosmetic outcome of facial lacerations closed with a single or double layer of sutures. METHODS: Patients aged 1 year or older presenting to a university-based emergency department with nongaping (width, < 10 mm), simple, nonbite, facial lacerations were randomized to closure with a single layer of simple interrupted 6-0 polypropylene sutures or a double layer of simple interrupted 6-0 polypropylene plus inverted deep dermal 5-0 polyglactin sutures. At 90 days, the scar width and cosmetic appearance were determined using a validated 100-mm visual analogue scale ranging from 0 (worst) to 100 (best) and a validated wound evaluation score ranging from 0 (worst) to 6 (best). RESULTS: Sixty-five patients were randomized to single-layer (n = 32) or double-layer (n = 33) closure. Mean age (SD) was 18.5 years (20.0), and 14 percent were female. Groups were similar in baseline patient and wound characteristics. Length of single-layer closure was 7 minutes shorter (95 percent CI, 2 to 11 minutes) than double-layer closure. There were no infections or dehiscences in either group. There were no between-group differences in patient (mean difference, 0.5 mm; 95 percent CI, -5.7 to 6.6 mm) or practitioner (mean difference, 1.0 mm; 95 percent CI, -4.8 to 6.7 mm) visual analogue scale scores. All but one patient had an optimal wound evaluation score of 6 (p = not significant). Scar width was similar at 90 days (mean difference, 0.2 mm; 95 percent CI, -0.05 to 0.5). CONCLUSIONS: Single-layer closure of nongaping, minor (< 3 cm) facial lacerations is faster than double-layer closure. Cosmetic outcome and scar width are similar in sutured wounds whether or not deep dermal sutures are used.
Asunto(s)
Traumatismos Faciales/cirugía , Laceraciones/cirugía , Técnicas de Sutura , Adolescente , Adulto , Niño , Preescolar , Femenino , Humanos , Lactante , Masculino , Estudios Prospectivos , Método Simple Ciego , Dehiscencia de la Herida Operatoria/prevención & controlRESUMEN
OBJECTIVE: Tissue adhesives have recently been approved for skin closure. Their low viscosity may result in inadvertent migration. The authors compared the tendency of the adhesive to migrate after laceration closure with a high- or low-viscosity octylcyanoacrylate (OCA). METHODS: This was a randomized, clinical trial set in university and community-based emergency departments. Participants included patients with simple traumatic lacerations. Patients were randomized to laceration closure with low- or high-viscosity OCA tissue adhesive. The outcome measured was immediate adhesive migration (interobserver agreement, kappa = 0.90). Data analysis was performed with proportions compared with chi-square and Fisher's exact tests. RESULTS: Eighty-four patients were randomized to low- (n = 42) or high- (n = 42) viscosity OCA tissue adhesive. Groups were similar in baseline patient and wound characteristics. The high-viscosity OCA was less likely to migrate than the lower-viscosity agent (21% vs. 78%, p < 0.001; odds ratio = 0.3, 95% confidence interval = 0.1 to 0.5). The proportion of patients who noted a sensation of heat during OCA application was higher in the high-viscosity groups (44% vs. 26% respectively, p = 0.11); however, all such patients in both groups would use the device again. At 14 days, there were no wound infections in either group. There was one dehiscence in the high-viscosity group. CONCLUSIONS: The high-viscosity OCA tissue adhesive was less likely to migrate than the lower-viscosity device. Wound dehiscence and infection rates were acceptably low in both treatment groups.