Laceration repair

Indications

Skin or mucosal laceration.

Contraindications

• Body laceration >12 hours old
• Face/scalp wounds >24 hours old

Management

Wound Preparation

• Debridement is most important step in reducing infection/ promoting healing
• Avoid betadine/chlorhexadine in wound
• Not necessary to remove hair (if do, avoid using razor)

Irrigation

• High pressure irrigation is best (can be achieved with 18 gauge syringe)
• Tap water is as effective as sterile water/ normal saline
• Irrigation optional for face/scalp wound as long as:
  • Not a bite wound
  • Not a contaminated wound
  • Not older than 6 hours

Anesthesia

• Can be topical or injected.
• Topical
  • LET for open wound, EMLA for intact skin
• Evaluate motor/sensation before giving local anesthesia
• To decrease pain of injection:
  • Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine)
  • Inject slowly

Maximum Doses of Anesthetic Agents

Agent	Without Epinephrine	With Epinephrine	Duration	Notes
Lidocaine	5 mg/kg (max 300mg)	7 mg/kg (max 500mg)	30-90 min	1% soln contains 10 mg/ml 2% soln contains 20 mg/ml
Mepivicaine	7 mg/kg	8 mg/kg
Bupivicaine	2.5 mg/kg (max 175mg)	3 mg/kg (max 225mg)	6-8 hr	0.5% soln contains 5 mg/ml May cause cardiac arrest if injected intravascularly Do not buffer with bicarbonate
Ropivacaine	3 mg/kg
Prilocaine	6 mg/kg
Tetracaine	1 mg/kg	1.5 mg/kg	3hrs (10hrs with epi)
Procaine	7 mg/kg	10 mg/kg	30min (90min with epi)

Exploration

• 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 in wound = get XR or US to evaluate

Suturing

• 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.

Aftercare

• 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
  • 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)

See Also

• Soft Tissue Foreign Body
• Sutures
• Lip Laceration
• Fingertip Laceration
• Eyelid Laceration
• Tongue Laceration
• Bites
• LET