Glue wounds closed with Dermabond
A liquid topical skin adhesive can now be used to close lacerations that otherwise would have required sutures, staples, or skin strips. "Dermabond is basically glue which can be substituted for sutures in certain cases," says Joyce Blazejewski, MD, FAAP, a pediatric ED physician at St. John Health Care System and assistant clinical professor of pediatrics and emergency medicine at Wayne State University in Detroit, MI. "It’s child friendly and parent friendly, and has a lot of potential for improved patient care and good public relations." FDA approval was given in August 1998.
Patients and families like it because it saves the child an injection, and application is faster than when sutures or staples are used, says Sherrie Gooch, RN, ED educator at Children’s Hospital in Birmingham, AL. "Our physicians and nurses like it because it is faster than suturing and because they do not have to inflict pain upon their pediatric patient," she explains.
Dermabond can be used for lacerations on the extremities if the laceration did not cross a joint area, says Gooch. "We have also gotten good results when using it on lacerations even 2 cm or longer, but nothing as large as 10 cm, even though the Dermabond rep says that you can," she notes.
At Children’s ED, Dermabond is not used on human or animal bites because of the potential for infection, says Gooch. "We have not used it on deep lacerations because we would have to use injectable lidocaine for anesthesia for the deep sutures and, therefore, just go ahead and suture the skin as well," she notes. "We usually use it on patients that we will not need to use any local anesthesia on or with patients that we only need to use a topical local anesthetic, such as LET (topical lidocaine, epinephrine, and tetracaine).
Listed are usage protocols and benefits of Dermabond:
Risks of infection are minimal. A body of research on Dermabond already exists, notes Norman Christopher, MD, director of emergency and trauma services at Children’s Hospital Medical Center in Akron, OH. "While newly introduced in the United States, wound adhesives (there are several different brands) have been used internationally for more than six or seven years," he says.
The literature shows that there are minimal risks of infection, says Christopher. "When used properly and on appropriate wounds (minor, clean, "fresh," no tension, not for bites, etc.), the infection rate is extremely small," he says.
Gloves can stick to adhesive. "One of the more frequent complications’ is that the physician/nurse/tech’s glove can stick to the wound adhesive when it’s being applied," says Christopher. "A little bit of ointment rubbed onto the glove where it meets the adhesive is usually enough to break the bond."
Minimal follow-up is required. (See patient discharge instructions in this issue.) "My sense is that these wounds need little or no follow-up by definition, they are minor wounds, and very low risk," says Christopher. "The best instructions for a family are to do nothing: Keep the wound relatively dry—exposure to water/moisture is okay, as long as the wound isn’t soaked,’ don’t pick at the adhesive once it dries, and don’t apply ointments or lotions."
A follow-up visit with the patient’s primary care physician usually isn’t necessary, says Christopher. "Unlike sutures, there is no work to be performed after the Dermabond is applied—it sloughs spontaneously," he explains. "However, we emphasize the signs and symptoms of infection or of dehiscence and request follow-up for those specific reasons."
Exercise caution. "It’s great to add to what we have, but we are being careful and fairly conservative," says Christopher. "Dermabond should not be used indiscriminately. The tenets of wound management need to be adhered to." Dermabond adhesive should be used in conjunction with subcuticular sutures when they are required, not in place of them, he stresses.
Don’t be swayed by parents’ demand. Because of the media attention, parents have come to Children’s demanding Dermabond be used, reports Christopher. "We started using it on a Saturday after it was first approved, and the local TV station had interviewed one of our doctors about it," he recalls. "So parents drove here from all over asking for it, but it wasn’t indicated for some of the wounds."
Be prepared to educate parents about appropriate usage of Dermabond. "We’ve spent a lot of time explaining to families that our ultimate interest is a good outcome," says Christopher. "We tell them this glue is an option, that we are anxious to use it, but only in the right situation for their child."
Track appropriate usage. "Like any new agent or drug, we are tracking it in our QA process. We want to be sure the right indications were there, and that the wound was managed correctly," says Christopher.
Whenever Dermabond is used, a nurse logs it so charts can later be pulled. "We will be starting a telephone follow-up with families to find out what their satisfaction is and if the wound healed nicely," says Christopher.
Use appropriately. "We use Dermabond on select patients who have uncomplicated linear lacerations," says Blazejewski. "Although the manufacturer states it can be used for wounds up to 4 inches, we haven’t been that gutsy, and have only used it for wounds up to 2 inches."
Wounds are cleaned and prepped as they normally would be, and a minimum of three thin layers of the glue are applied, which dry in seconds. "There have been some reports that 1-5% of children have burning sensations from this glue, but we haven’t experienced that," says Blazejewski.
Dermabond reacts with moisture on the skin’s surface to form a strong, flexible bond in 45-60 seconds, and reaches full strength within approximately two and a half minutes. As the wound heals, Dermabond adhesive sloughs from the skin, and complete healing typically occurs in 5-10 days, Blazejewski explains.
Know contraindications. Dermabond is not indicated for wounds in the scalp or across areas of high skin tension or unstabilized joints. "The manufacturer suggests it not be used across a joint, such as the elbow or knee," says Christopher. "It will probably hold, but there is a chance it will separate. It also shouldn’t be used on mucous membranes, areas covered by dense hair, or moist areas, such as under a diaper. If you have a 15 month old who is drooling, you may not want to use it on the hands, because they will wind up in the mouth."
Care is quicker. "By the time you anesthetize the wound, it can take up to a half hour depending on the type of cut," says Blazejewski. "Dermabond is much quicker."
Petroleum products cause Dermabond to break down. Patients should be instructed not to apply petroleum-based ointments such as Bacitracin or Neosporin. "These can actually cause the product to break down," says Blazejewski. "We also tell them not to bathe or shower for long periods of time because you don’t want the site waterlogged."
Children are less traumatized. Dermabond often eliminates the need for an anesthetic injection. "Even though we usually let parents stay with a child when they get stitches, some people swear that children are traumatized going to doctor’s office from then on," says Blazejewski. "Also, with Dermabond, there is no removal of sutures. As the new skin is generated, it sloughs off with time."
Consider cost issues. Dermabond costs $24.95 per bottle. "Our cost to purchase the Dermabond far exceeds our purchase cost of sutures or staples, and of course, we pass this cost on to the patient," says Gooch. "However, the patient does not need to return for suture removal and, therefore, saves money on that end rather than up front."
At present, only the physicians at Children’s are applying Dermabond because it is a new product, Gooch reports. "We do have plans for application by trained Registered Nurses in mid-1999," she notes.
Sources
For more information about Dermabond, contact the following:
• Joyce Blazejewski, MD, FAAP, St. John Health Care System, 22235 Maplewood, Southfield, Michigan, 48034. Telephone: (313) 343-2936. Fax: (248) 354-9024. E-mail: [email protected] World Wide Web: http://www.wjr.net
• Norman Christopher, MD, Children’s Hospital Medical Center of Akron, One Perkins Square, Akron, OH 44256. [email protected]
• Sherrie Gooch, RN. E-mail: Sherrie.Gooch@ XMAIL.TCHA.UAB.EDU
• Ethicon, Inc., a Johnson & Johnson Company, is the manufacturer of Dermabond. For more information, contact Ethicon, P.O. Box 151, Somerville, NJ 08876-0151. Telephone: World Wide Web: http:www.ethiconinc.com
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