What is the management for a patient with a lacerated wound at the scalp area due to a Motor Vehicle Accident (MVA) with bleeding but no fractures?

Management of Scalp Laceration from Motor Vehicle Accident

Immediate Bleeding Control

Apply direct pressure to the scalp wound immediately to achieve hemostasis, as scalp lacerations can cause greater than expected blood loss and contribute to rapid patient destabilization. 1

• Control bleeding using direct pressure, compression bandages, or tourniquets if necessary 2
• Scalp wounds have rich vascular supply and can bleed profusely despite appearing minor 1
• Assess hemodynamic status using vital signs to determine if the patient is in hemorrhagic shock 3

Clinical Assessment

Grade the extent of bleeding using the American College of Surgeons Advanced Trauma Life Support (ATLS) classification system to identify patients at risk. 3

• Evaluate for signs of hemorrhagic shock: tachycardia (>100 bpm), hypotension, altered mental status 3
• Examine the wound for depth, length, irregular edges, and continued bleeding after pressure application 4
• Since no fractures are present, focus on soft tissue injury management 5

Wound Preparation and Closure

Irrigate the wound with potable tap water or sterile saline, as tap water does not increase infection risk compared to sterile saline. 5

Closure Technique Selection:

• For wounds in hair-bearing areas with hair ≥1 cm long: Use modified hair apposition technique (modHAT) with cyanoacrylate glue by bundling 10-15 hairs, twisting them with clamps, and applying glue to the twisted hair only (avoiding excess glue on scalp or in wound) 4
• For wounds with continued bleeding after pressure, irregular edges, or hair <1 cm: Use sutures or staples 4
• For low-tension areas: Tissue adhesives or wound adhesive strips are effective 5

Timing Considerations:

• There is no absolute "golden period" - depending on wound type, closure may be reasonable even 18+ hours after injury 5
• However, minimize time to definitive repair when possible 3

Anesthesia

Use local anesthetic with epinephrine (1:100,000 to 1:200,000 concentration) for hemostasis and pain control, as this is safe for scalp use. 5

• Epinephrine provides vasoconstriction to reduce bleeding 5
• Use nonsterile gloves during repair, as they do not increase infection risk compared to sterile gloves 5

Wound Care and Follow-up

Apply occlusive or semiocclusive dressings to promote faster healing in a moist environment. 5

• Perform wound check at 2 days post-repair 4
• Remove sutures based on location: scalp sutures typically 7-10 days 5
• Provide tetanus prophylaxis if indicated 2, 5
• Consider antibiotic prophylaxis to prevent infection 2

Hemodynamic Management (If Unstable)

If the patient presents with hemorrhagic shock from scalp bleeding, target systolic blood pressure of 80-100 mmHg until bleeding is controlled. 3

• Establish large-bore IV access for fluid resuscitation 2
• Use crystalloids (0.9% NaCl or balanced solution) initially 3
• Obtain baseline labs: CBC, coagulation studies, type and cross-match 2

Common Pitfalls to Avoid

• Do not underestimate blood loss from scalp wounds - they can cause significant hemorrhage requiring resuscitation 1
• Avoid applying glue directly to the scalp or into the wound when using hair apposition technique 4
• Do not delay closure unnecessarily - wounds can be safely closed beyond traditional time frames 5
• Ensure adequate hemostasis before closure - continued bleeding after pressure requires sutures/staples rather than adhesive techniques 4