What is the best approach to managing a facial laceration in a clinically intoxicated patient with a history of alcohol use disorder and experiencing homelessness?

Management of Facial Laceration in an Intoxicated Patient with Alcohol Use Disorder and Homelessness

For this patient with a facial laceration who is clinically intoxicated and experiencing homelessness, interrupted stitches using rapid absorbing suture (Option C) is the best approach. This provides secure wound closure while eliminating the need for suture removal follow-up, which is critical given the patient's social circumstances and likely poor follow-up reliability.

Rationale for Rapid Absorbing Sutures

Rapid absorbing sutures should be strongly considered for facial wounds to avoid the pain and anxiety of suture removal, particularly in patients unlikely to return for follow-up care 1. This is especially relevant for:

• Patients experiencing homelessness who face significant barriers to accessing follow-up care
• Patients with alcohol use disorder who may have difficulty maintaining scheduled appointments 1
• Facial lacerations where suture removal at 5-7 days would typically be required 2

The American Academy of Pediatrics specifically recommends absorbable sutures for facial wounds to eliminate the need for removal 1, and this principle applies equally to adults with barriers to follow-up care.

Why Other Options Are Less Appropriate

Tissue Adhesive (Option A) - Not Recommended

While tissue adhesives provide painless closure and are effective for simple lacerations 3, 4, they are contraindicated in this clinical scenario because:

• The patient is intoxicated and uncooperative, making careful application difficult 5
• Tissue adhesives have significantly higher dehiscence rates compared to sutures 4
• The wound location (superior lateral nose with bleeding) suggests higher tension that requires more secure closure 1
• Gross contamination from the fight may be present, which is a relative contraindication 1

Delayed Primary Closure (Option D) - Not Recommended

Returning in 72 hours for delayed primary closure is impractical and inappropriate for this patient because:

• Patients experiencing homelessness have substantial barriers to follow-up care 1
• Facial lacerations typically do not require delayed closure unless heavily contaminated or devitalized 4
• The trauma evaluation was negative except for the facial injuries, suggesting the wound is suitable for immediate closure

ED Ophthalmology Consultation (Option B) - May Be Needed But Not Primary Management

While ophthalmology consultation may be warranted if there is:

• Concern for globe injury given the orbital ecchymosis
• Involvement of the lacrimal system with superior lateral nasal bleeding
• Eyelid margin involvement

This is an adjunctive measure, not the primary wound management approach. The question asks specifically about wound management, and the wound can be closed with sutures while awaiting or coordinating ophthalmology evaluation if needed.

Practical Implementation

The wound should be managed as follows:

• Thoroughly irrigate and explore the wound to ensure no foreign bodies or deeper structural injuries 1
• Use rapid absorbing sutures (such as 5-0 or 6-0 fast-absorbing gut) for facial closure 1, 2
• Place interrupted sutures to allow for drainage and reduce infection risk 2
• Apply topical antibiotic ointment and provide wound care instructions 1
• Provide clear verbal and written instructions that do not require follow-up for suture removal
• Consider social work consultation to address homelessness and alcohol use disorder 1

Critical Considerations for This Population

Patients with alcohol use disorder require specific attention:

• Brief motivational interventions should be offered during the ED visit 1
• Screening with validated tools (CAGE, AUDIT) should be performed 1
• Linkage to care programs are more effective than passive referrals for patients with barriers to care 1
• Active case management improves outcomes in vulnerable populations 1

The choice of rapid absorbing sutures directly addresses the reality that this patient may not return for follow-up, while still providing secure wound closure and good cosmetic outcomes for facial lacerations 1, 2.