Lacerations

1. When managing a laceration, identify those that are more complicated and may require special skills for repair (e.g., a second- versus third-degree perineal tear, lip or eyelid lacerations involving margins, arterial lacerations).
2. When managing a laceration, look for complications (e.g., flexor tendon lacerations, open fractures, bites to hands or face, neurovascular injury, foreign bodies) requiring more than simple suturing.
3. Given a deep or contaminated laceration, thoroughly clean with copious irrigation and debride when appropriate, before closing.
4. Identify wounds at high risk of infection (e.g., puncture wounds, some bites, some contaminated wounds), and do not close them.

Wound Assessment

• History
  • Mechanism of injury
    • Caution in small puncture wounds from paint guns or sandblasters
  • Age of injury
  • Contaminant or foreign body
  • Tetanus immunization/booster status
  • Allergies to anesthetics/antibiotics
• Exam
  • Extent of wound
  • Fracture
  • Neurovascular or tendon compromise
  • Risk factors for poor wound healing

Treatment

• Wound irrigation
• Foreign body removal, necrotic tissue debridement
• Tetanus vaccine as needed (minor clean wound >10y, otherwise >5y + Ig if not fully vaccinated)
• Primary Closure up to 18h (Facial wounds up to 24-72h if no risk factors for infection)
  • Suture
    • Extends through dermis, careful approximation (eg. vermillion border), tension
      • Simple interrupted standard
      • Vertical mattress if tension and edges fall or fold into wound
      • Horizontal mattress for eversion in areas of high tension
    • Procedure:
      • Clean with antiseptic around wound (but not inside wound to avoid impaired wound healing)
      • Local anesthetic 25-30G needle with lidocaine 1% with epi between dermis and subcutaneous tissue
        • Avoid dose exceeding:
          • Lidocaine without epi 5mg/kg (max 300mg = 30mL lidocaine 1%, 15mL lidocaine 2%)
          • Lido with epi 7 mg/kg (max 500mg = 50mL lido 1% with epi)
      • Irrigate wound vigorously (60mL syringe with splash guard)
      • Drape wound + sterile gloves
      • Explore wound (look for vessels, nerves, tendons, structure)
      • Suture (ensure depth greater than width, entering and exiting wound at 90 degrees)
        • 6-0 for face, 3-0 for thick skin (back, scalp, palms, soles), 4-0 for rest
    • Aftercare:
      • Apply sterile non-adherent dressing
      • Keep dry x 24h then can wash gently and use topical antibiotic for maintaining moist environment
      • Return to care instructions for signs of infection
      • Remove stitches in 5 days (face), 7-10 days (scalp, arms), 10-14 days (trunk, legs, hands, feet), 14-21 days (palms, soles, high tension)
  • Tissue adhesive or tape
    • <5cm, low tension, elderly fragile skin
  • Staples
    • Noncosmetic region, long linear >5cm (faster closure)

Generally, do NOT close if:

• Concern about wound infection, risk factors of proper wound healing (eg. immunocompromised, peripheral artery disease)
• Animal bites (especially if noncosmetic area)
  • Consider prophylactic Amoxicillin/clavulanate (Clavulin) 25-45 mg/kg divided q12h (max dose 875/125) mg every 12 hours x5d (unless dog bite not on hand)
  • Consider post-exposure rabies vaccine and immunoglobulin within 24h if high risk (call public health, send animal to laboratory if available)
  • Consider HIV/Hep B/C in human bites
• Deep puncture wounds when irrigation not effective
• Actively bleeding (first hemostasis to prevent hematoma)
• Superficial wounds (epidermis)