Laceration repair: Difference between revisions
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Ostermayer (talk | contribs) (Text replacement - " pts" to " patients") |
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**Wounds over flexor surfaces or tension | **Wounds over flexor surfaces or tension | ||
*Tetanus | *Tetanus | ||
**Tdap 0.5cc IM to | **Tdap 0.5cc IM to patients >7y w/ no booster w/in 5 yr | ||
**Hypertet 250 u IM @ diff site from Tdap if NO Hx of Td or < 3 doses given | **Hypertet 250 u IM @ diff site from Tdap if NO Hx of Td or < 3 doses given | ||
***Require f/u Tdap @ 1mo & 1 yr; age>60 = high risk of poor immunization | ***Require f/u Tdap @ 1mo & 1 yr; age>60 = high risk of poor immunization |
Revision as of 16:50, 21 June 2016
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 |
|
Mepivicaine | 7 mg/kg | 8 mg/kg | ||
Bupivicaine | 2.5 mg/kg (max 175mg) | 3 mg/kg (max 225mg) | 6-8 hr |
|
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
- Explore to base of wound
- Ideally done in bloodless field
- Look for foreign bodies, tendon injury, or fracture
- Possible glass in wound = get x-ray to evaluate
Suturing
- See Sutures
- If laceration not closed immediately 2/2 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 w/ no booster w/in 5 yr
- Hypertet 250 u IM @ diff site from Tdap if NO Hx of Td or < 3 doses given
- Require f/u Tdap @ 1mo & 1 yr; age>60 = high risk of poor immunization
- Dressing
- Keep moist, not wet
- Bandaid, xeroform, or ointment
- Keep moist, not wet
- Wound check
- 48-72 hrs ONLY if high risk wound
- No point in checking before 48hr (takes this long for infection to occur)
- 48-72 hrs ONLY if high risk wound