INTERNAL ONLY

STANDING ORDER

EMERGENCY DEPARTMENTS

Topical Skin Adhesives - Administration by Accredited Emergency Nurses for the management of acute lacerations

POLICY STATEMENT

This order may only be activated under the specific circumstances set out in the section “Indications” and provided there are no contraindications present.

The administering nurse must be accredited to administer the drug and record the administration in ink on the once only section of the medication chart. This order must be checkedand signed by a medical officer within 24 hours of activation of the standing order.

This standing order is only valid until the date noted by the Drug and Quality Use of Medicines Committee under the heading "Effective To:" at the end of this document.

1.NURSING ACCREDITATION REQUIREMENTS

Accredited Registered Nurses employed within SESLHD Emergency Departments (ED) whoare working in anextended or advanced practice nurse capacity must have at least a minimum of two (2) years emergency /critical care experience and must be able to work at a minimum of resuscitation level or above (i.e. triage / clinical initiatives nurse)and/or as approved by the ED Nurse Manager.

2.INDICATIONS

Adult and paediatric patients who present to SESLHD Emergency Department (ED) for closure of superficial, short (≤5cm), linear, low-tension lacerations that are less than 12 hours old, and have easily approximated wound edges.

3.CONTRAINDICATIONS1-3

  • Consent or understanding of the process is not able to be obtained
  • Understanding of the process is not able to be obtained
  • Known hypersensitivity to cyanoacrylates or formaldehyde
  • Wound greater than 5cm in length or wound edge 0.5cm apart
  • Deep wound requiring subcutaneous as well as cutaneous closure
  • Wounds over 12hours old
  • Wounds requiring sutures to approximate skin edges
  • Crushed, infected, bite or puncture wounds
  • Oedematous wounds
  • Wounds sustained over joints or under high tension
  • Wounds which cross muco-cutaneous borders
  • Wounds that have active microbial, bacterial or fungal infections or gangrene.
  • Wounds that are decubitus ulcers, animal or human bite wounds, or stab wounds
  • Wounds adjacent to eye or eye lid
  • Wounds in auditory meatus
  • Mucosal surfaces or across mucocutaneous junctions, or on skin which may be regularly exposed to body fluids.
  • Wound on densely hairy skin
  • Hand injuries or injuries where tendons are visible require Medical Officer (MO) review
  • DO NOT apply internally, inject intravascularly, or ingest.
  1. PRECAUTIONS
  • Exothermic(heat generating) reaction – dermal adhesives produce heat when drying, the sensation of which is variable and may cause patient discomfort or thermal damage. This can be exacerbated if i) excessive amounts of the agent are appliedor ii) the wound is not dry prior to application.

5.ADMINISTRATION

Pre-application:

  1. Assess the wound. Ensure no contraindication to use of adhesives. Examine wound for complications such as neurovascular involvement or retained foreign body
  2. Assess for pain and manage as per local policy
  3. Assess tetanus status and manage as per local policy
  4. Explain the procedure to the patient (and a parent if the patient is a child). Explain that the adhesive will feel warm but isn’t painful.
  5. Thoroughly irrigate and clean, then dry, the wound. Use aseptic technique at all times.
  6. Dry surrounding wound area with sterile gauze to ensure wound edges are dry

Application:

  1. Appose the edges of the wound with either longitudinal traction in the long axis of the wound or lateral pressure either side of the wound. If possible slightly evert the edges of the wound as they are apposed. Avoid placing fingers too close to the edge of the wound. Remember if the edges are difficult to appose with simple traction it is likely the wound is under high tension and adhesives will be ineffective for wound closure.
  2. If using a safety applicator (e.g. LIQUIBAND), the tip should have a wet appearance. Do not allow drops of wound adhesive to form on tip.
  3. Apply the adhesive in a thin film to the entire length of the wound, maximum two layers. Application of excessive amounts will reduce strength of closure. Alternatively ‘spot welding technique’ may be used; the safety applicator should not be used in this circumstance.
  4. Take care not to stick swabs, gloves or other instruments to the patient (Accidental spillage onto skin away from the wound need not be removed unless it will cause two surfaces to adhere. If done immediately, spillage can be removed by wiping with gauze before the adhesive dries. If you must remove the adhesive once dry e.g. for inadequate repair, in less sensitive areas it may be freed by carefully pulling apart whilst flushing with warm soapy water).
  5. After application of the adhesive continue to apply traction for 30 seconds until the wound adhesive has fully dried and wound is secure.
  6. Protective dry dressings, such as gauze, may be applied over wounds closed with topical skin adhesive once the adhesive has completely polymerised and is no longer tacky(approximately 2 minutes after application).
  1. MONITORING & NURSING IMPLICATIONS
  • Evaluate and document wound management.
  • Educate the patient/relative on dermal adhesive and give discharge instructions.
  1. DOCUMENTATION

Document patient observations including the patient’s pain score on the EDStandard Adult General Observation (SAGO) Chart, the EDStandard Paediatric Observation Chart (SPOC)and/or electronically within Firstnet.

  • The administering nurse must record the administration in ink on the ‘once-only’ section of the National Inpatient Medication Chart (NIMC) or Paediatric National Inpatient Medication Chart (PNIMC)as Emergency Department Standing Order (i.e. “ED STO” with a circle around it) plus print and sign their name.
  • The signatures of the administering nurse must be clearly documented on the NIMC or PNIMC and includes completing the date, time, drug, dose, route and time of administration sections.
  • The EDSO drug order must be countersigned by the medical officer that subsequently assesses and treats the patient within 4 hours.
  • The administering nurse must record in the patient’s progress notes the administration and wound management.
  • Drugs must be checked and ordered according to hospital policy and adhering to the Ministry of Health Policy Medication Handling in NSW Public Health Facilities PD2013_043.

8.DOSAGE / ROUTE

Caution: CHECK for allergies and/or contraindications

Drug / Dose / Route / Frequency
DermaBond® Topical Skin Adhesive / 1-3 thin layers, waiting 30secs between application of each layer / Topical / Stat
LiquiBand® Topical Skin Adhesive / 1-3 thin layers, waiting 30secs between application of each layer / Topical / Stat

9.POTENTIAL ADVERSE EFFECTS/INTERACTIONS:

  • Exothermic (heat generating) reaction – dermal adhesives produce heat when drying, the sensation of which is variable and may cause patient discomfort or thermal damage. This can be exacerbated if i) excessive amounts of the agent are applied or ii) the wound is not dry prior to application.
  1. REFERENCES:

1.Lo, S. and Aslam, N., A review of tissue glue use in facial lacerations: potential problems with wound selection in accident and emergency. European Journal of Emergency Medicine, 2004. 11: p. 277-279.

2.Marshell, G., Skin glues for wound closure. Australian Prescriber, 2013. 36(2): p. 49-51.

3.SESLHD. Patient with Acute Condition for Escalation (PACE): Management of the Deteriorating Adult and Maternity Inpatient (SESLHD/PR283). 2013 [cited 2014 March]; Available from:

4. Clinical Emergency Response System (CERS) for Paediatric Inpatients: Management of the Deteriorating Paediatric Inpatient. SESLHDPR/284.

5. LiquiBand® Topical Skin Adhesive - Instructions for Use. Available Online

6. Bruns, T; Worthington, JM. (2000) Using Tissue Adhesive for Wound Repair: A Practical Guide to Dermabond. American Family Physician,61(5):1383-1388. Available Online:

Authorised by: Emergency / Critical Care Stream Director

Name / Designation / Signature / Date
Professor Gordian Fulde / Emergency/ Critical Care Stream Director

Endorsed by:

Name / Designation / Signature / Date
Endorsed / Effective To:
TBC / TBC / Maximum 12 Months

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