Vol. 17• Issue 7 • Page 37
Wound closure can be intimidating in the office setting. Many nurse practitioners do not receive training in such procedures in school and may have misconceptions about their complexities. Concerns about wound infection and cosmetic outcomes may prompt you to send these patients to the emergency department for a set of more experienced hands.
But sending patients to the emergency department can be detrimental to the patient-provider relationship and emotionally traumatic to patients. Considering that a visit to the emergency department averages more than 4 hours and rings up considerable costs, most patients prefer an office visit with a provider they know and trust.1In addition, simple wound closure is a source of revenue for the office. This additional income can easily be captured by the addition of a few simple skills and tools. In addition to the initial office visit, a wound check 2 days after closure and suture or staple removal a week or so later may be sources of more revenue.
While some types of wound closure are complex and require specific experience and manual dexterity, several types of wound closure are simple to perform and require little manual dexterity. Scalp lacerations, for example, are usually simple to repair. In most cases, cosmetic concerns are moot because the patient's hair covers the wounded area once it is healed.
Perhaps the easiest technique for wound closure is surgical stapling. Staples provide strong retention of wound edges with sterile stainless steel staples. Application of the staples is much quicker than suturing, and this procedure provides pleasing cosmetic outcomes at appropriately chosen sites.2
Surgical staples should not be used in areas where cosmetic appearance is a paramount concern, such as the face. They also should not be used near articulating surfaces such as joints, because the constant movement may hinder healing and promote dehiscence of the wound over time.
Before the Patient Arrives
To add surgical stapling to your office services, contact the company or service that provides medical equipment for your setting to inquire about surgical staplers. Staple devices are available for applications in the operating room as well as the office setting, with a capacity of five to 25 staples. Most simple scalp lacerations can be repaired with 10 or fewer staples.
Staplers for use in the office have similar mechanisms of action with slight variability. It is a good idea to obtain and practice with a few staplers before an actual patient encounter, to get used to the mechanism and to determine which one works best for you. The stapler should fit well into the dominant hand and function easily with a slight squeeze of the mechanism.
History and Physical Examination
When deciding whether to close a wound in the office, first gather the history of the event. Ask about the details of the trauma that caused the laceration. Could a foreign body be present? Do other injuries require evaluation in an emergency department? Are comorbid conditions present that might hinder the healing process, such as diabetes, history of keloids or an immunocompromised state? Any of these could lead to infection or poor cosmetic outcomes and suggest the need for referral.
Meticulously examine the wound for a foreign body, because foreign bodies present a significant risk for infection. Move hair out of the way by moistening it with sterile water-based gel and pushing it to the side. The gel will hold the hair in place and provide for easier examination. If a lot of hair prevents visualization of the wound, trimming may be necessary. As long as no hair is inside the wound at the completion of repair, the surrounding hair presents no risk for infection.
Only wounds that are straight or moderately straight are appropriate for closure with stapling. To determine the appropriateness of staples for a particular wound, use a gloved hand to approximate the wound edges. If they approximate well, staples can be used. Complicated or multidirectional wounds may require a different method of repair.
The administration of lidocaine provides complete analgesia to the wounded area, but the injection of it may be traumatic in children or anxious adults. If only one or two staples are needed to close the wound, infiltration may not be necessary; administration of the drug may be more painful than the quick application of a couple of staples. An alternative to lidocaine is the application of topical anesthetics such as EMLA or TrioCaine to prevent discomfort. These topical agents require several minutes to achieve a therapeutic effect.3Waiting for that therapeutic effect defeats the benefit of rapid wound closure and may prolong the patient's anxiety about the impending procedure.
As with all lacerations, preparation is the key to preventing infection in a scalp wound. Although the use of sterile saline vs. nonsterile tap water has been recently debated, one thing is certain: No matter what you use to irrigate the wound, the key is to use enough volume to flush any contaminates or bacteria.4
After you have properly prepared the wound, use the nondominant gloved hand to approximate the wound edges. With the stapler in the dominant hand, line up the opening of the laceration with the center line marker on the head of the stapler. This will ensure that each leg of the staple is placed within an equal distance of the wound. Once the stapler is lined up in a satisfactory position, simply squeeze the activator mechanism on the device, and a staple will be inserted into the skin. Continue the process until the wound is completely closed. Each staple should be placed about 3 mm to 5 mm from the previous one, until the wound is completely closed.
For lacerations longer than about 10 cm, place the first staple in the middle of the wound to line up the edges more precisely. Place subsequent staples above and below the first one until the wound is closed.
In general, a dressing is not needed for scalp lacerations that have been repaired with staples. The wound need only be kept clean and dry until staples are removed. After staple placement, patients may wish to take a shower or wash their hair. The wound may get slightly wet during showering, and this is acceptable. Complete submersion in water is not advisable. Daily showers do not increase the likelihood of infection, but advise patients to wash the area only lightly.5
Instruct patients to apply antibiotic ointment over the staples two to three times per day until they are removed.6
Instruct the patient to return in 2 to 3 days for a wound check. At that visit, evaluate the wound for signs of infection, and treat appropriately. Staples in the scalp can be removed 7 to 10 days after closure, using a commercial staple remover.7These are available through the same distributor as the stapler.
Putting It Into Practice
Many healthcare providers hesitate to incorporate wound repair in office settings, but it is a feasible and potentially profitable service. The scalp is a good place to hone wound closure skills and gain experience. Because it is a vascular area, it is associated with low infection rates and good cosmetic healing. Any mistakes are usually hidden by the patient's hair and are a normal part of building clinical experience.
To feel even more comfortable with the procedure, consider obtaining a pig foot from a local butcher. Make several incisions in the foot, and practice wound closure in the comfort and privacy of home before attempting to perform such procedures in the office.
Jim Jolly is a family nurse practitioner in the emergency department at Kaweah Delta Medical Center in Visalia, Calif.
1. Polevoi SK, et al. Factors associated with patients who leave without being seen. Acad Emerg Med. 2005;12(3):232-236.
2. Khan AN, et al. Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial. Pediatr Emerg Care. 2002;18(3):171-173.
3. Eidlman A, et al. Topical anesthetics for dermal instrumentation: a systematic review of randomized, controlled trials. Ann Emerg Med. 2005;46(4):343-351.
4. Moscati RM, et al. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007;14(5):404-409.
5. Heal C, et al. Can sutures get wet? Prospective randomized controlled trial of wound management in general practice. BMJ. 2006;332(7549):1053-1056.
6. Dire DJ, et al. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft tissue wounds repaired in the ED. Acad Emerg Med. 1995;1(2):4-10.
7. Autio L, et al. The four S's of wound management: staples, sutures, Steri-Strips, and sticky stuff. Holist Nurs Pract. 2002;16(2):80-88.