Pediatric Corner
Here’s how to avoid problems with Dermabond
When a child presents with a laceration, painful sutures are avoided. Instead, the wound is "glued" shut. This once was wishful thinking, but now may be commonplace in your emergency department (ED), thanks to Dermabond Topical Skin Adhesive (2-octylcyanoacrylate), a wound tissue adhesive manufactured by Somerville, NJ-based Ethicon Products, currently the only wound tissue adhesive approved by the Food and Drug Administration.
"Dermabond has certainly found its place in our ED and is used on a regular basis," reports Michael Ludwig, RN, CEN, EMT-P, an ED nurse at Children’s Hospital of Dallas. "It has proven a far less traumatic closure technique than suturing. With appropriate use, it has saved many children from the needle."
But the substance is not without problems. Here are some recent examples:
- A child’s eye accidentally was glued shut after some of the Dermabond got onto the eyelashes. After hours of soaking, the eye reopened.
- A glove was glued to a patient’s forearm while Dermabond was being applied.
- Plastic forceps adhered to a wound on a boy’s chin.
According to Cindy Reschke, RN, a wound-care specialist at Children’s Hospital Medical Center at Akron (OH), the main problems she’s experienced with Dermabond are infection, dripping into the eye when used too close to the eyelids, and bleeding due to repeated trauma.
According to a spokesman for the distributor, who isn't named according to company policy, Dermabond is not associated with an increased incidence of wound infections. According to the spokesman, who points clinicians to the use instructions, actively bleeding wounds should not be closed. Failure to stop bleeding with any wound closure method will result in a hematoma and increase the risk of infection and poor wound healing, the spokesman says.
There is a tendency to oversimplify its use, argues Emory Petrack, MD, MPH, MS, chief of the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland. "On the surface, it seems it should be simple to glue the skin together," he says. "But if not used correctly, or used on the wrong types of lacerations, problems will occur."
Here are ways to avoid problems with Dermabond:
• Irrigate the wound thoroughly.
Reschke reports that patients have come to the ED with infected dog-bite wounds that had been closed with Dermabond. She warns not to assume that once the wound is cleaned prior to examination, it is ready to be closed, and she recommends copious irrigation. "Dilution of the bacteria at the site of laceration is still the key to prevent infection," she says.
• Use a barrier for eyes.
At Children’s Hospital, ophthalmic ointment is used as a barrier around the eye area, so the drip flows away from the patient’s eye, says Reschke. "Keeping the patient’s head below the rest of the body and tilting the head to one side prevents the drip from going into the eyes," she adds. However, according to the distributor's spokesman, it is not sufficient to use a barrier near the eye when applying Dermabond. As outlined in the instructions for use, thin layers are to be applied while the patient is on a level surface.
• Aspirate wounds instead of removing Dermabond.
If a Dermabond-closed wound does become infected, remove the Dermabond with an antibiotic ointment to let the pus drain out, advises Adarsh Gupta, MD, medical director of the wound care and suture program for the division of emergency medicine at Children’s Hospital Medical Center of Akron (OH). Intravenous antibiotics also should be given, and the patient should be started on oral antibiotics, says Gupta.
• Use ophthalmic ointment to remove Dermabond.
If Dermabond gets into the patient’s eye, Gupta recommends using ophthalmic ointment to remove it. "Apply gently to be able to open the eyelashes, and be careful not to pull them off," Gupta adds. Gupta notes that if Dermabond gets into the eye, burning will occur, but there is no reported long-term effect.
Ludwig notes that closing wounds with this technique is at least a two-person task: one to hold the patient still and approximate the laceration, and the second to apply the Dermabond to the site.
There is always the risk of having your glove glued to the patient’s head, says Ludwig. "This becomes a source of stress to the patient, family, and the staff member who finds himself stuck to the child," he says. Application of a petroleum-based solvent will break the seal, says Ludwig. He recommends careful application, with extreme caution used around the eye area, with gauze handy to immediately soak up any Dermabond that may approach the eye.
To prevent forceps from getting stuck, researchers recommend using metal instruments instead of plastic. According to one study, Dermabond only adhered to metal forceps after a long period of time and if the instrument remained perfectly still.1 According to instructions for use, if removal of Dermabond is necessary for any reason, carefully apply petroleum jelly or acetone to the adhesive to loosen the bond.
• Only use Dermabond on appropriate wounds.
Gupta says that although Dermabond is a useful tool in closing wounds, the wounds must be superficial, or the deeper layers must be closed already. It never should be used on any infected, dirty, or contaminated wounds or bites, he adds.
In spite of the obvious benefits, Dermabond does have limitations, says Ludwig. "This technique cannot be used across joints such as knees or elbows and is limited to lacerations that do not require multiple layers of suture to close," he explains.
According to the spokesman for the distributor, Dermabond should not be used across any areas of increased skin tension.
[Editor’s note: According to the manufacturer, health care professionals should refer to the instructions for use in the package labeling when using Dermabond adhesive. If you have any questions regarding Dermabond, call (877) 384-4266, a toll-free number that reaches nurses who are knowledgeable about this product.]
Reference
1. Yamamoto LG. Preventing adverse events and outcomes encountered using Dermabond. Am J Emerg Med 2000; 18:511-515.
Sources
For more information about Dermabond, contact:
• Adarsh Gupta, MD, Medical Director, Wound Care and Suture Program, Division of Emergency Medicine, Children’s Hospital Medical Center of Akron, One Perkins Square, Akron, OH 44308. Telephone: (330) 543-8452. Fax: (330) 543-3761. E-mail: [email protected].
• Michael Ludwig, RN, CEN, EMT-P, Children’s Medical Center of Dallas, 1935 Motor Street, Dallas, TX 75235. Telephone: (214) 456-2995, ext. 9470. Fax: (214) 456-6014. E-mail: [email protected].
• Emory Petrack, MD, MPH, MS, Chief, Division of Pediatric Emergency Medicine, Rainbow Babies and Children’s Hospital, 11100 Euclid Ave., M/S MTH6097, Cleveland, OH 44106. Telephone: (216) 844-8716. Fax: (216) 844-8233. E-mail: [email protected].
• Cindy Reschke, RN, Wound Care & Suture Program, Division of Emergency Medicine, Children’s Hospital Medical Center of Akron, One Perkins Square, Akron, OH 44308. E-mail: [email protected].
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