What is the management for a patient with scalp lacerations presenting 6 hours after injury?

Management of Scalp Lacerations Presenting at 6 Hours

Clean and repair the scalp laceration immediately with primary closure, as wounds presenting within 6-12 hours can be safely closed after thorough irrigation without increased infection risk. 1, 2

Immediate Wound Assessment and Preparation

• Irrigate the wound copiously with large volumes of warm or room temperature potable water or sterile normal saline until all foreign matter and debris are removed 1
• Remove only superficial debris; avoid deep debridement as it may impair skin closure 1
• No need for iodine or antibiotic-containing solutions for initial cleaning 1
• Examine carefully for underlying skull fracture, active bleeding from scalp vessels, or signs of deeper injury 3

Critical pitfall: Hair and coagulated blood can effectively hide wound edges and the true extent of injury—thorough cleaning is essential before assessment 4

Primary Closure Decision at 6 Hours

At 6 hours post-injury, you are well within the safe window for primary closure. The evidence shows:

• Clean, non-contaminated scalp lacerations presenting less than 6 hours after injury have extremely low infection rates (0.9-1.4%) regardless of irrigation technique 2
• Guidelines recommend repair of ear lacerations (similar vascular supply to scalp) within 12-24 hours for optimal outcomes 1
• The 6-hour mark is not an absolute contraindication for primary closure in clean scalp wounds with excellent blood supply 2

Closure Technique Selection

For scalp lacerations with hair ≥1 cm length, use the modified hair apposition technique (modHAT) with cyanoacrylate glue as your primary method:

• Bundle 10-15 hairs on each side of the wound, twist together with clamps, and secure with tissue adhesive 5
• This technique achieves 100% satisfactory wound healing versus 95.7% with sutures 6
• Significantly less scarring (6.3% vs 20.4%), fewer complications (7.3% vs 21.5%), and lower pain scores 6
• Procedure time is dramatically shorter (median 5 minutes vs 15 minutes for suturing) 6
• No need for shaving, anesthesia injection, or suture removal 6, 5

Use standard sutures or staples instead if:

• Hair length is <1 cm 5
• Wound edges are irregular or jagged 5
• Active bleeding persists after 5-10 minutes of direct pressure 5
• Wound involves areas without adequate hair for apposition 5

Critical technique point: Apply glue only to the twisted hair bundle—avoid excess glue running onto scalp or into the wound 5

Post-Closure Management

• Cover with clean occlusive dressing to maintain moist wound environment 1
• Consider topical antibiotic ointment if superficial and no antibiotic allergies 1
• Instruct patient to keep wound clean and dry 1
• No routine prophylactic oral antibiotics needed for clean scalp lacerations (only 2.8-4.0% of patients in studies received antibiotics) 2

Tetanus Prophylaxis

• Verify tetanus immunization status and update if needed 1
• Administer tetanus toxoid if status is outdated or unknown 1

Follow-Up Protocol

• Schedule follow-up within 24 hours by phone or office visit 1
• Monitor for infection signs: increasing pain, redness, swelling, warmth, or purulent discharge 1
• For HAT technique: no suture removal needed; glue falls off naturally 6
• For sutured wounds: remove sutures at 7-10 days 6

Red Flags Requiring Immediate Intervention

• Hemodynamic instability from scalp hemorrhage—scalp wounds can cause greater than expected blood loss and rapid destabilization 3
• Signs of underlying skull fracture or intracranial injury 4
• Development of infection requiring wound opening and drainage (more important than antibiotics) 7
• Continued bleeding despite direct pressure—may require vessel ligation or hemostatic agents 3, 5

Key clinical pearl: The scalp's rich vascular supply makes infection rare but also means these wounds can bleed profusely—control hemorrhage first before definitive closure 3