Tissue adhesives

Tissue AdhesiveInevitably the act of caring for children will lead you to dealing with multiple lacerations. While there are a wide variety of techniques that can be deployed to make these wounds disappear, the one that is most often asked for by patients and families is Tissue Adhesives: “Can you just glue it?”
Tissue adhesives (N-2-octylcyanocrylate [Dermabond] or N-butyl-2-cayanoacrylate [Indermil]) are excellent products to use when repairing simple linear lacerations and can produce excellent results with less patient and physician (di)stress. YET, while the act of “gluing” a wound may be easier than suturing, the procedure should not be taken as a remedial task.

All aspects of Wound Management still need to be considered:

  • Anesthetize the wound properly, to ensure patient comfort and aid in evaluation.
  • Ensure hemostasis (LET is helpful for that. Tissue adhesive won’t stick to blood well).
  • Evaluate for foreign bodies… just because it appears simple, doesn’t mean it is.
  • Irrigate with COPIOUS fluids (saline, tap water).
  • DOCUMENT all of the above!

A few things to remember prior to starting to apply the adhesive:

  • Tissue adhesives won’t work well if the wound is under tension.
  • Thinking you’ll be able to “make it work” by smashing the edges together will only likely lead to you gluing your fingers to the wound or inverting the wound edges (both are suboptimal).
  • Excess wound tension will likely overcome the tensile strength of the tissue adhesive and lead to product failure, poor outcome, and grumpy parents.
  • BONUS MORSEL:
    • Consider making large wounds into simple ones under less tension with deep sutures and then close the superficial skin with glue (like a surgeon might do).
    • Wounds with mild tension can be repaired with “Steri-Strips” first and then glue over top (just remember to always leave space between Steri-strips).
    • Gravity works!  Consider where the product may drip to before you apply it (Eyes, Ears, Nose, etc).  Position the patient so that if gravity prevails, the overflow of the adhesive won’t enter sensitive areas.
    • Create barriers to limit and control the application.
      • Moist gauze can be used to contain run-off.
      • Petroleum products (ex, Surgi-Lube) can create a damn or even encircle the wound. Be careful not to allow the petroleum product to enter the wound… then the glue won’t stick.
      • Tegaderm dressing can be used to restrict the application area of the glue.
        • Before peeling the backing off, cut a hole in the middle large enough to encircle the wound.
        • Apply the Tegaderm and ensure that the margins of the pre-cut hole are well affixed to the skin surrounding the wound.
        • Apply the tissue adhesive.
        • Peel away the Tegaderm gently when the glue is almost dry.
        • See http://www.acep.org/content.aspx?id=37472 for further description.
      • Glue is sticky and will stick to latex gloves, your fingers, plastic instruments, and gauze. Consider using vinyl gloves or metal instruments.

Know what to do if the Tissue runs amuck (this also applies for Krazy-Glue).

  • Use copious irrigation and then Antibiotic Ointment (E-Mycin ophthalmic ointment) or Petroleum Product (not acetone or alcohol – which won’t go well in the eyes). Gently rubbing with the ointment can remove the glue.
  • Often there will be an associated corneal abrasion… treat it as other corneal (E-Mycin ointment would be useful here too).

 

Zempsky WT, Parrotti D, Grem C, Nichols J. Randomized controlled comparison of cosmetic outcomes of simple facial lacerations closed with Steri Strip Skin Closures or Dermabond tissue adhesive. Pediatr Emerg Care. 2004 Aug; 20(8): 519-24.

Lammers RL. “Tissue Adhesive (Tissue Glue)” in Roberts: Clinical Procedures in Emergency Medicine, 5th

Sean Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renown educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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