How to Chart a Laceration
Document the laceration systematically by recording: anatomic location with landmarks, dimensions (length × width × depth in cm), wound characteristics (edges, contamination, underlying structures), neurovascular status distal to injury, anesthesia type and amount, irrigation volume and solution, closure method with suture details, tetanus status and prophylaxis given, antibiotic indication if applicable, wound care instructions provided, and follow-up plan.
Essential Documentation Components
Initial Wound Assessment
Record the precise anatomic location using anatomical landmarks (e.g., "3 cm laceration on volar aspect of left forearm, 5 cm proximal to wrist crease"). Document:
- Dimensions: Length, width, and depth in centimeters
- Wound edges: Smooth vs. jagged, approximation quality, tissue viability
- Contamination level: Clean, contaminated with visible debris, or grossly contaminated
- Mechanism of injury: This guides infection risk assessment and tetanus prophylaxis decisions
Structural Examination
Document examination of underlying structures:
- Neurovascular status: Sensation, motor function, and perfusion distal to wound (capillary refill, pulses, color)
- Tendon integrity: Active range of motion testing
- Bone involvement: Palpation for crepitus or visible bone
- Joint capsule: Note if injury near or potentially penetrating joint space
Critical pitfall: Pain disproportionate to injury near bone or joint suggests periosteal or capsular penetration, requiring prolonged antibiotic therapy 1.
Procedural Documentation
Anesthesia
Record:
- Agent used (e.g., lidocaine 1% with or without epinephrine)
- Concentration and total volume/dose administered
- Route (topical, infiltration, or nerve block)
- Time of administration
For topical anesthetics like LET (lidocaine-epinephrine-tetracaine), document application time and duration (typically 10-20 minutes until wound edges blanch) 2.
Wound Preparation
Document irrigation details:
- Solution type: Sterile saline is standard; tap water is acceptable and does not increase infection risk 1
- Volume used: Copious irrigation is essential, especially for contaminated wounds
- Debridement: Note if performed and extent (cautious debridement to avoid enlarging wound) 1
Closure Technique
Record specific closure method:
- Sutures: Material type (absorbable vs. non-absorbable), size, technique (simple interrupted, running, mattress), and number placed
- Staples: Number used and location
- Tissue adhesives: Type used (e.g., octyl cyanoacrylate) - appropriate for low-tension wounds
- Steri-Strips: For wound approximation or delayed closure
Important consideration: Primary closure is generally NOT recommended except for facial wounds, which should receive copious irrigation, cautious debridement, and preemptive antibiotics before closure 3, 4. Other wounds may be approximated but consider delayed primary closure.
Hemostasis
Document method of bleeding control and final hemostatic status.
Prophylaxis and Medications
Tetanus Status
Document and administer per these criteria 3, 4:
- Last tetanus vaccination date
- For clean wounds: Give Tdap (preferred) or Td if >10 years since last dose
- For dirty/contaminated wounds: Give if >5 years since last dose
- Tdap is preferred over Td if patient has not previously received Tdap
Antibiotic Prophylaxis
Document indication and prescription if given. Preemptive antibiotics (3-5 days) are recommended for patients who 3:
- Are immunocompromised
- Are asplenic
- Have advanced liver disease
- Have preexisting or resultant edema of affected area
- Have moderate to severe injuries, especially to hand or face
- Have injuries potentially penetrating periosteum or joint capsule
For contaminated wounds requiring antibiotics: Amoxicillin-clavulanate covers both aerobic and anaerobic bacteria 3, 1.
Dressing and Aftercare Instructions
Document:
- Dressing type applied (occlusive dressings promote faster healing in moist environment)
- Wound care instructions given to patient
- Activity restrictions
- Signs of infection to watch for
- Follow-up timing and suture removal schedule (location-dependent)
Suture Removal Timing
Note planned removal date based on location:
- Face: 3-5 days
- Scalp: 7-10 days
- Trunk: 7-10 days
- Extremities: 10-14 days
- Joints: 14 days
Special Circumstances
For hand wounds: These are higher risk and often more serious than wounds to fleshy areas 1. Document extra caution and lower threshold for specialist referral.
For wounds >8 hours old: Closure timing is controversial. Document time from injury and clinical judgment regarding closure vs. delayed closure 1.
For bite wounds: Document animal type, provoked vs. unprovoked, and consider rabies prophylaxis consultation with local health department 3, 4.