Laceration repair

• Debridement is most important step in reducing infection/ promoting healing
• Avoid betadine/chlorhexadine in wound
• Not necessary to remove hair as this can increase chances of infection (if do, avoid using razor)
  • Can use antibiotic ointment to help keep hair out of the way

• High pressure irrigation is best (can be achieved with 18 gauge syringe)
• Tap water is as effective as sterile water/ normal saline[1][2][3]
  • Pressure from tap is ~45 psi, higher than syringe[4]
• Irrigation optional for face/scalp wound as long as:
  • Not a bite wound
  • Not a contaminated wound
  • Not older than 6 hours
    • Often best to avoid irrigation of face and opt for cleaning with gauze to help prevent tissue distortion

• Can be topical or injected.
• Topical
  • LET for open wound, EMLA for intact skin
    • EMLA needs to be left on 1-2 hours [5]
    • LET onset is 20-30 minutes[5], area will appear pale
• Evaluate motor/sensation before giving local anesthesia
• To decrease pain of injection:
  • Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine)
  • Inject slowly
• Consider nerve blocks to avoid tissue distortion for cosmetic areas such as vermillion border
  • Also helpful for extremities, sole of foot
  • Digital block for finger lacerations

• See Soft tissue foreign body
• Explore to base of wound
• Ideally done in bloodless field
• Look for foreign bodies, tendon injury, or fracture
• Possible glass or metal in wound = get XR or US to evaluate

• See Sutures

• If laceration not closed immediately secondary to age of wound:
  • Irrigate and explore wound, then pack with non-adherent or vaseline gauze
  • Re-check in 3 days - may suture at that point if wound appears clean.

Note: consider use of Fast Absorbing Gut (5-0/6-0) on Ear, Eyelid, Eyebrow, Nose, Lip and Face if anticipated difficulty with suture removal

Note: Favor absorbable sutures for facial repair especially in children

• Just as good a suturing according to this [6] and other articles. Picture on how to do it property from the same article [6] which is under CC BY-NC-SA 4.0 license:

Steri-Strips

• Useful for areas of low tension and well approximated wounds
• Apply 3 layers allowing 30 seconds for first layer to dry
• Avoid in bite wounds, contaminated wounds, puncture wounds, mucosal surfaces, areas of high moisture (groin, axilla)
• Avoid antibiotic ointments which can prematurely dissolve glue

• Scalp laceration can be done with staples or if the patient has enough hair with Hair Apposition Technique by twisting hair together and using dermabond.
• Can bleed a lot, consider figure of 8 stitch to help with hemostasis
• Often accompanied by hematomas which may require evacuation for proper skin alignment

• Consider antibiotics for
  • Wounds contaminated by debris or feces
  • Caused by punctures or bites
  • Tissue destruction or in avascular areas
  • Neglected wounds

Wounds contaminated by fresh water and plantar puncture wounds through athletic shoes should include Pseudomonas coverage

• Splinting
  • Wounds over flexor surfaces or tension
• Tetanus prophylaxis
  • Tdap 0.5cc IM to patients >7y with no booster within 5 yr
  • Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given
    • Require follow up Tdap at 1mo & 1 yr; age>60 = high risk of poor immunization
• Dressing
  • Keep moist, not wet
    • Bandaid, xeroform, or ointment
• Wound check
  • 48-72 hrs ONLY if high risk wound
    • No point in checking before 48hr (takes this long for infection to occur)

• Preventing infection
  • Keep wound clean and covered
  • Apply antibiotic ointment twice daily
• Once healed, encourage daily sunscreen use and Vitamin E creams

• Signs of neurovascular or tendon injury
• Facial wounds that cross cosmetic boundaries
• Tissue loss