Simple Lacerations - Sterile of Nonsterile Technique?

[ventana]

What's yall's thoughts on simple head lacs that only need a few staples (1-5)?  Sterile or "non-sterile" but clean?  Obviously with no intent to cause more harm and do it as clean as possible (removing gross contaminants, etc...)

 

 

staples ONLY please

(just had to fish out some sutures last week - PIA

 

clean is fine

[TheDude]

I can't say I've ever sutured a scalp lac, I've only used staples.  But have seen the whole sch'bang on putting the drapes up and parting the hair and all, and then I've done the get it as clean as possible and pop a few staples in.  Want to make sure I'm not being a dingus and doing the patient a disservice.

[GetMeOuttaThisMess]

You haven't lived till you've had the opportunity to debride a self-induced scalping from highway pavement in a flipped old 240Z. Gravel and road mess everywhere. Never did get it all out. It was one of our hospital rad techs who had just gotten off work. Two flaps, sew together, which becomes one large triangular flap. Healed perfectly. He was sutured and took forever.

[sk732]

I can't say I've ever sutured a scalp lac, I've only used staples.  But have seen the whole sch'bang on putting the drapes up and parting the hair and all, and then I've done the get it as clean as possible and pop a few staples in.  Want to make sure I'm not being a dingus and doing the patient a disservice.

 

I sew them a lot - use chromic or plain gut, saves them a return visit.  Had to toss some ligatures into a noodle a week or so ago because of a squirter - so much clot around it was like playing wack a mole.

 

SK

[sas5814]

..... devils advocate incoming..... who doesn't pack <5 cm abscesses? Who doesn't worry about copiously irrigating every spec of pus out of there?

 

Sorry for the somewhat of a thread derail

about 2 years ago based on advice from a gen surgeon I stopped packing abcesses and stopped giving antibiotics to all of them. I haven't had one require additional treatment yet. It will probably happen but the dozens of people who didn't have to suffer the pain of multiple re-packing visits has made this my standard of care for now. I'm always willing to modify when/if new data develops.

[marktheshark89]

I don't typically pack, but I do often write antibiotics. Here is the latest I have seen on this: https://www.ncbi.nlm.nih.gov/pubmed?term=26962903

[d2305]

No pain no gain. Abscesses need to drain. Patients don't like it very much.

[HMtoPA]

Fot lacs & abscesses I typically go clean (but irrigate copiously). I figure they're both pretty dirty to begin with, and much of my practice has been in austere conditions where I haven't always had sterile gloves anyway (or at least not in endless supply). Now I'm in more of a 8-5 "real" clinic environment, but old habits die hard - I only use sterile gloves if whoever did the setup happens to lay them out, and even then, not always.

 

I try to avoid abx after an I&D because the literature doesn't really support it, but I find oftentimes my judgement suggests a course of Septra to be prudent - e.g., I'm a little more worried about MRSA in a Marine Corps infantryman, or homeless person, or just someone with poor hygiene, than I might be with someone who works in an office.

 

I do use sterile gloves for simple excisions (EICs, lipomas), Nexplanon (ins & outs), and IUD insertions,

[BruceBanner]

By definition, I&D of an abscess is not a sterile procedure.

 

I only I&D if it's fluctuant and obviously pyogenic.

 

I never pack an abscess. I dont believe in it. You can always place a small drain. Dressing changes bid, close frequent follow up for wound checks and re-expression of the abscess if necessary.

[JDayBFL]

Non-sterile. Could you potentially introduce different bacteria into an already infected abscess? Sure. But by the time they get to you they are going on antibiotics and it doesn't matter...

 

I don't pack the abscess initially. Sometimes leave a vessel loop. Have them come back in a week and as granulation tissue is forming maybe loosely pack xeroform Vaseline gauze if still a large open wound. Most will close pretty quickly.

[Guest ral]

I only I&D if it's fluctuant and obviously pyogenic.

 

^^^This

I have witnessed too many colleagues attempt to I&D a localized area of skin/soft tissue infection, or even cellulitis, over the years. Then they keep digging deeper and deeper, searching for a pot of gold pocket of exudate that simply doesn't exist. For crying out loud, if it isn't a true abscess, keep your fingers and scalpels off of/out of it. Not every red spot requires breaking out the instruments.

[sk732]

^^^This

I have witnessed too many colleagues attempt to I&D a localized area of skin/soft tissue infection, or even cellulitis, over the years. Then they keep digging deeper and deeper, searching for a pot of gold pocket of exudate that simply doesn't exist. For crying out loud, if it isn't a true abscess, keep your fingers and scalpels off of/out of it. Not every red spot requires breaking out the instruments.

 

Funnily enough, doing an ultrasound course tomorrow to better differentiate the subtle abscesses from bad cellulitis.  Look forward to using it more.

 

SK

[EMSGuy1982]

Funnily enough, doing an ultrasound course tomorrow to better differentiate the subtle abscesses from bad cellulitis. Look forward to using it more.

 

SK

The same goes for the opposite. Ive seen some gnarly cellulitis that you wouldn't think has any pocket and boom, ultrasound shows a deep pocket. I've been pushing for the use of US at the UC I am at. Allegedly the benefits don't outweigh the cost per some folks.. I understand it's operator dependent but there really is a lot you can/could do with US in the urgent care setting.

 

P.S non-sterile.

[BruceBanner]

^^^This

I have witnessed too many colleagues attempt to I&D a localized area of skin/soft tissue infection, or even cellulitis, over the years. Then they keep digging deeper and deeper, searching for a pot of gold pocket of exudate that simply doesn't exist. For crying out loud, if it isn't a true abscess, keep your fingers and scalpels off of/out of it. Not every red spot requires breaking out the instruments.

 

Yeah this myth exists in primary care that anything red and indurated potentially needs an I&D. I've put people through needless cutting only to get nothing, so now I ONLY cut if it is a juicy, fluctuant pocket of pus. If it's already open, leave that damn thing alone! Induration in my opinion is a reason not to cut. It's interstitial edema, not pus!!

[Katera]

Yeah, they come with their lac covered with a kitchen towel or a random paper napkin. the cut was over a dirty object and sterile gloves would make all the difference... give me a break

 

 

 

That's why you clean the wound before suturing genius.

[camoman1234]

That's why you clean the wound before suturing genius.

Tunafish has a valid point... cleaning it won't stop from getting an infection if you cut yourself, drive 45 minutes to the UC/ED (which is how close we are from the nearest UC/ED) and sat for a few hours. That if you leave within 5 minutes of cutting yourself. Most people (including myself) wait at least 30 min to 1 hour to leave the house to even head to the UC/ED. I cut my thumb a few years ago while cooking, we had to turn everything off, get the kiddos ready, put dogs up etc and it was 45 minutes to even get out of the house. So please be nice in your comments, but also don't think by "cleaning" the wound is gonna stop it from getting infected...

[HMtoPA]

^^^This

I have witnessed too many colleagues attempt to I&D a localized area of skin/soft tissue infection, or even cellulitis, over the years. Then they keep digging deeper and deeper, searching for a pot of gold pocket of exudate that simply doesn't exist. For crying out loud, if it isn't a true abscess, keep your fingers and scalpels off of/out of it. Not every red spot requires breaking out the instruments.

 

 

It's a judgment call, obviously, and the fewer times you've done it, the less experience you have to inform good judgement. Conversely, I've had some colleagues that were maybe not as confident in their procedure skills just throw antibiotics at an abscess that obviously needed to be cut, or refer out a simple excision of a lipoma or EIC, for example.

[Evolute]

^^^This

I have witnessed too many colleagues attempt to I&D a localized area of skin/soft tissue infection, or even cellulitis, over the years. Then they keep digging deeper and deeper, searching for a pot of gold pocket of exudate that simply doesn't exist. For crying out loud, if it isn't a true abscess, keep your fingers and scalpels off of/out of it. Not every red spot requires breaking out the instruments.

 

Bed side ultra sound answers the question (if you have the training). Its fast to do and noninvasive. You see a puss pocket, drain it, you don't... don't cut 

[sk732]

Bed side ultra sound answers the question (if you have the training). Its fast to do and noninvasive. You see a puss pocket, drain it, you don't... don't cut 

 

Just finished my skin/soft tissue course - going to see if I can put it to use today...

 

Addendum - used it twice today, no abscesses found, tissue edema only.

 

SK