Did you wait 8 hours after getting bitten by that rottweiler before coming to the ED? Anand explains why it's probably not the dog's bacteria that's gonna give you a nasty infection. What's that? It was on your head? Oh, never mind then, you're gonna be fine.
Jennifer M. - March 9, 2014 8:01 PM
If you have a pt who is greater than 8 hours out from dog bite and dog bite is on the face, do you recommend suturing and antibiotics? Thanks
Tor K. - March 13, 2014 8:10 PM
I suspect a lot of wounds that we close with sutures would have decent outcomes if allowed to close secondarily, especially those wounds not on the face or hands. I am more than happy to use the dog bite rationale as a reason not to close a wound which will probably heal fairly well on its own.
Please don't take that away from me.
Sean G., M.D. - March 31, 2014 10:55 AM
I agree totally with Tor K... I think there was far too much emphasis here on how suturing improves cosmesis...really? For wounds under 2 cm it really does not. Particularly in highly vacularized tissue and closing these wounds clearly will increase to some extent chance of infection. The longer I practice the more I understand my early mentor Dr David Wagner, he often stepped back and did nothing...we too often feel we must get our grimey paws involved. I was always trained if the wound is very large and relatively fresh, clean it well, close it and place on abx. if it is pretty small, particularly on hands leave it alone. I think that advice from the 90's holds true today, and the tenor of this segment(that we can make a big difference in cosmesis) is just incorrect. Facial wounds depending on their physics(vertical horizontal, curvolinear etc) should be dealt on a case by case basis. Some will be improved w sutures some will not.
Anand S. - April 1, 2014 3:27 PM
Below is a comment sent in:
I am a retired surgeon working ER full time. I have some comments about the 3/14 section on abscess drainage and also the section on dog bites.
1) The cruciate incision was dismissed without discussion. It works well to facilitate continued drainage as the elasticity of the skin contracts the released skin keeping the area from epithelializing as easily and allows no wick or drain more often. I have used it for decades with good success. Naturally, I don't use it where cosmesis is an issue.
2) The Greek study on cosmetic result from open tx vs primary closure ignores the basics of wound healing. The stages of wound healing are hemostasis, inflammation, granulation, scar formation and scar contraction. Scar contraction does not start for 6-8 weeks after injury. While a better cosmetic result may be found after closure vs secondary healing, to evaluate and rate the cosmesis after only 4 weeks is mis leading and "bad science"
I agree on your thoughts with the cruciate incision. Not widely taught but may play a role. However, if it's a simple abscess, I'd like to move more towards small incision and closure if possible in select patients.
It would be nice to have data after 4 weeks. However, it seems to me that if the wound healing is worse at 4 weeks without closure, it'll likely be worse at 6-8 weeks as well.
Amelia R. - March 1, 2015 6:44 AM
Help needed re puncture wounds. Our group (Urgent Care) is having a debate about this. The hand surgeons are advising irrigation for puncture wounds. You all seem to think this increases risk of infection but I can't find any study citations to share. Are there any good studies on this? Thanks