Vol. 12 •Issue 9 • Page 15
Scrubbing In
A Guideline to Dermabond Use
With millions of visits to the emergency room for treatment of lacerations or pierce injuries annually, many practitioners are looking for ways to treat patients that are more time efficient, with less discomfort and good cosmetic outcome. Practitioners have the choice of using tape strips, sutures, staples and liquid adhesives. Wound closure ideally is fast, easy to do, painless, minimally scarring and inexpensive with a low infection rate and a meticulous closure.
Suturing historically has been the preferred method for closure. With meticulous approximation, strong tensile strength and the lowest dehiscence rate, suturing is superior to other methods. Nonetheless, suturing requires advanced technical skills, generally takes more time, requires the use of local anesthetic, possibly requires removal and has the greatest tissue reactivity compared with other closure methods.
Staples are fast, with low cost, low tissue reactivity and low risk of needlestick. But closure with staples is not as meticulous and can interfere with imaging studies. Surgical tapes are good for fast application, present no risk of needlestick, are inexpensive and have the lowest infection rate. But tape falls short in tensile strength, has a higher rate of dehiscence and has poor adherence over areas hair-covered.1
Cyanoacrylate adhesives were introduced in 1949; recently, medical formulations have become available and have been approved for clinical use. Dermabond (2-octyl cyanoacrylate) is a cyanoacrylate tissue adhesive that is less toxic and four times stronger than is its cousin N-butyl-2-cyanoacrylate. Dermabond is marketed as an alternative for 5-0 or smaller sutures. It can be used to close lacerations of the face, extremities and torso. It can be used to close the surface over deep subcutaneous sutures.2
Advantages of Tissue Adhesives
Tissue adhesives have maximum bonding strength at 150 seconds. Dermabond is considered to be equivalent in strength to healed tissue at seven days after repair. It can be applied using only a topical anesthetic, requiring no use of needles and thus allowing for faster repair time. Tissue adhesives may be better accepted by patients, especially children. Dermabond forms a water-resistant covering that is an effective barrier against bacteria; it is the first and only FDA-approved topical skin adhesive with that distinction. Dermabond sloughs off naturally, which means no return visit for suture removal.1
Dermabond has other benefits, but it is not always the best choice to close a wound. It is not to be used on any wound with obvious signs of infection, on animal bites or on puncture wounds. It is not indicated for use over mucosal surfaces or across mucocutaneous junctions (e.g., oral cavity, lips). It should not be used over areas with high moisture levels, such as the axillae and perineum. Caution needs to be used in areas of high tension and movement, such as the skin over hands, feet and joints (unless kept dry and immobilized). Dermabond should not be used in a patient with known sensitivity to cyanoacrylates.2
Using Dermabond
Proper use of Dermabond does take some time to learn. Practitioners need to familiarize themselves with use of the applicator and flow of the glue. Dermabond comes in two different levels of viscosity, original and high viscosity. Ethicon also makes chisel tip and precision tip applicators to facilitate application.
Wound evaluation should be performed, including time of injury, mechanism of injury and neurovascular exam. Wound preparation may require anesthesia and irrigation, debridement, exploration and scrubbing of the wound. Next, apply topical anesthetic as needed and prepare the wound with antiseptic. Approximate wound edges manually and evenly. If needed, sutures can be used to close deeper layers. Forceps, surgical tape or manufactured skin approximation devices can be used to facilitate closure.
Crush the Dermabond vial, invert it and use gentle brushing strokes over the laceration. Avoid pushing adhesive into wound—this can cause foreign body reaction. Hold the edges together for at least 30 seconds before releasing, with at least three layers applied to ensure optimal strength to the wound closure. The glue forms a seal that does not require a dressing, but one may be applied, especially with children to prevent them from picking at it.
No antibiotic ointment should be used, since it will break down the adhesive. The area can get wet but should be patted dry if it does. The patient should not bathe or swim, avoiding any excess moisture to the area. In five to 10 days, the adhesive peels off on its own.
Tips for Application
• The laceration should be positioned as close as possible to horizontal to help prevent Dermabond runoff.
• When working near the eyes, protect them with a barrier of ophthalmic petroleum jelly and a gauze pad.
• If done immediately, excess adhesive simply can be wiped away with dry gauze (you have about a 10-second “grace period”).
• If your fingers or forceps become glued to the patient, place pressure on the patient’s skin adjacent to the edge of the object and gently roll the object away.
• Use of antibiotic ointment or petroleum jelly for 30 minutes loosens the polymer for removal.
• Use a peeling motion to remove glue.
Chad J. Pechumer is a surgical PA student at the University of Alabama at Birmingham Surgical Physician Assistant Program in Birmingham, Ala. William B. Nickell is a surgeon at the Plastic Surgery Center P.C., in Birmingham, Ala., and is chief of plastic surgery service at Medical Center East in Birmingham.
References
1. Singer AJ, Hollander JE. Lacerations and Acute Wounds: An Evidence-Based Guide. Philadelphia, Pa: FA Davis; 2003:56-62, 83-96.
2. Bruns TB, Worthington JM. Using tissue adhesive for wound repair: a practical guide to Dermabond. Am Fam Physician. 2000;61:1383-1388.
Last issue’s “Scrubbing In” column, “Laser Tattoo Removal,” was written by Matthew Bryant Herndon, BS, PA-S, a surgical PA student at the University of Alabama at Birmingham Surgical Physician Assistant Program, and Patricia R. Jennings, MHS, PA-C, an associate professor at the UAB Surgical PA Program. Last issue’s column inadvertently bore the bylines of this month’s authors. For a corrected version of the tattoo removal article, go to www.ADVANCEweb.com/pa.
