What is the appropriate treatment for an adult patient with no significant medical history presenting with a lacerated wound?

Treatment of Lacerated Wounds in Adults

For an adult with a lacerated wound and no significant medical history, thoroughly irrigate the wound with tap water or sterile saline until debris-free, apply appropriate anesthesia, close with sutures or tissue adhesives depending on wound tension, cover with an occlusive dressing, and ensure tetanus prophylaxis is current. 1

Immediate Wound Assessment and Cleaning

Initial Irrigation

• Irrigate thoroughly with running tap water or sterile saline until no visible debris or foreign matter remains in the wound 1
• Tap water is equally effective as sterile saline for wound irrigation and does not increase infection rates 1, 2
• Antiseptic agents like povidone-iodine provide no additional benefit over simple irrigation 1
• Adequate irrigation pressure is critical to remove bacterial contamination, though simple rinsing may be insufficient 1

Special Wound Considerations

• Any wound involving animal or human bites, or contamination with saliva, requires immediate medical facility evaluation for antibiotic prophylaxis 1
• Early antibiotics prevent infection in high-risk bites, particularly to the hand 1

Pain Management and Anesthesia

Topical Anesthetics

• Apply topical lidocaine-epinephrine-tetracaine (LET) combinations for 20-30 minutes to achieve excellent wound anesthesia 1
• LET is contraindicated in patients with amide anesthetic allergies or grossly contaminated wounds 1
• Dose: 3 mL for patients >17 kg; 0.175 mL/kg for patients <17 kg 1

Injectable Anesthesia

• When topical anesthesia is insufficient or time-sensitive, use buffered lidocaine with bicarbonate, warmed before injection, administered slowly with a small-gauge needle to minimize pain 1
• Local anesthetic with epinephrine (up to 1:100,000 concentration) is safe for use on digits 2

Wound Closure Methods

Suturing

• Suturing remains the preferred method for most lacerations, particularly in high-tension areas 3, 4
• Wounds can be safely sutured up to 18-24 hours after injury depending on wound location, as no definitive "golden period" exists 2, 5
• Use absorbable sutures for facial wounds to avoid the pain of suture removal 1
• Nonsterile gloves are acceptable and do not increase infection risk compared to sterile gloves 2

Tissue Adhesives

• Tissue adhesives (octyl cyanoacrylate) provide essentially painless closure for low-tension wounds with linear edges that can be evenly approximated 1, 4
• Equally effective as sutures for patient satisfaction, infection rates, and scarring in appropriate wounds 3, 4
• More cost-effective than suturing in suitable cases 3

Wound Adhesive Strips

• Steri-Strips provide painless closure for appropriate wounds and are less expensive than tissue adhesives 1

Wound Dressing

Occlusive Dressings

• Cover clean wounds with occlusive dressings (film, petrolatum, hydrogel, or cellulose/collagen) to promote faster healing compared to dry dressings 1
• Wounds heal faster in moist environments, supporting the use of occlusive and semiocclusive dressings 2
• Antibiotic or antibacterial dressings do not improve healing or decrease infection rates in clean wounds 1

Post-Closure Care

• Wounds can get wet within 24-48 hours after suturing without increasing infection risk 5
• Monitor for infection signs: redness, swelling, foul-smelling drainage, increased pain, or fever 1

Antibiotic Considerations

When Antibiotics Are NOT Needed

• Most clean lacerations do not require prophylactic antibiotics 1, 5
• For surgical site infections with <5 cm erythema, temperature <38.5°C, WBC <12,000 cells/µL, and pulse <100 bpm, antibiotics are unnecessary after incision and drainage 1

When Antibiotics ARE Indicated

• Human or animal bites require early antibiotic administration 1, 3
• Wounds with temperature >38.5°C, heart rate >110 bpm, or erythema extending >5 cm beyond wound margins may require 24-48 hours of antibiotics 1

Tetanus Prophylaxis

Assessment

• All penetrating wounds, crush injuries, wounds contaminated with feces/soil/saliva, burns, or avulsions are tetanus-prone 1
• Patients without reliable vaccination history should be assumed unvaccinated 1

Administration

• Adults without confirmed tetanus booster in the preceding 5 years should receive Tdap (or Td if Tdap unavailable, or if age >65 years) 1
• Appropriate wound debridement is critical to tetanus prevention 1

Common Pitfalls to Avoid

• Do not delay wound closure waiting for a "golden period"—assess each wound individually for closure timing 2
• Avoid aggressive cleansing that damages fragile tissue 6
• Do not routinely use topical antiseptics or antimicrobial dressings for clean wounds 1, 6
• Do not prescribe prophylactic antibiotics for simple clean lacerations 1, 5
• Ensure tetanus status is addressed—this is frequently overlooked 3