First of all, loose closure is closure as stated –wounds will close unless you force them open with a drain or loop type device (abscess treatment). So don’t loosly suture any wound that is high risk of infection – that is bad for the patient. You should use delayed primary closure – “proven” in war after war and in wilderness medicine for 100 years. I am surprised that the speaker thinks that delayed primary closure (DPC) is not an option for the ER. All DPC requires is one additional visit on day 4 for wound closure with a reduction in infection risk of a high risk wound that is closed from 30-50% down to less than 5%. I would say that NOT scheduling a revisit and either getting closed and infected, or left open for closure by secondary intention if far more inconvenient to patients. We tell patients to revisit us all the time for worsening abdominal pain, repeat dosing of antibiotics, etc so we should not think DPC is not an option. We should all discuss DPC with our partners so we are on the same treatment path, wash dirty wounds out, pack them and have them return in 4 days for PRIMARY closure – this results in just as fast healing, just as good a cosmetic result and 10 times less infection risk. The literature on this is not level 1 evidence but there is enough out there to suggest DPC as superior for dirty wounds. (Lowry and Curtis 1946, 1950, Rosenfeld 1946, shepard 1967, Edlich 1969, recent data from Thailand Tsunami treatments, etc). Unfortunately we have “rediscovered” this technique in every major war in the last 100 years, then promply forgotten it. In the the Indonesian/Thai Tsunami 15 years ago – “loose closure” or any closure of dirty wounds led to not only increased infection but far higher mortality. Stop shortcutting, learn about DPC and just do it. Antibiotics do NOT impact infection of dirty wounds and are a dis-service to our patients. " Despite strong .. evidence .. that wound management with delayed closure is the treatment of choice for contaminated wounds, surgeons continue to rely on antibiotics to manage high risk wounds. .. The temptation to rely upon antibiotics as a short cut .. continues to create unnecessary risk to the patient, .. The reluctance of many surgeons to leave the wound open seems to be an emotional response to perceived patient dissatisfaction. This is a serious mistake, since the risk benefit analysis... shows clear benefit from open management with negligible risk." Smilanich 1995 Tim Wolfe, MD
Thank you for your very thoughtful and detailed comments. We couldn’t agree with you more. DPC is an excellent and under-utilized option. I work between ER and urgent care practice, and have used exactly this strategy: booking my ED patients for follow up in my urgent care clinic (after anesthesia, irrigation, exploration, debridement and local wound care in the ED) in 4-5 days and performing delayed primary closure (when appropriate), with excellent results. We feel this would also be a great option for rural settings, and for family practitioners who can ensure good follow up with their patients.
Our claim about the difficulty with delayed primary closure Is largely logistical and applies to the urban emergency department setting. I've heard from many practitioners when I advocate for DPC that it can be challenging to arrange follow up ( and count on your patient to get there reliably!). As you aptly point out, it would also require complete buy-in from a physician group to create a policy where this is done within a single hospital, which can be tough to do with larger physician groups.
All of these logistical challenges are probably why the most recent Cochrane review on best evidence for delayed primary closure (Eliya-Masamba, Banda 2013) still couldn’t firmly support it as a well studied technique for traumatic lacerations.
We are with you in hoping that this excellent strategy for wound care gains some traction. Thanks for your thoughtful comments!
I agree DPC does not achieve Cochrane level of evidence just like many treatments we do in medicine and hear about every month on EMRAP. That said, it is crystal clear that primary closure of a dirty wound does achieve high level evidence to increase morbidity and mortality, while secondary intention closure leads to long delays in healing, discomfort, scarring and reduced ability to return to prior levels of activity. Hence the military figuring this out 100 years ago allowing them to get a soldier back into service fast without a serious infection- DPC (even of infected punji stick wounds ). What would you do for your spouse? Or child? of friend? Leave them open and uncomfortable for weeks? Our practice is next to a mountain bike trail - we see daily dirty macerated knee and elbow lacerations. After erroneously closing some of these and having them disabled for weeks with deep infections, open wounds, antibiotics, we figured out DPC was a great option and have been able to dramatically reduce infections using this concept for 20 years. I have to disagree that it is too complex for a large ER group to logistically adapt to. It is super easy compared to our adaptations to stroke care, STEMI, etc, This is a nothing change in practice relative to those and the info can be disseminated pretty quickly if there is a person in the group motivated enough to improve patient care on this issue and create a treatment pathway. If we can change every time there is a core measure (some which are not so good for the patient) I suspect we can make this change as well. Sorry, I just fundamentally disagree that this is too difficult for emergency physicians to understand or implement even in a large group setting (how did you do it for door to needle times for STEMI, stroke), I know from my own practice in a non-rural moderately sized city and group (Salt lake City) that it is pretty easy to adapt to this practice and you do not need an urgent care clinic or wound clinic to do it. Just have them come back to the ER - I usually suggest the best time when a new doctor or extender is coming on shift so their care is not overly delayed, but even with a delay it is much less hassle in the long run than the other healing options. If the patient fails to return - well then they are getting the next most optimal care - healing by secondary intention, so it does not HURT their outcome other than delaying their healing and giving them a scar but that was their choice.
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Timothy R. W. - November 15, 2018 8:03 PM
First of all, loose closure is closure as stated –wounds will close unless you force them open with a drain or loop type device (abscess treatment). So don’t loosly suture any wound that is high risk of infection – that is bad for the patient. You should use delayed primary closure – “proven” in war after war and in wilderness medicine for 100 years. I am surprised that the speaker thinks that delayed primary closure (DPC) is not an option for the ER. All DPC requires is one additional visit on day 4 for wound closure with a reduction in infection risk of a high risk wound that is closed from 30-50% down to less than 5%. I would say that NOT scheduling a revisit and either getting closed and infected, or left open for closure by secondary intention if far more inconvenient to patients. We tell patients to revisit us all the time for worsening abdominal pain, repeat dosing of antibiotics, etc so we should not think DPC is not an option. We should all discuss DPC with our partners so we are on the same treatment path, wash dirty wounds out, pack them and have them return in 4 days for PRIMARY closure – this results in just as fast healing, just as good a cosmetic result and 10 times less infection risk. The literature on this is not level 1 evidence but there is enough out there to suggest DPC as superior for dirty wounds. (Lowry and Curtis 1946, 1950, Rosenfeld 1946, shepard 1967, Edlich 1969, recent data from Thailand Tsunami treatments, etc). Unfortunately we have “rediscovered” this technique in every major war in the last 100 years, then promply forgotten it. In the the Indonesian/Thai Tsunami 15 years ago – “loose closure” or any closure of dirty wounds led to not only increased infection but far higher mortality. Stop shortcutting, learn about DPC and just do it. Antibiotics do NOT impact infection of dirty wounds and are a dis-service to our patients.
" Despite strong .. evidence .. that wound management with delayed closure is the treatment of choice for contaminated wounds, surgeons continue to rely on antibiotics to manage high risk wounds. .. The temptation to rely upon antibiotics as a short cut .. continues to create unnecessary risk to the patient, .. The reluctance of many surgeons to leave the wound open seems to be an emotional response to perceived patient dissatisfaction. This is a serious mistake, since the risk benefit analysis... shows clear benefit from open management with negligible risk."
Smilanich 1995
Tim Wolfe, MD
Brian L. - November 16, 2018 10:31 PM
Hi Tim,
Thank you for your very thoughtful and detailed comments. We couldn’t agree with you more. DPC is an excellent and under-utilized option. I work between ER and urgent care practice, and have used exactly this strategy: booking my ED patients for follow up in my urgent care clinic (after anesthesia, irrigation, exploration, debridement and local wound care in the ED) in 4-5 days and performing delayed primary closure (when appropriate), with excellent results. We feel this would also be a great option for rural settings, and for family practitioners who can ensure good follow up with their patients.
Our claim about the difficulty with delayed primary closure Is largely logistical and applies to the urban emergency department setting. I've heard from many practitioners when I advocate for DPC that it can be challenging to arrange follow up ( and count on your patient to get there reliably!). As you aptly point out, it would also require complete buy-in from a physician group to create a policy where this is done within a single hospital, which can be tough to do with larger physician groups.
All of these logistical challenges are probably why the most recent Cochrane review on best evidence for delayed primary closure (Eliya-Masamba, Banda 2013) still couldn’t firmly support it as a well studied technique for traumatic lacerations.
We are with you in hoping that this excellent strategy for wound care gains some traction. Thanks for your thoughtful comments!
Timothy R. W. - November 20, 2018 10:01 AM
I agree DPC does not achieve Cochrane level of evidence just like many treatments we do in medicine and hear about every month on EMRAP. That said, it is crystal clear that primary closure of a dirty wound does achieve high level evidence to increase morbidity and mortality, while secondary intention closure leads to long delays in healing, discomfort, scarring and reduced ability to return to prior levels of activity. Hence the military figuring this out 100 years ago allowing them to get a soldier back into service fast without a serious infection- DPC (even of infected punji stick wounds ). What would you do for your spouse? Or child? of friend? Leave them open and uncomfortable for weeks? Our practice is next to a mountain bike trail - we see daily dirty macerated knee and elbow lacerations. After erroneously closing some of these and having them disabled for weeks with deep infections, open wounds, antibiotics, we figured out DPC was a great option and have been able to dramatically reduce infections using this concept for 20 years. I have to disagree that it is too complex for a large ER group to logistically adapt to. It is super easy compared to our adaptations to stroke care, STEMI, etc, This is a nothing change in practice relative to those and the info can be disseminated pretty quickly if there is a person in the group motivated enough to improve patient care on this issue and create a treatment pathway. If we can change every time there is a core measure (some which are not so good for the patient) I suspect we can make this change as well. Sorry, I just fundamentally disagree that this is too difficult for emergency physicians to understand or implement even in a large group setting (how did you do it for door to needle times for STEMI, stroke), I know from my own practice in a non-rural moderately sized city and group (Salt lake City) that it is pretty easy to adapt to this practice and you do not need an urgent care clinic or wound clinic to do it. Just have them come back to the ER - I usually suggest the best time when a new doctor or extender is coming on shift so their care is not overly delayed, but even with a delay it is much less hassle in the long run than the other healing options. If the patient fails to return - well then they are getting the next most optimal care - healing by secondary intention, so it does not HURT their outcome other than delaying their healing and giving them a scar but that was their choice.