Laceration repair: Difference between revisions
(14 intermediate revisions by 6 users not shown)
Line 1: Line 1:
==Indications==
==Indications==
*Do not close body wounds >12 hr old
Skin or mucosal laceration.
*Do not close face/scalp wounds >24 hr old
*If don't close, prepare wound as if going to close:
**Irrigate, explore, non-adherent or vaseline gauze to prevent wound edges from closing
**Wrap, consider oral abx
**On day 3 remove packing, irrigate & suture if appears clean


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


==Irrigation==
===Irrigation===
*High pressure irrigation is best (can be achieved with 18 gauge syringe)
*High pressure irrigation is best (can be achieved with 18 gauge syringe)
*Tap water is as effective as sterile water/ normal saline
*Tap water is as effective as sterile water/ normal saline<ref>Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007 May;14(5):404-9</ref><ref>Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013  Jan 16;3(1).</ref><ref>Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD003861. </ref>
**Pressure from tap is ~45 psi, higher than syringe<ref>Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998 Nov;5(11):1076-80.</ref>
*Irrigation optional for face/scalp wound as long as:
*Irrigation optional for face/scalp wound as long as:
**Not a bite wound
**Not a bite wound
**Not a contaminated wound
**Not a contaminated wound
**Not older than 6 hours  
**Not older than 6 hours
 
==Anesthesia==
===Anesthesia===
*Put LET in open wound, EMLA on intact skin (doesn't work in open wound)
*Can be topical or injected.
*Check motor/sensory before give anesthesia
*Topical
**LET for open wound, EMLA for intact skin
*Evaluate motor/sensation before giving local anesthesia
*To decrease pain of injection:  
*To decrease pain of injection:  
**Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine)
**Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine)
Line 29: Line 32:
{{Maximum doses of anesthetic agents}}
{{Maximum doses of anesthetic agents}}


==Exploration==
===Exploration===
*See [[Soft tissue foreign body]]
*Explore to base of wound
*Ideally done in bloodless field
*Ideally done in bloodless field
*Look for foreign bodies, tendon tears, or fracture
*Look for foreign bodies, tendon injury, or fracture
*Glass in wound = need for xray
*Possible glass in wound = get XR or US to evaluate


==Suturing==
===Suturing===
*See [[Sutures]]
*See [[Sutures]]


==Aftercare==
*If laceration not closed immediately secondary to age of wound:
*Antibiotics
**Irrigate and explore wound, then pack with non-adherent or vaseline gauze
**Consider for:
**Re-check in 3 days - may suture at that point if wound appears clean.
***Wounds contaminated by debris or feces
 
***Caused by punctures or bites
{{Suture chart}}
***Tissue destruction or in avascular areas
 
***Neglected wounds
===Aftercare===
**Wounds contaminated by fresh water and plantar puncture wounds through athletic shoes should include Pseudomonas coverage
*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
*Splinting
**Wounds over flexor surfaces or tension
**Wounds over flexor surfaces or tension
*Tetanus
*Tetanus
**Tdap 0.5cc IM to pts >7y w/ no booster w/in 5 yr
**Tdap 0.5cc IM to patients >7y with no booster within 5 yr
**Hypertet 250 u IM @ diff site from Tdap if NO Hx of Td or < 3 doses given
**Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given
***Require f/u Tdap @ 1mo & 1 yr; age>60 = high risk of poor immunization
***Require follow up Tdap at 1mo & 1 yr; age>60 = high risk of poor immunization
*Dressing
*Dressing
**Keep moist, not wet
**Keep moist, not wet
Line 57: Line 67:
**48-72 hrs ONLY if high risk wound
**48-72 hrs ONLY if high risk wound
***No point in checking before 48hr (takes this long for infection to occur)
***No point in checking before 48hr (takes this long for infection to occur)
==Billing==
*Anatomical location of wound
*Size of wound
**Length (cm) <2.5, 2.6-5.0, 5.1-7.5, 7.6-12.5, 12.5-20.0, 20.1-30.0, >30.0
*Complexity
**Simple, intermediate, or complex (depends on debridement, layers, complex stitch, drain, etc.)
*Type and number of sutures


==See Also==
==See Also==
*[[Soft Tissue Foreign Body]]
*[[Sutures]]
*[[Sutures]]
*[[Lip Laceration]]
*[[Lip Laceration]]
Line 65: Line 84:
*[[Tongue Laceration]]
*[[Tongue Laceration]]
*[[Bites]]
*[[Bites]]
*[[LET]]


==Source==
==References==
*UpToDate
<references/>
*Tintinalli
 
[[Category:Trauma]]
[[Category:Trauma]]
[[Category:Procedures]]
[[Category:Procedures]]

Revision as of 22:48, 21 November 2017

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[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

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

  • 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.

Laceration Areas and Their Common Suture Type and Duration

Suture Usage
Area Size Type Days to Removal
Scalp Staples or 4-0 or 5-0 non absorbable 7
Ear 6-0 non absorbable (absorbable for cartilage repair) 5-7
Eyelid 6-0 or 7-0 absorbable or nonabsorbable 5-7
Eyebrow 5-0 or 6-0 absorbable or nonabsorbable 5-7
Nose 6-0 absorbable or nonabsorbable 5-7
Lip 6-0 absorbable NA
Oral mucosa 5-0 absorbable NA
Other face / forehead 6-0 absorbable or nonabsorbable 5
Chest/abdomen 4-0 or 5-0 non absorbable 12-14
Back 4-0 or 5-0 non absorbable 7-10
Extremities 4-0 or 5-0 non absobrable 7-10
Hand 5-0 non absorbable 7-10
Foot / Sole 4-0 non absorable 12-14
Joint (Extensor) 4-0 non absorable 10-14
Joint (Flexor) 4-0 non absorbable 7-10
Vagina 4-0 absorbable NA
Penis 5-0 non absorbable 7-10
Scrotum 5-0 non absorbable 7-10

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

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)

Billing

  • Anatomical location of wound
  • Size of wound
    • Length (cm) <2.5, 2.6-5.0, 5.1-7.5, 7.6-12.5, 12.5-20.0, 20.1-30.0, >30.0
  • Complexity
    • Simple, intermediate, or complex (depends on debridement, layers, complex stitch, drain, etc.)
  • Type and number of sutures

See Also

References

  1. ↑ Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007 May;14(5):404-9
  2. ↑ Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013 Jan 16;3(1).
  3. ↑ Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD003861.
  4. ↑ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998 Nov;5(11):1076-80.
Retrieved from "https://www.wikem.org/w/index.php?title=Laceration_repair&oldid=165054"