What are the steps for managing a laceration?

Laceration Management

Wounds should be thoroughly irrigated with a large volume of warm or room temperature potable water with or without soap until there is no foreign matter in the wound. 1 This approach is supported by evidence showing that irrigation is better than no irrigation, and tap water is as effective as other irrigation solutions in reducing infection rates 1.

Initial Assessment and Preparation

1. Ensure adequate lighting and visualization of the wound
2. Provide appropriate anesthesia:
   • Local anesthetic infiltration for simple lacerations
   • Regional or general anesthesia for complex lacerations 1
3. Prepare the wound site with betadine or chlorhexidine 1
   • Povidone-iodine is standard
   • Use chlorhexidine gluconate if patient is allergic to iodine 1

Wound Irrigation and Cleansing

1. Irrigate thoroughly with potable water (tap water is effective) 1
   • Higher irrigation pressures are more effective than lower pressures
   • Higher volumes (100-1000 mL) are better than lower volumes 1
   • Body temperature water is more comfortable than cold water 1
2. Remove all foreign material from the wound

Wound Closure Options

For Simple Lacerations (First-Degree)

1. Consider non-surgical management options:

   • No suturing if hemostatic and well-approximated
   • Skin adhesives for low-tension areas
   • These options are associated with shorter procedure time, less pain, and similar functional outcomes 1, 2

2. If using skin adhesive:

   • Reduces pain and procedure time (2.29 vs 7.88 minutes) 1
   • Patients become pain-free faster (3.18 vs 8.65 days) 1
   • Results in less need for local anesthetic 1

For Deeper Lacerations (Second-Degree)

1. Close in layers from deep to superficial:

   • Start by anchoring suture above apex of laceration in vaginal epithelium (if applicable)
   • Use continuous non-locking sutures for deep tissue layers 1, 3
   • Close muscles in a running, continuous, non-locking fashion 1
   • For skin closure, use continuous non-locking subcuticular sutures or consider leaving skin unsutured/using skin adhesive 1, 3

2. Suture material selection:

   • Avoid catgut (associated with more pain and need for resuturing)
   • Use standard synthetic or rapidly dissolving synthetic sutures 1
   • Monofilament non-absorbable sutures (5-0 or 6-0) are recommended for skin closure due to less bacterial seeding and reduced infection risk 3

Wound Dressing

1. Cover with clean occlusive dressing and/or topical antibiotic 1
   • Wounds heal better with less infection when covered
   • Apply antibiotic ointment only if the wound is superficial and patient has no known allergies 1
   • Occlusive and semi-occlusive dressings create a moist environment that promotes faster healing 4

Post-Repair Care

1. Pain management:

   • Acetaminophen and ibuprofen for pain control
   • Ice packs to reduce swelling
   • Sitz baths if applicable 1

2. Monitor for complications:

   • Infection signs (redness, warmth, increased pain, purulent discharge)
   • Wound dehiscence
   • Poor cosmetic outcome

3. Timing of suture removal depends on location and is based on expert opinion 4

Special Considerations

• For complex lacerations (involving specialized structures like fingertips, ears, nose, lips, tongue, or eyelids), consider specialist consultation 5
• For lacerations near joints, consider splinting to protect the repair 6
• Topical skin adhesives are used in about 25% of ED wound closures and are associated with shorter ED length of stay (101 vs 136 minutes) 2

Common Pitfalls to Avoid

1. Inadequate irrigation leading to increased infection risk
2. Excessive tension on sutures causing tissue necrosis and poor healing 3
3. Improper layered closure resulting in dead space and potential seroma/hematoma formation
4. Overlooking foreign bodies in the wound
5. Failure to provide tetanus prophylaxis when indicated 4

By following these steps systematically, most lacerations can be effectively managed with optimal cosmetic results and minimal risk of infection.