Difference between revisions of "Laceration repair"

(Management)
(Skin Glue)
 
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==Indications==
 
==Indications==
Skin or mucosal laceration.
+
*Skin or mucosal [[laceration]].
  
 
==Contraindications==
 
==Contraindications==
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*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 as this can increase chances of infection (if do, avoid using razor)
 +
**Can use antibiotic ointment to help keep hair out of the way
  
 
===Irrigation===
 
===Irrigation===
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**Not a contaminated wound
 
**Not a contaminated wound
 
**Not older than 6 hours
 
**Not older than 6 hours
 +
***Often best to avoid irrigation of face and opt for cleaning with gauze to help prevent tissue distortion
  
 
===Anesthesia===
 
===Anesthesia===
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*Topical
 
*Topical
 
**LET for open wound, EMLA for intact skin
 
**LET for open wound, EMLA for intact skin
 +
***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>
 +
***LET onset is 20-30 minutes<ref name=aafp></ref>, area will appear pale
 
*Evaluate motor/sensation before giving local anesthesia
 
*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)
 
**Inject slowly
 
**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
  
 
{{Maximum doses of anesthetic agents}}
 
{{Maximum doses of anesthetic agents}}
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*Ideally done in bloodless field
 
*Ideally done in bloodless field
 
*Look for foreign bodies, tendon injury, or fracture
 
*Look for foreign bodies, tendon injury, or fracture
*Possible glass in wound = get XR or US to evaluate
+
*Possible glass or metal in wound = get XR or US to evaluate
  
 
===Suturing===
 
===Suturing===
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{{Suture chart}}
 
{{Suture chart}}
 +
 +
===Steri-Strips===
 +
*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]]
 +
 +
===Skin Glue===
 +
*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
 +
*If you accidentally glue the eyes shut use dexamethasone, neomycin, polymyxin B eyedrops (brand name Maxitrol in the U.S.) on the glue then gentle rubbing after 45 or 90 seconds <ref>Liu et al. Inadvertent tissue adhesive tarsorrhaphy of the eyelid: a review and exploratory trial of removal methods of Histoacryl.  Emerg Med J. 2020 Apr;37(4):212-216. doi: 10.1136/emermed-2019-209177. Epub 2020 Jan 9.  https://www.ncbi.nlm.nih.gov/pubmed/31919233?dopt=AbstractPlus</ref>
 +
 +
===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.
 +
*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
  
 
===Aftercare===
 
===Aftercare===
*Consider antibiotics for
+
*Consider [[antibiotics]] for
 
**Wounds contaminated by debris or feces
 
**Wounds contaminated by debris or feces
**Caused by punctures or bites
+
**Caused by punctures or [[animal bites|bites]]
 
**Tissue destruction or in avascular areas
 
**Tissue destruction or in avascular areas
 
**Neglected wounds
 
**Neglected wounds
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*Splinting
 
*Splinting
 
**Wounds over flexor surfaces or tension
 
**Wounds over flexor surfaces or tension
*Tetanus
+
*[[Tetanus prophylaxis]]
 
**Tdap 0.5cc IM to patients >7y with no booster within 5 yr
 
**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
 
**Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given
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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)
 +
 +
===Scar Minimization===
 +
*Preventing infection
 +
**Keep wound clean and covered
 +
**Apply antibiotic ointment twice daily
 +
*Once healed, encourage daily sunscreen use and Vitamin E creams
 +
 +
===When to Call a Consultant===
 +
*Signs of neurovascular or tendon injury
 +
*Facial wounds that cross cosmetic boundaries
 +
*Tissue loss
  
 
==Billing==
 
==Billing==
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*[[Eyelid Laceration]]
 
*[[Eyelid Laceration]]
 
*[[Tongue Laceration]]
 
*[[Tongue Laceration]]
 +
*[[Nailbed laceration]]
 +
*[[Conjunctival laceration]]
 
*[[Bites]]
 
*[[Bites]]
 
*[[LET]]
 
*[[LET]]

Latest revision as of 11:25, 9 May 2020

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 as this can increase chances of infection (if do, avoid using razor)
    • Can use antibiotic ointment to help keep hair out of the way

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
      • Often best to avoid irrigation of face and opt for cleaning with gauze to help prevent tissue distortion

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], 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

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 or metal 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

Skin Glue

  • 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
  • If you accidentally glue the eyes shut use dexamethasone, neomycin, polymyxin B eyedrops (brand name Maxitrol in the U.S.) on the glue then gentle rubbing after 45 or 90 seconds [7]

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.
  • 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

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)

Scar Minimization

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

When to Call a Consultant

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

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
  7. Liu et al. Inadvertent tissue adhesive tarsorrhaphy of the eyelid: a review and exploratory trial of removal methods of Histoacryl. Emerg Med J. 2020 Apr;37(4):212-216. doi: 10.1136/emermed-2019-209177. Epub 2020 Jan 9. https://www.ncbi.nlm.nih.gov/pubmed/31919233?dopt=AbstractPlus