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Keywords:

  • topical skin adhesives;
  • octylcyanoacrylate;
  • lacerations

Abstract

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

Objectives:  The objective was to determine patterns of use of topical skin adhesives (TSA) for laceration repair. The authors hypothesized that TSA use would be more common in children and facial lacerations.

Methods:  This was a structured retrospective chart review. The setting was a suburban, university-based emergency department (ED) with an emergency medicine (EM) residency; the annual census is 85,000 visits. Charts from consecutive patients presenting with lacerations in the summer of 2008 (June 2008 through August 2008) were reviewed. Demographic, clinical, and wound characteristics were extracted from electronic medical records by trained investigators using structured data collection forms. Characteristics of lacerations repaired with TSA or other closure devices were compared with bivariate and multivariate analyses using odds ratios (ORs) and 95% confidence intervals (CIs).

Results:  A total of 755 patients presented to the ED with lacerations over the study period, of whom primary closure was used in 667; nine were excluded because the method of closure was unknown. The most common methods of laceration closure were sutures (485), adhesives (88), and staples (86). Adhesives were used to close 27% of facial lacerations, compared to 4% of all other body locations (difference = 23%, 95% CI = 18% to 29%), and in 20% of pediatric versus 8% of adult lacerations (difference = 13%, 95% CI = 7% to 18%). Adjustment for other potential patient and wound characteristics showed that adhesives were more likely to be used to close facial lacerations (OR = 10.0 CI, 95% CI = 5.5 to 18.0) and lacerations in children (OR = 1.8, 95% CI = 1.1 to 3.0) and less likely to be used as laceration length increased (OR = 0.6, 95% CI = 0.4 to 0.8). Adhesive use was not statistically associated with patient sex or race, laceration edges or shape, or the need for deep sutures. Forty-three percent of adhesive wounds were closed with no anesthetic, and a topical agent was used in another 48%. In contrast, a local anesthetic agent was injected in 87% of sutured wounds (p < 0.001) and 73% of stapled wounds (p < 0.001).

Conclusions:  Topical skin adhesives are used more often for children, facial lacerations, and short lacerations. Use of adhesives may improve patient comfort as need for injecting a local anesthetic is reduced.

ACADEMIC EMERGENCY MEDICINE 2010; 17:670–672 © 2010 by the Society for Academic Emergency Medicine

A topical skin adhesive (TSA) is an adhesive or glue used to close wounds in the skin, as an alternative to sutures, staples, or adhesive tapes. Their main advantage over traditional wound closure devices (such as sutures) is their noninvasive nature that results in a painless wound closure and obviates the need for device removal and follow-up.1 They also create a moist occlusive dressing and act as a microbial barrier.1

TSAs have been available in the United States since 1999;2 however, their pattern of use is unknown. The current study was designed to describe the use of TSA in a high-volume emergency department (ED) and to explore the association between patient and wound characteristics and use of TSA.

Methods

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

Study Design

This was a standardized medical chart review. The study was approved by our institutional review board with waiver of informed consent. In our ED the only available TSA is the octylcyanoacrylate Dermabond (Ethicon Inc., Somerville, NJ).

Study Setting and Population

Our suburban academic ED has an annual census of 85,000 patient visits. We included consecutive patients presenting to the ED during June 2008 through August 2008 with a laceration.

Study Protocol

A structured, standardized review of all medical records of study group patients was performed using criteria developed by Gilbert et al.3 Interrater agreement was determined by having a second independent reviewer reabstract a subset of 10% of the cases. The items reviewed included type of closure device used, laceration location, laceration length, patient age, and patient sex. Interobserver agreement for all these items was 100%. The abstractors were not informed of the study purpose.

A structured closed-question data sheet was used to record patient and wound characteristics.4 Data included patient demographics (age, sex, race); medical history and medications; wound characteristics (etiology of wound, time of injury, wound location, length, width, shape and margin, degree of contamination and presence of foreign bodies); wound preparation (type of anesthetic, method of irrigation or scrub and solution used, and wound debridement); and wound closure techniques and devices used. The degree of contamination was not defined and left to the discretion of the treating physician.

Data Analysis

Data were analyzed using SPSS 17.0 software (SPSS Inc., Chicago, IL) for Windows (Microsoft Corp., Redmond, WA). Quantitative variables are reported as medians and interquartile ranges (IQR), and categorical variables are expressed as percentage frequency of occurrence. Univariate associations of predictor variables with use of TSA were determined using chi-square tests. Multivariate associations between predictor variables and use of TSA were determined using logistic regression and are shown as odds ratios (ORs) with 95% confidence intervals (CIs). All predictor variables were included in the multivariate regression model based on a priori decisions. The sample size was sufficient to allow up to eight predictor variables in the multivariate model. The Hosmer-Lemeshow statistic was used to measure the fit of the model. Statistical significance was defined as p < 0.05.

Results

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

General Characteristics

Of more than 20,000 patients presenting to our ED during the study period, 755 (3.1%) had a traumatic laceration. Their median age was 24 years (IQR = 12–43 years); 180 (23.8%) were female; 601 (79.6%) were white, 82 (10.9%) were Hispanic, 34 (4.5%) were African American, and 18 (2.4%) were Asian. Thirty-four percent were under age 18 years old. The mean time from injury to ED presentation was 1.8 hours (95% CI = 1.6 to 2.1). Lacerations were most commonly located on the extremities (n = 331; 44%), face (n = 262; 35%), and scalp (n = 105; 14%). Of all lacerations, 344 (45%) were under 2 cm long, 335 (44%) were between 2 and 5 cm long, and 67 (9%) were longer than 5 cm. Sharp (368; 49%) and blunt (354; 47%) mechanisms were responsible for most lacerations. Most lacerations (95.5%) were limited to the dermis and subcutaneous fat, and the majority (85.7%) were linear. Gross contamination and foreign bodies were each apparent in five (0.7%) patients. All foreign bodies were removed. There were only 15 lacerations described as contaminated; 11 were closed using sutures, and four were not closed. None were closed using TSA.

Laceration Closure

Primary wound closure was performed in 667 (88.3%) of the lacerations. The remaining 88 lacerations (11.7%) were allowed to heal by secondary intention. The wound closure devices used for primary closure of the 667 lacerations included 485 sutures (72.7%), 88 TSA (13.2%), 86 staples (12.9%), and eight with surgical adhesive tape (1.2%). In the majority of sutured wounds (84.5%) only a single percutaneous layer was used. The median number of sutures used was five (IQR = 3–7) and the median number of staples used was three (IQR = 2–5).

Topical skin adhesives were used to close 27% of facial lacerations compared to 4% of all other body locations (difference = 23%; 95% CI = 18% to 29%). TSAs were used in 20% of the pediatric patients compared with only 8% of adults (difference = 12%; 95% CI = 7% to 18%). Adjustment for other potential patient and wound factors demonstrated that adhesives were still more likely to be used in children and on faces (Table 1). TSAs were less likely to be used as the length of the laceration increased (Table 1). The model fit was adequate (goodness of fit p = 0.23).

Table 1.    Univariate and Multivariate OR for Predicting TSA Use
 UnivariateMultivariate
OR95% CIOR95% CI
  1. OR = odds ratio; TSA = topical skin adhesive.

Pediatric (<18 yrs)3.01.9–4.81.81.1–3.0
Male0.90.5–1.51.050.6–1.9
Facial10.05.8–17.510.05.5–18.0
Deep sutures0.20.02–1.30.20.02–1.6
Shape (linear)2.10.96–4.72.40.9–6.1
Edges (smooth)2.20.3–16.70.40.05–3.2
Length0.50.4–0.70.60.4–0.8

Topical anesthetics were used in 48% of the lacerations closed with a TSA while local infiltration of anesthetics was only used in 9% of the wounds. Thus, 43% of lacerations repaired with a TSA required no anesthetic at all. In contrast, a local anesthetic was injected in 87% of the sutured wounds (p < 0.001) and in 73% of the stapled wounds (p < 0.001).

Discussion

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

This study demonstrates that TSAs are used to repair approximately one in eight lacerations in the ED, and that their use is mostly limited to short lacerations, children, and facial lacerations. While TSAs are appropriate for a wide range of wounds, they are not appropriate for all wounds. For example, high tension wounds should not be closed with TSAs alone. In addition, TSAs cannot be used in hairy areas, in areas subject to frequent moisture, or in patients with allergies to cyanoacrylates or formaldehyde.

It is unclear why emergency practitioners tend to limit the use of TSAs to children, facial wounds, and short lacerations. The focus on children is rather intuitive. Of all patients with lacerations, the ones that have the most to benefit from a noninvasive, nonthreatening, painless closure device that eliminates the need for device removal are children. However, all of these advantages that are associated with the TSA also apply to adults. Indeed, when surveyed, most adult patients would prefer the use of TSA over sutures or staples.5 With regards to limiting the use of TSA to facial wounds, the causes are less obvious or clear. There is now a large body of evidence demonstrating the efficacy and safety of the TSA (mostly octylcyanoacrylate) for a wide range of ages and body locations including the face, chest, abdomen, back, scalp, genitalia, and both lower and upper extremities.1,2,6,7 With regard to the tendency to limit the use of TSA to short lacerations, it is possible that practitioners consider long wounds more likely to dehisce than shorter wounds and therefore avoid TSA in long wounds. However, with long wounds, the tension is distributed over the entire length of the wound. Thus the wound tension per unit length is similar to shorter wounds. Indeed, there is evidence that the TSA octylcyanoacrylate performs comparably to sutures for long as well as short lacerations and surgical incisions. A prospective randomized clinical trial specifically designed to evaluate the performance of octylcyanoacrylate in long surgical incisions enrolled 217 patients with wounds ranging in size from 4 to 69 cm (mean = 16 ± 3 cm).8 The authors found that 10-day healing rates were excellent for both sutured and glued wounds and similar infection rates in glued wounds (3% vs. 7%; p = 0.11). In contrast, due to their lower strength and flexibility,9 the use of the butylcyanoacryaltes TSA has generally been limited to wounds less than 4 to 8 cm in length. Thus, many physicians may believe that all TSAs have similar properties and their use should be avoided in long incisions and lacerations.

Limitations

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

This study was conducted at a single academic center with considerable experience using TSAs. Thus these results may not generalize to other settings. However, if anything, our results probably overestimate the use of TSAs, given our prior familiarity with and focus on TSA use in the ED. Second, this was a retrospective study that did not prospectively evaluate why practitioners chose to use TSAs or not. Thus our study is limited to associations between predictor variables and TSA use. Finally, our study was limited to the summer months. It is possible that factors such as temperature and humidity may have affected practitioner choice of wound closure device that may not be reflective of other seasons. A prior study in volunteers has shown that frequent exposure to moisture hastens sloughing of octylcyanoacrylate.10

Conclusions

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References

Our study demonstrates that topical skin adhesives are used to close approximately one in eight lacerations in the ED. The use of topical skin adhesive is mostly limited to short, pediatric, and facial lacerations.

References

  1. Top of page
  2. Abstract
  3. Methods
  4. Results
  5. Discussion
  6. Limitations
  7. Conclusions
  8. References