What is the recommended treatment for a laceration, including irrigation, anesthesia, suturing technique, tetanus prophylaxis, antibiotics, analgesia, wound care, activity restrictions, and follow‑up?

Laceration Treatment

Irrigate the wound copiously with potable tap water or sterile saline, use local anesthesia (lidocaine with epinephrine is safe even on digits and face), close with appropriate technique based on wound characteristics, update tetanus prophylaxis if >5 years for dirty wounds or >10 years for clean wounds, reserve antibiotics only for high-risk wounds, and provide moist wound care with occlusive dressings.

Initial Wound Assessment and Irrigation

Irrigate thoroughly with large volumes of warm or room temperature potable tap water or sterile saline 12. Tap water is equally effective as sterile saline and does not increase infection risk 23. Remove all visible foreign matter and debris during irrigation 1. Note that not all foreign bodies are visible on plain radiographs 4.

Anesthesia

Use topical anesthetics like lidocaine-epinephrine-tetracaine (LET) gel for painless application, particularly useful in pediatric patients 5. Local anesthetic with epinephrine up to 1:100,000 concentration is safe for use on digits, and 1:200,000 concentration is safe for nose and ears 2. This contradicts older teaching about avoiding epinephrine on end-arterial structures—the evidence supports its safety.

Wound Closure Technique

Timing: Wounds can be closed up to 18-24 hours after injury without significantly increasing infection risk 623. There is no rigid "golden period" 2.

Closure method selection:

• Low-tension wounds with linear edges: Tissue adhesives or wound adhesive strips are equally effective as sutures 25
• Facial wounds: May be closed primarily after copious irrigation, cautious debridement, and preemptive antibiotics 77
• Most other wounds: Absorbable sutures perform similarly to nonabsorbable sutures and eliminate need for removal visit 6
• High-risk wounds (hand, heavily contaminated, deep structure involvement): Consider delayed closure or approximation only 77

Primary closure is NOT recommended for most bite wounds except facial wounds 787.

Tetanus Prophylaxis

Critical decision point: Assess vaccination history and wound characteristics.

For tetanus-prone wounds (puncture wounds, crush injuries, wounds contaminated with soil/feces/saliva, avulsions, burns) 999:

• If last tetanus booster >5 years ago: Give Tdap (preferred if not previously given) or Td if >65 years 9977
• If vaccination history uncertain or incomplete: Give age-appropriate vaccine PLUS consider tetanus immune globulin (TIG) 250 units IM at separate site 999

For clean wounds:

• If last booster >10 years ago: Give Tdap or Td 77

Pediatric dosing 99:

• DTaP if <7 years
• Td if 7-10 years
• Tdap if ≥11 years

Appropriate wound care and debridement are critical to tetanus prevention 9999.

Antibiotic Prophylaxis

Antibiotics are NOT routinely indicated for simple lacerations 3. Reserve antibiotics for high-risk wounds only 63:

High-risk criteria requiring antibiotics 78:

• Immunocompromised patients
• Asplenic patients
• Advanced liver disease
• Preexisting edema of affected area
• Moderate to severe injuries, especially hand or face
• Injuries penetrating periosteum or joint capsule
• Gross contamination
• Involvement of deeper structures
• Stellate wounds
• Selected bite wounds

Antibiotic selection for high-risk wounds: Amoxicillin-clavulanate for coverage of aerobes and anaerobes 78. Alternative: fluoroquinolone (ciprofloxacin or levofloxacin) plus metronidazole, or moxifloxacin alone if β-lactam allergy 7.

Duration: 3-5 days for preemptive therapy 78.

Wound Care and Dressings

Maintain moist wound environment with occlusive or semiocclusive dressings—wounds heal faster when kept moist 235. Apply antibiotic ointment (e.g., petrolatum-based) only to superficial abrasions if no known allergies 15.

Wounds can get wet within 24-48 hours after closure without increasing infection risk 3. This contradicts traditional "keep it dry" advice.

Analgesia

Topical anesthetics provide painless application 5. For procedural pain, LET gel is effective. Systemic analgesia should be based on pain severity using standard analgesic ladder.

Activity Restrictions

Avoid tension on wound during healing. For facial lacerations, minimize excessive facial movements. Specific restrictions depend on wound location and depth—use clinical judgment based on anatomic considerations.

Follow-up and Suture Removal

Suture removal timing (based on expert opinion) 2:

• Face: 3-5 days
• Scalp: 7-10 days
• Trunk: 7-10 days
• Arms/legs: 10-14 days
• Joints: 14 days
• Hands/feet: 10-14 days

Absorbable sutures eliminate need for removal 6.

Monitor for signs of infection: increasing pain, erythema, warmth, purulent drainage, fever. Superficial mild infections can be treated with topical agents; deeper infections require oral antibiotics 3.

Common Pitfalls

• Don't avoid epinephrine on digits/face—it's safe and provides better hemostasis 2
• Don't routinely prescribe antibiotics—they're only for high-risk wounds 63
• Don't insist on sterile technique for irrigation—tap water works 23
• Don't delay closure beyond 24 hours unnecessarily—infection risk doesn't dramatically increase 62
• Don't forget tetanus status—this is the most preventable complication 77
• Don't close bite wounds (except face with proper precautions) 77