Tools for Practice


#141 Time to Laceration Repair: Definitively dogmatic to purposefully pragmatic


CLINICAL QUESTION
Is the time from injury to wound closure a risk factor for infection in traumatic lacerations?

BOTTOM LINE
There is no evidence that a “golden period” or cut-off point exists in which to repair simple, traumatic lacerations to reduce infections. Other patient and wound characteristics (e.g. diabetes, wound size, location, and contamination) are likely more predictive of infection than time to wound closure. In the absence of evidence for maximum duration, clinical judgment/experience and patient preferences should inform decisions. 


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EVIDENCE
  • No randomized controlled trials (RCTs) found.1  
  • Cohort studies:  
    • Emergency department (three sites, 2,663 patients):2 
      • No significant difference in patients requiring reassessment and infection (antibiotic treatment) at 30 days between closure <12 hours (2.9%) and >12 hours (1.4%).  
      • Limitations: Only 67% patient follow-up, low numbers in >12 hours group (n=72).  
    • Pediatrics (2,834 children):3 
      • No difference in infection (frank pus, lymphangitis, or cellulitis) between closure <6 hours (1.2%) and >6 hours (1.3%). 
      • Limitations: No information on longer time periods. 
    • Neither observational study controlled for type of injury, management, or other potential confounders.  
  • A cross-sectional study of 5,521 patients4 and two smaller studies5,6 confirm above findings. 
  • Other papers that found delayed wound closure was associated with increased infections were:  
    • Smaller (297 patients), and did not account for other wound/patient factors.7  
    • Secondary analysis (example RCT of 217 patients examining role of antibiotics in wounds)8 or modeling clinician’s ability to predict wound infections.9 
Context 
  • A “golden period” in which to repair simple lacerations by primary closure is often discussed, with time frames ranging from four to 19 hours.6,8 
  • Risk factors more predictive of infection include: 
    • Patient variables: Diabetes (Relative Risk (RR) of infection = 2.7 - 3.9)2,4 and increasing age.4,9  
    • Wound characteristics: length >5cm2,4,7 (example RR Infection = 2.9)2 location2,3,5-9 (examples lower extremity RR infection = 4.1, head/neck RR infection = 0.3)2,3 and wound contamination at time of presentation2,4,9 (example RR infection 2.0 - 2.9).2,4   
June 22, 2015

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Author(s):

  • Brianne Tetz MD
  • Christina Korownyk MD CCFP
  • Sheny Khera MD CCFP

1. Eliya-Masamba MC, Banda GW. Cochrane Database Syst Rev. 2013; 10:CD008574.

2. Quinn JV, Polevoi SK, Kohn MA. Emerg Med J. 2014; 31:96-100.

3. Baker MD, Lanuti M. Ann Emerg Med. 1990; 19:1001-5.

4. Hollander JE, Singer MD, Valentine SM, et al. Acad Emerg Med. 2001; 8:716-20.

5. Van den Baar MT, Van der Palen J, Vroon MI, et al. Emerg Med J. 2010; 27;540-3.

6. Berk WA, Osbourne DD, Taylor DD. Ann Emerg Med. 1988; 17:496-500.

7. Waseem M, Lakdawala V, Patel R, et al. Int J Emerg Med. 2012; 5:32.

8. Morgan WJ, Hutchinson D, Johnson HM. Br J Surg. 1980; 67:140-1.

9. Lammers RL, Hudson DL, Seaman ME. Am J Emerg Med. 2003; 21:1-7.

Authors do not have any conflicts of interest to declare.