Difference between revisions of "Laceration repair"

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==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==
 
*Put LET in open wound, EMLA on intact skin (doesn't work in open wound)
 
*Check motor/sensory before give anesthesia
 
  
*Lidocaine 1% solution (10mg/mL)
+
===Anesthesia===
**Maximum safe dose = 4mg/kg (~300mg)
+
*Can be topical or injected.
*Lidocaine + epinephrine
+
*Topical
**Maximum safe dose = 500mg
+
**LET for open wound, EMLA for intact skin
**Delays healing, increases infection risk?
+
***EMLA needs to be left on 1-2 hours <ref name=aafp>[https://www.aafp.org/afp/2002/0701/p99.html KUNDU S, et. al. Principles of Office Anesthesia: Part II. Topical Anesthesia Am Fam Physician. 2002 Jul 1;66(1):99-102.]</ref>
*Bupivicaine (0.25%)
+
***LET onset is 20-30 minutes<ref name=aafp></ref>
**Maximum safe dose = 175mg
+
*Evaluate motor/sensation before giving local anesthesia
**Do not buffer with bicarbonate
 
*Bupivicaine + epinephrine
 
**Maximum safe dose = 225mg
 
 
 
*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)
 
**Inject slowly
 
**Inject slowly
  
==Exploration==
+
{{Maximum doses of anesthetic agents}}
 +
 
 +
===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
+
===Steri-Strips===
**Wounds contaminated by fresh water and plantar puncture wounds through athletic shoes should include Pseudomonas coverage
+
*Just as good a suturing according to this <ref name=Esmailian>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5887701/ Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds' Scar. Adv Biomed Res. 2018;7:49. Published 2018 Mar 27. doi:10.4103/abr.abr_148_16]</ref> and other articles. Picture on how to do it property from the same article <ref name=Esmailian></ref> which is under CC BY-NC-SA 4.0 license:
 +
[[File:Steri-strips.png|thumb|Steri-Strips]]
 +
 
 +
===Scalp Laceration===
 +
*Scalp laceration can be done with staples or if the patient has enough hair with [https://lacerationrepair.com/techniques/alternative-wound-closure/hair-apposition-technique/ Hair Apposition Technique] by twisting hair together and using dermabond.
 +
 
 +
===Aftercare===
 +
*Consider [[antibiotics]] for
 +
**Wounds contaminated by debris or feces
 +
**Caused by punctures or [[animal bites|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 prophylaxis]]
**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
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**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]]
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*[[Eyelid Laceration]]
 
*[[Eyelid Laceration]]
 
*[[Tongue Laceration]]
 
*[[Tongue Laceration]]
 +
*[[Nailbed laceration]]
 +
*[[Conjunctival laceration]]
 
*[[Bites]]
 
*[[Bites]]
 +
*[[LET]]
  
==Source==
+
==References==
*UpToDate
+
<references/>
*Tintinalli
 
 
 
 
[[Category:Trauma]]
 
[[Category:Trauma]]
 
[[Category:Procedures]]
 
[[Category:Procedures]]

Latest revision as of 14:12, 12 December 2019

Indications

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
      • EMLA needs to be left on 1-2 hours [5]
      • LET onset is 20-30 minutes[5]
  • 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.

Sutures chart

Suture Usage
Area Size Type Days to Removal
Scalp Staples or 4-0 or 5-0 non absorbable 7
Ear 6-0 non absorbable 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

Steri-Strips

  • 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

Scalp Laceration

  • 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.

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 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)

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.
  5. 5.0 5.1 KUNDU S, et. al. Principles of Office Anesthesia: Part II. Topical Anesthesia Am Fam Physician. 2002 Jul 1;66(1):99-102.
  6. 6.0 6.1 Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds' Scar. Adv Biomed Res. 2018;7:49. Published 2018 Mar 27. doi:10.4103/abr.abr_148_16