What is the treatment for deep skin lacerations?

Treatment of Deep Skin Lacerations

Deep skin lacerations require thorough irrigation, wound assessment, layered closure when appropriate, and consideration of antibiotic prophylaxis based on specific risk factors rather than routine administration.

Immediate Wound Management

Irrigation and Cleaning

• Irrigate wounds with tap water or sterile saline using moderate pressure to remove foreign bodies and pathogens, as both are equally effective at reducing infection rates 1
• Use volumes between 100-1000 mL, with higher volumes being more effective 1
• Avoid high-pressure irrigation as it may drive bacteria deeper into tissue layers 1
• Body temperature saline is more comfortable than cold saline during irrigation 1
• Soap and water may be more effective than saline alone for thorough cleansing 1

Wound Assessment and Debridement

• Examine the wound radiographically if foreign body contamination is suspected 2
• Remove necrotic tissue and superficial debris mechanically to reduce pathogen burden 1, 2
• Assess wound depth, location, and time since injury to determine closure appropriateness 3, 4

Timing of Wound Closure

General Principles

• There is no absolute "golden period" for wound closure - timing depends on wound characteristics rather than arbitrary time limits 4
• Wounds may be safely closed up to 18 hours or more after injury depending on type and location 4
• Facial wounds can be closed primarily even with some delay due to excellent blood supply 3

High-Risk Wounds Requiring Caution

• Hand bite wounds should NOT be closed primarily due to higher infection rates 3
• Human and animal bite wounds are high-risk and may require delayed primary closure or healing by secondary intention 3
• Facial bite wounds are the exception and can be closed primarily with copious irrigation, cautious debridement, and prophylactic antibiotics 3

Closure Technique

Layered Closure Principles

• The dermis provides the skin's greatest tensile strength - accurate approximation of the entire dermal depth to the opposite side is essential 2
• Close wounds in layers: deep dermal layer first, then superficial layers 2
• Epidermal coaptation provides cosmetic appearance but does not contribute to wound strength 2
• Fat and muscle do not hold sutures effectively 2

Specific Technique for Deep Lacerations

• Use interrupted subcuticular sutures for optimal results 2, 5
• Slightly bevel skin edges and undermine with precise, even thickness at wound margins 5
• Ensure accurate approximation without tension to minimize scarring 5
• Full-thickness sutures may only be safely used on palmar and plantar surfaces 2

Anesthesia Considerations

• Local anesthetic with epinephrine up to 1:100,000 concentration is safe for use on digits 4
• Epinephrine 1:200,000 concentration is safe for nose and ears 4
• Use nonsterile gloves during repair - they do not increase infection risk compared to sterile gloves 4

Antibiotic Prophylaxis

When NOT to Use Antibiotics

• Universal antibiotic prophylaxis is NOT recommended for most lacerations 1
• Simple abscesses treated with incision and drainage alone do not require antibiotics if the patient has minimal systemic signs (temperature <38.5°C, WBC <12,000, pulse <100) 1
• Do not give antibiotics if patient presents ≥24 hours after bite injury without clinical infection signs 1

When to Consider Antibiotics

• Fresh, deep wounds in critical locations (hands, feet, joints, face, genitals) warrant 3-5 days of early antibiotic treatment 1
• Bite wounds on hands specifically benefit from prophylactic antibiotics 1
• Patients with elevated infection risk: severe comorbidities, immunosuppression, prosthetic devices 1
• Associated severe cellulitis or deep wounds require broad-spectrum coverage 1

Antibiotic Selection for Bite Wounds

• Use agents covering oral flora, Staphylococcus, Streptococcus, and anaerobes 1
• Common pathogens include Pasteurella spp. (cat/dog bites), Eikenella corrodens (human bites), and anaerobes 1

Wound Dressing

• Cover superficial traumatic wounds with occlusive dressings or topical antibiotics to maintain moist environment and accelerate healing 1
• Wounds heal faster in moist environments, so use occlusive or semiocclusive dressings when available 4
• For minor dermatologic wounds, petrolatum-based ointments (like Aquaphor) demonstrate superior healing compared to antibiotic ointments 6
• Topical antibiotics are unnecessary for clean surgical wounds and may cause allergic contact dermatitis 6

Tetanus Prophylaxis

• Ensure tetanus immunization is current 3
• Administer booster if >10 years for clean wounds 3
• Administer booster if >5 years for contaminated wounds 3

Post-Repair Management

• Examine wounds 2-3 days after suture placement for infection signs 2
• Use splints or slings for extensive lacerations or those near joints 2
• Suture removal timing depends on location and is based on wound tension and healing progress 4

Critical Pitfalls to Avoid

• Do not use high-pressure irrigation that forces bacteria deeper 1
• Do not attempt primary closure of infected wounds 3
• Avoid closing hand bite wounds primarily 3
• Do not routinely prescribe antibiotics for clean lacerations 1
• Never use rifampin as monotherapy if antibiotics are indicated 1