Many wound care techniques originate in antiquity, and despite tremendous advances, dogma still clouds common practices.

Recent literature has sought to disprove long-held beliefs and introduce simpler methods. Topical anasthetics containing epinephrine may be a safe and effective adjunct to injected local anesthetics for the digits. Tap water may be an inexpensive alternative for wound irrigation. Clean, nonsterile gloves may be adequate for use during closure of routine lacerations. Tissue adhesive has become a common method for wound closure, and modications have been introduced to overcome many of the products shortfalls. Absorbable suture may be a cosmetically viable option for repairing skin lacerations. Finally, evaluation of the need for tetanus prophylaxis is an important, but possibly underused, nish to the wound care process. Clin Ped Emerg Med 5:239-245. 2004 Elsevier Inc. All rights reserved.

New Concepts in Wound Management

By Robert D. Schremmer
KANSAS CITY, MISSOURI
NE OF THE FIRST written records of wound care is included in an ancient Egyptian papyrus thought to originate circa 1600 BC. The document describes techniques for wound repair using adhesive tape and sutures and occasionally leaving wounds open while applying fresh meat to facilitate healing.1 It seems that although some techniques have undergone tremendous advancement in the last 3,500 years, many of the fundamentals of laceration repair have endured. Control of pain and hemorrhage and prevention of infection and unsightly scarring remain primary goals of wound management. Modern technology often facilitates these goals through pharmaceuticals for pain relief, mechanisms for preserving sterility, and new materials for approximating wound edges. While these advances have been signicant, many dogmatic views are still held with regard to the process of wound management. It is in the spirit of the ancient Egyptians and their insightful approach to medicine that we endeavor to refute doctrine and advance efcient techniques of wound care.

Local Anesthesia
From the Division of Emergency Medical Services, Childrens Mercy Hospitals and Clinics, Kansas City, MO. Address reprint requests to Robert D. Schremmer, MD, Division of Emergency Medical Services, Childrens Mercy Hospitals and Clinics, 2401 Gillham Road, Kansas City, MO 64104. E-mail: rschremmer@cmh.edu 1522-8401/$see front matter 2004 Elsevier Inc. All rights reserved. doi:10.1016/j.cpem.2004.09.001

The rst step in repairing any laceration is relieving the patients pain and assuring that as little pain as possible will result from the treatment. Pain control for wound closure is often achieved through topical application or subcutaneous inltration of a local anesthetic. Topical anesthetics include liquids or gels containing 0.5% tetracaine, 0.05% epinephrine (adrenaline) and 11.8% cocaine (TAC) or 4% lidocaine, 0.1% epinephrine and 0.5% tetracaine (LET). Obvious advantages of these topical agents include painless application and reduced patient anxiety. Both mixtures, however, must be applied for at least 20 to 30 minutes, potentially adding to the patients time in department. Other
N EW CON CEPTS I N W OUN D MA N A G EMEN T / ROB ERT D . SCH REMMER 239

240

N E W CONCEP T S IN W O U ND M A NA GEM ENT / R OB ERT D . SCH REMMER

difculties encountered with TAC result from the cocaine component and include high cost, necessary drug regulatory measures, and rare occurrences of seizures and death when applied to mucous membranes.2 Both agents seem to be more effective when applied to the highly vascularized, thinner skin of the face. Conventional wisdom dictates that neither mixture should be applied to digits or other areas of end-arteriolar circulation. One study,3 however, involving digit lacerations in 63 children concluded that LET is safe and effective for simple nger lacerations, especially those on the dorsal surface. Seventy percent of patients with dorsal nger lacerations needed no further anesthesia, while only 43% of patients with ventral wounds experienced complete pain control from LET. No patient experienced signs of digital ischemia as a result of the topical epinephrine application. EMLA cream, a eutectic mixture of local anesthetics, has been available for procedures involving intact skin such as intravenous (IV) catheter insertion and lumbar puncture. This emulsion of agents containing 2.5% lidocaine and 2.5% prilocaine manifests the chemical property of having a lower melting point than the component agents alone and is a liquid at room temperature. Some research has been done to determine if EMLA is a useful anesthetic for laceration repair, but the results have been mixed. When compared with LET, EMLA was found to provide inferior anesthesia based on a greater proportion of patients who required additional lidocaine inltration.4 Similarly, Singer and Stark5 found no difference in local anesthesia between LET and EMLA applied at the time of patient presentation to triage. The mean duration of EMLA application was only 40 minutes, however, which is less than its recognized time required for adequate anesthesia. Another study6 found EMLA to lend anesthesia superior to TAC for simple extremity lacerations, but it required a longer application time, 26 minutes more on average. One alternative to consider that would accomplish adequate pain control and improve emergency department (ED) efciency is the application of a topical anesthetic to lacerations at the time of presentation to triage. It is common practice in many EDs for triage nurses to administer oral analgesics or antipyretics, obtain rapid antigen diagnostic tests, and order radiographs for injured extremities, all according to well-dened protocols. The application of a topical anesthetic equivalent to LET at triage has been shown to signicantly reduce the time in the ED for repair of simple lacerations.7 In this study, no complications were

experienced as the result of prolonged exposure to the anesthetic, lasting as long as 2 hours. Time for adequate anesthesia seems to be one of the greater disadvantages of EMLA, but not the only one. Prilocaine metabolites from EMLA application have been implicated in methemoglobinemia in infants younger than 3 months, with an increased risk for premature neonates.8 Older infants and children generally tolerate the mixture well and only occasionally encounter local side effects such as contact dermatitis and temporary erythema. L-M-X (formerly ELA-max; Ferndale Laboratories, Inc., Ferndale, MI) is a more recently developed product. Topical 4% lidocaine delivered in a liposomal vehicle, L-M-X has the advantage of shorter application time and longer duration of action. It has been found to be as effective as EMLA for pain control,8 and no serious adverse effects have been reported. Unlike EMLA, an occlusive dressing is not mandatory for application but is recommended for patients likely to rub off the cream before completion of an adequate application time. Unfortunately, no data are available regarding the use of L-M-X for laceration repairs. The cream is currently approved for use in pain control on intact or nonintact skin, such as on minor cuts, burns, and abrasions, but the manufacturer does not currently advocate its use in wound closure. Local inltration of the wound with lidocaine usually accomplishes complete anesthesia of the site, but at the cost of increased patient anxiety and pain. The pain of injection can be reduced by using a long, ne (27 or 30) -gauge needle; injecting at a slow rate; warming the medication to body temperature; and buffering with sodium bicarbonate.2 Patient distraction is another effective way to reduce injection pain. Epinephrine is frequently added to the anesthetic to improve hemostasis and prolong the duration of anesthesia. Nerve blocks can be an effective alternative to local inltration for prevention of pain. The most common location where blocks are used is for laceration repairs involving the digits. Traditionally, lidocaine without epinephrine has been advocated for digital blocks because of fear of ischemia from vasoconstriction. In fact, literature reviews conducted by Denkler9 and Wilhelmi et al10 found no instance where lidocaine with epinephrine was the sole cause of nger ischemia. Details from many of the citations of epinephrine-induced ischemia are incomplete, but factors contributing to the ischemia include use of older anesthetics such as cocaine, hot soaks post-repair, use of tourniquets, injection of excessive volume, and presence of infection. Wilhelmi et al10 found in their trial of 60

N EW CON CEPTS I N W OUN D MA N A G EMEN T / ROB ERT D . SCH REMMER

241

digital blocks that no complications occurred in the 31 who received lidocaine with epinephrine. Similarly, in an unpublished study, Andrades11 concluded that lidocaine with epinephrine is safe for digital blocks and offers the advantages of quicker onset of action, reduced need for subsequent doses, improved hemostasis, and longer postoperative anesthesia. Authors recommend using epinephrine in concentrations of 1:200,000 or less, using no more than 1.5 mL on each side of the digit, and using a dorsal approach with a ne needle near the metacarpal head. Lidocaine with epinephrine is discouraged in patients with peripheral vascular disease, hyperthyroidism, severe hypertension, cardiac disease, or pheochromocytoma,10 or those with infection or trauma at the base of the proximal phalynx.

Irrigation and Sterile Technique

Once appropriate analgesia or anesthesia is achieved, the next step in wound repair is to ensure that contaminated material is cleaned out of the wound and surrounding skin. This goal is commonly accomplished by irrigation of the wound with sterile saline. Irrigation pressures in excess of 8 psi recommended for adequate decontamination12 can be obtained using a 35-mL syringe attached to a 19-guage needle or a splashguard (Zerowet, Inc., Palos Verdes, CA). Heavily contaminated wounds can be cleaned using a nonionic surfactant cleanser (Shur-Clens, ConvaTec, Division of E.R. Squibb and Sons, Inc., Princeton, NJ) and soft scrub brush. The traditional choice of irrigation solution is sterile saline. This is one process where dogma has persisted because of a paucity of data. Wound infection is the most common severe complication of lacerations.13 Although preventing infection by irrigation with a sterile solution is intuitive, some studies have shown that no greater risk of infection is encountered when a wound is irrigated with tap water. An animal model14 found that irrigation with tap water eliminated more bacteria from wounds than irrigation with normal saline from a 20-mL syringe with splashguard. A prospective clinical trial in a pediatric emergency department found no differences in rate of infection between tap-water irrigated wounds and those cleansed with sterile saline.15 There are several advantages of tap water that contribute to its success as an irrigant. Among these benets are the much larger volume of uid used from a faucet; the constant high-pressure ow supplied by most city water supplies; the cheap,

plentiful supply of tap water; and the elimination of the need for extra supplies such as syringes, splashguards, and basins. The water supplies of most areas in the United States are chlorinated and monitored closely for pathogenic bacteria, so there is little reason to expect that the use of tap water would contribute to wound infection rates. Certainly, many minor wounds are irrigated with tap water daily in homes throughout the country without any adverse effects. Most wounds can simply be placed under a faucet and irrigated for about 30 seconds. Warm or lukewarm water should be used for patient comfort. For wounds located on body parts that are awkward to place in a sink, a length of tubing can be attached to the faucet and used to reach the patients laceration, or the more traditional water or saline in a basin may be employed. One observational study16 questions the need for any irrigation of clean wounds on the face and scalp. These highly-vascularized areas generally have low rates of infection. Excluding high-risk patients (those with kidney disease, diabetes, immunocompromised state) and high-risk wounds (those with fascia or muscle involvement, overlying vital structures, open fractures, involvement of the intraoral mucosa, visible contamination, with foreign bodies present, with delayed presentation), the authors found no difference in the rate of infection between those repaired with and without irrigation. Also, wounds that were irrigated displayed a nonsignicant reduced likelihood of optimal cosmetic appearance at the time of suture removal. Local trauma from the process of irrigation may, in fact, contribute to scarring. This study certainly raises an important question about the need for vigorous irrigation of clean lacerations in areas not prone to infection. Another precaution commonly taken during repair of lacerations to minimize risk of infection is the use of sterile surgical gloves. The rationale is that even clean gloves may be contaminated with pathogenic bacteria. Usually packaged in boxes of 100, the gloves may have been touched by previous personnel removing other gloves from the box. Sterile gloves, however, are more expensive and often necessitate an assistant to accomplish the procedure. In fact, no data are available to support the use of sterile gloves during routine laceration repair. One recent prospective single-blinded study, however, reported no difference in wound infection rates when clean, nonsterile boxed gloves were used in wound closure.17 One caveat noted in the report was that damp boxes containing gloves may be more likely to contain mold and should be

242

N E W CONCEP T S IN W O U ND M A NA GEM ENT / R OB ERT D . SCH REMMER

avoided. Certainly, caution should be exercised when decisions about usual practice are made based on evidence from a single study, but more work may demonstrate support for abandoning surgical gloves during routine laceration repair. Advantages would include increased convenience and reduced cost.

Laceration Closure Techniques

In August 1998, the Food and Drug Administration (FDA) approved the rst tissue adhesive for use in the United States. Although cyanoacrylates have been used for many years in Canada and Europe, 2-octylcyanoacrylate (2-OCA; Dermabond, Ethicon, Inc., Closure Medical Corp., Raleigh, NC) is the rst to be considered medical grade because of improved tensile strength over the butylcyanoacrylates and fulllment of standards for nontoxic medical devices.18 The US introduction of 2-OCA was much anticipated, and the demand for the product was immediately great. In the rst month and a half of availability, $2.7 million worth of product was sold.19 Tissue adhesives were lauded as the cutting edge of laceration repair, soon to render sutures obsolete. The advantages of rapid and painless application, increased patient convenience, relatively low cost and ease of use were quickly recognized. Marketing for the product was extensive, from pharmaceutical representative visits educating physicians and hospitals to magazine advertisements and news releases specically targeting parents and patients. As the use of 2-OCA grew, its shortfalls became more familiar, causing many practitioners to lose interest and use the product more selectively. Several studies have been conducted to evaluate the merits of 2-OCA in laceration repair. A Cochrane review20 analyzed 13 articles representing 9 studies and concluded that tissue adhesive is an acceptable option for the repair of simple wounds and provides rapid application with less pain than conventional wound closure. One caveat mentioned, however, is a small increase in the rate of wound dehiscence. While single studies have not had the power to show a signicant complication rate, pooled data examined by the Cochrane review found a 4% risk difference versus sutures. The cosmetic outcome of wounds repaired with 2-OCA has been found to be equivalent to that achieved with sutures,18 so it is unknown what clinical signicance the increase in dehiscence represents. Furthermore, the study conducted for FDA approval of 2-OCA found a trend toward an increased rate of infection in wounds closed with tissue adhesive.

Hollander12 postulates, however, that any increase in likelihood of infection is due to inadequate cleansing because local anesthetic was not applied. In addition to thorough irrigation of wounds closed with 2-OCA, other cautions must be heeded to prevent complications. The wound edges should be dry and well approximated. Any adhesive that is placed within the wound will impair healing and possibly produce a foreign-body reaction. Good wound hemostasis should be assured prior to application or blood can become sealed into the adhesive, producing a displeasing appearance. Due to the liquid nature of 2-OCA, runoff can be a common complication for the inattentive or inexperienced practitioner. Anecdotes of patients eyes glued shut, practitioners gloves attached to the skin of patients, and tissue adhesive staining of clothing are all too common. Ointments or acetone may be applied to areas of unintentional runoff to speed removal of the adhesive. For that reason, antibacterial ointments should not be used after laceration repair. Adhesive strips and bandages may similarly strip the dried adhesive from the wound, so they too should be avoided. Since the initial release of 2-OCA for use in the United States, several modications have been made in the product and packaging, especially to reduce the problem of runoff. The rst change in the product was the addition of the chisel-tip applicator. Previously, the only available applicator was a rounded, dome-shaped tip that tended to hinder precision in the hands of an inexperienced user. Development of the new tip was an effort to add accuracy to the delivery of the liquid adhesivethe practitioner now has the choice of painting a wide strip of adhesive for larger wounds or, by turning the applicator 90, a narrow strip for smaller lacerations. Using either applicator tip provides equivalent wound approximation; it is a matter of personal preference which is used. Both applicator tips will continue to be available. Another tissue adhesive innovation to correct the problem of runoff is High Viscosity Dermabond. This product has been available since January 2003. It is another formulation of 2-OCA, differing only in its increased viscosity. The newer product has a syruplike viscosity, reducing the likelihood that it will ow away from the wound. The newest modication to counter runoff is the Dermabond ProPen. This device contains high-viscosity 2-OCA and is intended to increase the control of application. The device is held like a pencil, and a large button on the side is pressed to release the adhesive in a steady ow. The pen comes with

N EW CON CEPTS I N W OUN D MA N A G EMEN T / ROB ERT D . SCH REMMER

243

interchangeable tips including a new narrow applicator for delivery of a thin line of adhesive. Now that 2-OCA has been available for use for several years, its advantages and disadvantages are becoming clearer. There is little doubt that wound closure is more rapid with tissue adhesive than sutures, and patients prefer the greatly reduced amount of pain involved, just as parents prefer the increased convenience of no return visit for suture removal. Certainly, care must be exercised when identifying patients and lacerations appropriate for skin adhesive. Contraindications still include evidence of infection, wounds on mucosal surfaces or mucocutaneous interfaces, injury to dense hairbearing areas, or hypersensitivity to cyanoacrylates or formaldehyde. Relative contraindications include use in areas of high tension such as joints and likelihood that the patient (such as a child) will pick off the adhesive before the wound heals. Ongoing developments have improved the usefulness of 2-OCA, so problems such as runoff do not happen as often. Further work should be done to better elucidate the issues of wound infection and dehiscence and see if these complications occur at a clinically signicant rate. Sutures remain as the conventional, time-honored technique for repairing lacerations. This method is particularly useful in situations where tissue-adhesive closure is not appropriate such as high-tension areas over joints and with lacerations that have higher risk of infection. Sutures have the advantage of greater tensile strength than tissue adhesives and, therefore, lower the rate of wound dehiscence. Most often, nonabsorbable sutures are used to close the skin surface, necessitating removal some days later. Absorbable suture is used to approximate the subcuticular areas in deeper lacerations. Deep sutures assist in approximating wound edges by decreasing tension and lessening dead space in which transudate and blood could accumulate. A better cosmetic outcome is thought to result. One relative contraindication to deep suture placement is contamination of the laceration. The option to close skin lacerations with absorbable suture offers the patient increased convenience due to the lack of need to return for suture removal. A survey performed as part of a study documenting the efcacy of absorbable sutures in pediatric scalp lacerations showed that 79% of parents would prefer not to return to the ED for suture removal.21 This information is hardly an epiphany. Generally, the tensile strength of many absorbable sutures lasts from 2 to 4 weeks, which is adequate time for the laceration to heal (Table 1). Tissue reactivity to absorbable materials tends to be

TABLE 1. Tissue Half-Life of Absorbable Suture

Suture Material Gut Poligecaprone 25 (Monocryl) Chromic Gut Polyglactin 910 (Vicryl) Polyglyconate (Maxon) Tissue half-life (in days) 5-7 7 10-14 28 28-36

Trott AT: Instruments and suture materials, in: Wounds and Lacerations: Emergency Care and Closure, 2nd ed. St. Louis, MO, Mosby, 1997, pp. 102-116. higher than to nonabsorbable suture, so concern about increased scar formation has traditionally discouraged the use of absorbable stitches for skin closure (see Table 1). Some work, however, has been done to shed light on the beliefs surrounding absorbable sutures. One study22 compared the use of plain gut and nylon on uncomplicated pediatric laceration repairs. No differences in a visual analog scale (VAS) or optimal wound evaluation score (WES) were found at the 4-month follow-up by a plastic surgeon who did not know which type of suture was used. These results suggest that cosmesis is equivalent for wounds closed with absorbable and nonabsorbable suture. Similarly, 44 wounds from resection of skin cancers on the head and neck areas of adult patients that were closed halfway with polyglactin 910 (Vicryl Rapide; Ethicon, Inc., Somerville, NJ) and halfway with polypropylene (Prolene; Ethicon, Inc.) were found to show no difference in scarring23 This is not new information. Studies in the 1970s and 1980s reported the use of catgut suture to close skin wounds.24,25 These papers suggest that one author had used absorbable material since the late 1940s. Indeed, a 1990 letter to the editor26 submits that absorbable sutures are commonplace in EDs in the United Kingdom. Perhaps the practice is also more common in the United States than is published or widely known.

Tetanus Prophylaxis
The nal step in wound management, after appropriately dressing the traumatized area, is to double-check the patients tetanus immunization status. Tetanus prophylaxis has been available since World War II and is very safe and effective. The American Academy of Pediatrics Committee

244

N E W CONCEP T S IN W O U ND MA NA GEMENT / R OB ERT D . SCH REMMER

on Infectious Diseases has published guidelines for tetanus prophylaxis in routine wound care.27 For most patients with a history of at least 3 doses of tetanus toxoid in primary immunization, protection lasts 10 years. Those patients who sustain clean, minor wounds less than 10 years after their last tetanus toxoid require no further prophylaxis. Tetanus-prone wounds (contaminated wounds, punctures, bites, crushing wounds, burns, etc.) necessitate a booster tetanus toxoid vaccine if sustained more than 5 years after the last dose. Patients who were given less than 3 doses of tetanus toxoid in primary immunization or who do not know how many were received should receive tetanus toxoid at the time of wound care. If the wound is judged to be more serious than a clean, minor wound, tetanus immunoglobulin (TIG) should also be given. Although these guidelines seem relatively uncomplicated, there is evidence that they are not well followed. A study published in 200428 examined tetanus prophylaxis practice in a general ED. The authors found that 35% of patients were not provided adequate prophylaxis. Surprisingly, none of the 504 patients who had sustained tetanusprone wounds and had not completed primary immunization were given appropriate prophylaxis (tetanus toxoid and TIG). Also, physicians failed to give the proper booster vaccine to 21% of patients with history of completed primary immunization who had sustained a tetanus-prone wound more than than 5 years after their last dose of tetanus toxoid. On the other hand, the study also found that many adults have sufcient protective titers despite a history of underimmunization. Certain subpopulations, however, are more likely to have low tetanus protection, including the elderly, immigrants, and people with limited formal education. Although it is unknown how often pediatric patients fail to receive adequate prophylaxis, this data should serve as a warning that only careful vigilance will keep this easily preventable disease from becoming more common.

New topical creams and expanded indications for the currently available anesthetics will enhance patient comfort during laceration cleaning and repair. Irrigation with tap water is a safe, effective and economic method of cleaning wounds, and perhaps even the use of sterile gloves is superuous in preventing wound contamination. Several alternative wound-closure materials are currently available including tissue adhesive in an array of applicators and formulations, adhesive strips, staples, and nonabsorbable as well as absorbable suture material. Finally, prophylaxis for tetanus is a simple, if possibly underused, technique. Further research into new materials and procedures will only improve our care of patients who have sustained skin trauma.

References
1. Pahor AL: Medicine and Surgery in Ancient Egypt. Centre for the History of Medicine, University of Birmingham School of Medicine Web Site. Available at: http://medweb.bham.ac.uk/histmed/pahor.html. Accessed February 27, 2004. 2. Kennedy RM, Luhmann JD: Pharmacological management of pain and anxiety during emergency procedures in children. Paediatr Drugs 3:337-354, 2001. 3. White N, Kim M, Brousseau I, et al: The anesthetic effectiveness of lidocaine-adrenaline-tetracaine gel on the nger. Acad Emerg Med 10:474, 2003 (abstr). 4. Krief W, Sadock V, Tunik M, et al: EMLA vs LET for topical anesthesia in wound repair. Acad Emerg Med 9:398, 2002 (abstr). 5. Singer AJ, Stark MJ: LET versus EMLA for pretreating lacerations: A randomized trial. Acad Emerg Med 8:223-230, 2001. 6. Zempsky WT, Karasic RB: EMLA versus TAC for topical anesthesia of extremity wounds in children. Ann Emerg Med 30:163-166, 1997. 7. Priestley S, Kelly AM, Chow L, et al: Application of topical local anesthetic at triage reduces treatment time for children with lacerations: A randomized controlled trial. Ann Emerg Med 42:34-40, 2003. 8. Chen BK, Cunningham BB: Topical anesthetics in children: Agents and techniques that equally comfort patients, parents, and clinicians. Curr Opin Pediatr 13: 324-330, 2001. 9. Denkler K: A comprehensive review of epinephrine in the nger: To do or not to do. Plast Reconstr Surg 108:114-124, 2001. 10. Wilhelmi BJ, Blackwell SJ, Miller JH, et al: Do not use epinephrine in digital blocks: Myth or truth? Plast Reconstr Surg 107:393-397, 2001. 11. Andrades PR, Olguin FA: Digital blocks with or without epinephrine. Plast Reconstr Surg 111:1769-1770, 2003. 12. Hollander JE, Singer AJ: Laceration management. Ann Emerg Med 34:356-367, 1999.

Summary
Children with lacerations and other minor wounds are among the most often encountered in the ED. The steps in management of these patients are well-known and often well-researched, but dogma still permeates the process. Local anesthetics are effective, and several choices are available.

N EW CON CEPTS I N W OUN D MA N A G EMEN T / ROB ERT D . SCH REMMER

245

13. Knapp JF: Updates in wound management for the pediatrician. Pediatr Clin North Am 46:1201-1213, 1999. 14. Moscati RM, Reardon RF, Lerner EB, et al: Wound irrigation with tap water. Acad Emerg Med 5:1076-1080, 1998. 15. Valente JH, Forti RJ, Freundlich LF, et al: Wound irrigation in children: Saline solution or tap water? Ann Emerg Med 41:609-616, 2003. 16. Hollander JE, Richman PB, Werblud M, et al: Irrigation in facial and scalp lacerations: Does it alter outcome? Ann Emerg Med 31:73-77, 1998. 17. Perelman VS, Francis GJ, Rutledge T, et al: Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: A randomized controlled trial. Ann Emerg Med 43:362-370, 2004. 18. Quinn J, Wells G, Sutcliffe T, et al: Tissue adhesive versus suture wound repair at 1 year: Randomized clinical trial correlating early, 3-month, and 1-year cosmetic outcome. Ann Emerg Med 32:645-649, 1998. 19. Hicks B: Wound glue revisited: Closure medical (CLSR NASDAQ) hits US$48 a share, blowing through my one-year price target of US$40for a 94% gain within two months! Taipan Online Web Site. Available at: http:// www.taipanonline.com/archive/0299/marketupdate. html. Accessed March 30, 2004. 20. Farion K, Osmond MH, Hartling L, et al: Tissue adhesives for traumatic lacerations in children and adults. The Cochrane Library 1:1-33, 2003.

21. Start JN, Armstrong AM, Robson WJ: The use of chromic catgut in the primary closure of scalp wounds in children. Arch Emerg Med 6:216-219, 1989. 22. Karounis H, Gouin S, Eisman H, et al: Plain gut versus non-absorbable nylon sutures in traumatic pediatric lacerations: Long-term outcomes. Pediatr Res 51: 86A, 2002 (abstr). 23. Parell GJ, Becker GD: Comparison of absorbable with nonabsorbable sutures in closure of facial skin wounds. Arch Facial Plast Surg 5:488-490, 2003. 24. Webster RC, Davidson TM, Smith RC: Wound closure with absorbable sutures. Laryngoscope 86:12801284, 1976. 25. Webster RC, McCollough EG, Giandello PR, et al: Skin wound approximation with new absorbable suture material. Arch Otolaryngol 111:517-519, 1985. 26. Flowers MW: The use of catgut in the primary closure of scalp wounds in children. Arch Emerg Med 7:54-55, 1990. 27. American Academy of Pediatrics: Tetanus, In: Pickering LK (ed): Red Book: 2003 Report of the Committee on Infectious Diseases (26th ed). Elk Grove Village, IL, American Academy of Pediatrics, 2003, pp 611-616. 28. Talen DA, Abrahamian FM, Moran GJ, et al: Tetanus immunity and physician compliance with tetanus prophylaxis practices among emergency department patients presenting with wounds. Ann Emerg Med 43:305314, 2004.