Laceration repair

Revision as of 19:09, 17 February 2015 by Rossdonaldson1 (talk | contribs) (Anesthesia)

Indications

  • Do not close body wounds >12 hr old
  • 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

  • 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

  • Put LET in open wound, EMLA on intact skin (doesn't work in open wound)
  • Check motor/sensory before give 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

  • Ideally done in bloodless field
  • Look for foreign bodies, tendon tears, or fracture
  • Glass in wound = need for xray

Suturing

Aftercare

  • Antibiotics
    • Consider 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 pts >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
  • 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

Source

  • UpToDate
  • Tintinalli