Tissue adhesive: how to avoid sticky situations

Topical lidocaine with epinephrine, working in teams, and avoiding lid margins can help you glue like a pro.

Tissue adhesive: how to avoid sticky situations
Tissue adhesive: how to avoid sticky situations

There are three things I love in life: my family, my friends, and tissue adhesive. I use tissue adhesive any chance I get, and I often push the boundaries when using it in the emergency department.

It's a spectacular time-saving solution for closing linear lacerations, and being needle free children and needle-phobic adults love the idea of simply being glued back together.

While tissue adhesive seems incredibly easy at first sight, it can actually be pretty tricky to use. But with a little skill and some simple tricks, it can yield wonderful results. Here are some of my favorite tricks:

Topical lidocaine-epinephrine (TLE)

This first trick is actually something I learned from one of my attendings. Applying TLE for about 15 to 20 minutes prior to using glue takes away a lot of the sting that can be felt from the tissue adhesive.

Using TLE also serves a second purpose. Epinephrine will cause vasoconstriction, making it less likely that your wound will start to bleed when you manipulate it. This prevents those dreaded white, blood-tinged, glue spots that can develop if the glue comes in contact with a liquid, creates a better seal for the laceration, and produces a more aesthetically pleasing end result.

Never glue alone

Unless it is an extremely small laceration, attempting to use tissue adhesive solo can quickly turn into a disaster.

Approximating wound edges with one hand, breaking and applying the glue with your second hand, and trying to prevent runaway glue into unwanted areas with your imaginary third hand can be an impossible and stressful task, and can quickly make you regret your decision not to suture.

To combat this, I always have at least one, if not two, colleagues helping me when I glue. The first person serves to approximate the wound edges, which allows me to place the glue. The second person serves to prevent glue runoff into any unwanted areas such as hair or the eyes. The more help you have, the quicker the task can be completed.

Avoid lid margins at all costs

I love using adhesive on the face. The only problem is the risk of gluing a patient's eyelids shut. Although it can be resolved by applying liberal amounts of ophthalmic ointment, this can suddenly become a time consuming and traumatic event for both you and the patient. Please remember to consult ophthalmology, if you actually get glue on the eye or if a patient develops visual problems.

To avoid runoff into the eye, slant the patient in a direction that will allow the glue to run away from the eye. If you are gluing above the eyes, put the patient in the Trendelenburg position. If it is below the eyes, putting the patient in reverse-Trendelenburg will do the trick every time. 

Like suturing, using skin glue is a skill that becomes easier every time you do it. It took me several months, and a lot of lacerations before I felt comfortable using it. Hopefully these tricks will help you become a gluing pro in no time!

Jillian Knowles, MMS, PA-C, is an emergency medicine physician assistant in the Philadelphia area. 

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