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. 1, 2

Immediate Wound Assessment and Preparation

Irrigate the wound copiously with warm or room temperature sterile normal saline or potable water using high-pressure irrigation (20-mL or larger syringe) to remove all foreign matter and debris. 1, 3 At 6 hours post-injury, this patient falls well within the safe window for primary closure, as clean scalp lacerations can be repaired up to 12-24 hours after injury with excellent outcomes. 1

• Remove only superficial debris during cleaning; avoid aggressive debridement that may impair skin closure or enlarge the wound. 1, 3
• No iodine or antibiotic-containing solutions are needed for initial cleaning. 1
• Examine the wound carefully after irrigation, as coagulated blood and hair can obscure the true extent of injury and wound edges. 4

Important caveat: Research demonstrates that for clean, noncontaminated scalp lacerations presenting within 6 hours, irrigation before closure does not significantly alter infection rates (0.9% vs 1.4%, p=0.28) or cosmetic outcomes. 2 However, irrigation remains standard practice for removing visible debris and assessing wound depth.

Wound Closure Technique Selection

For scalp lacerations in hair-bearing areas with hair ≥1 cm long, use the modified hair apposition technique (modHAT) with cyanoacrylate glue as the primary closure method. 5, 6

• Bundle 10-15 hairs from each wound edge, twist them together with clamps, and secure with tissue adhesive. 5
• This technique achieves 100% satisfactory wound healing compared to 95.7% with sutures (p=0.057), with significantly less scarring (6.3% vs 20.4%, p=0.005), fewer complications (7.3% vs 21.5%, p=0.005), lower pain scores (median 2 vs 4, p<0.001), and faster procedure time (median 5 vs 15 minutes, p<0.001). 6
• Apply glue only to the twisted hair bundle, avoiding excess glue running onto the scalp or into the wound. 5

Use standard sutures or staples if:

• Hair length is <1 cm. 5
• Wound edges are irregular or jagged. 5
• Active bleeding continues after direct pressure. 5
• The laceration involves areas without adequate hair. 5

Post-Closure Wound Care

• Cover the wound with a clean occlusive dressing to maintain moisture and prevent drying. 1
• Consider topical antibiotic ointment for superficial injuries if no antibiotic allergies exist. 1
• Instruct the patient to keep the wound clean and dry. 1
• Advise elevation of the head during the first few days if swelling is present. 1

Tetanus Prophylaxis

Administer tetanus toxoid booster if >5 years since last dose or if vaccination status is unknown. 1, 3

Mandatory Follow-Up and Monitoring

Schedule follow-up within 24 hours by phone or office visit to assess for infection. 1, 3

Monitor for these infection warning signs:

• Increasing pain, redness, swelling, or warmth. 1
• Purulent discharge. 1
• Fever or systemic symptoms. 1

Critical pitfall: Scalp lacerations can cause significant blood loss and acute anemia, particularly if initially overlooked or inadequately controlled. 4, 7 The rich vascular supply of the scalp can lead to greater-than-expected hemorrhage that contributes to patient destabilization. 7 Ensure hemostasis is achieved before closure.

Antibiotic Prophylaxis Decision

Routine antibiotic prophylaxis is NOT indicated for clean scalp lacerations presenting at 6 hours. 2 The infection rate for clean, noncontaminated scalp lacerations is extremely low (0.9-1.4%) regardless of irrigation or antibiotic use. 2

Consider antibiotics only if:

• The wound shows signs of contamination or debris that cannot be fully removed.
• There are early signs of infection at presentation.
• The patient is immunocompromised.