What are the step‑by‑step procedures for assessing and repairing a laceration, including consent, anesthesia, irrigation, layered suturing, dressing, tetanus prophylaxis, antibiotic use, follow‑up, and special considerations for anticoagulant therapy and comorbidities such as diabetes or vascular disease?

Laceration Repair: Step-by-Step Protocol

For simple lacerations, perform immediate irrigation with copious sterile saline, sharp debridement of devitalized tissue, primary closure within 8 hours (facial wounds may be closed beyond this with antibiotics), tetanus prophylaxis per immunization status, and reserve antibiotics for contaminated wounds or high-risk patients. 1

Initial Assessment and Preparation

Wound Evaluation

• Remove all callus, necrotic tissue, and debris to fully visualize the wound depth and extent before proceeding 2
• Probe the wound to assess depth and determine if it penetrates to fascia, tendon, muscle, joint, or bone 2
• Document wound measurements, surrounding cellulitis extent, drainage characteristics (color, clarity, odor), and photograph if possible 2
• Check for signs of serious infection: cellulitis >2 cm from wound edge, crepitus, bullae, discoloration, necrosis, or systemic signs (fever, hypotension, confusion) 2

Patient Risk Stratification

• Assess for diabetes, vascular disease, immunosuppression, or anticoagulation therapy as these increase infection risk and alter healing 2, 1
• In diabetic patients, evaluate arterial perfusion to determine if revascularization is needed before repair 2
• Patients with peripheral vascular disease have increased risk of complications and may require vascular surgery consultation 3

Consent

• Inform patient that debridement will cause bleeding and the wound will appear larger after full exposure 2
• Discuss closure method, expected healing time, infection risk, and need for follow-up 2

Anesthesia

• Local anesthesia is required for patients with intact sensation 2
• Patients with diabetic neuropathy and loss of protective sensation may not require anesthesia 2

Wound Preparation

Irrigation

• Irrigate thoroughly with large volumes of warm or room-temperature sterile saline until no foreign matter remains 2
• Avoid high-pressure irrigation as it may drive bacteria into deeper tissue layers 2
• Cold water is equally effective but less comfortable than warm water 2

Debridement

• Perform sharp debridement using scalpel, scissors, or tissue nippers to remove all necrotic tissue, slough, foreign material, and surrounding hyperkeratosis 2
• This removes colonizing bacteria, facilitates granulation tissue formation, reduces pressure at callused sites, and permits proper culture collection 2
• Debride cautiously to avoid unnecessarily enlarging the wound 1
• Repeat debridement as often as needed if nonviable tissue continues to form 2
• Debridement may be contraindicated in primarily ischemic wounds 2

Wound Closure Decision Algorithm

Timing Considerations

• Close clean wounds within 8 hours of injury to minimize infection risk 1
• Facial wounds may be closed primarily even after 8 hours with copious irrigation, cautious debridement, and prophylactic antibiotics 1
• Never close infected wounds primarily, regardless of timeframe 1

Closure Method Selection

Primary Closure Indicated:

• Clean wounds within 8 hours 1
• Facial wounds beyond 8 hours with proper preparation and antibiotics 1
• Wounds without purulent material, significant devitalization, or contamination 1

Delayed Primary or Secondary Closure Indicated:

• Presence of purulent material (overt infection) 1
• Injury >8 hours old with clinical contamination signs 1
• Significant tissue devitalization that cannot be adequately debrided 1
• Patient risk factors (obesity, immunosuppression, diabetes) combined with wound contamination 1
• Contaminated or dirty extremity wounds should undergo planned surgical revision 2-5 days after initial debridement 1

For wounds not suitable for primary closure:

• Approximate wound margins using Steri-Strips 1
• Plan delayed primary closure at 2-5 days or allow secondary intention healing 1

Layered Suturing Technique

• Close deep layers first if wound extends to fascia or deeper structures 2
• Approximate skin edges without excessive tension 2
• Ensure hemostasis throughout the procedure 2

Dressing

• Apply antibiotic ointment or cream to abrasions or superficial wounds (if no known allergies) 2
• Cover with clean occlusive dressing to promote healing and reduce infection 2
• Loosely cover any blisters but leave them intact 2

Tetanus Prophylaxis

• Administer tetanus toxoid to patients without vaccination within 10 years 1
• Consider tetanus immune globulin for high-risk wounds in inadequately immunized patients 2

Antibiotic Use

Indications for Antibiotics

• Contaminated or dirty wounds 1
• Bite wounds on hands (demonstrated benefit in meta-analysis) 2
• Fresh deep wounds in critical areas: hands, feet, near joints, face, genitals 2
• Patients at elevated risk: immunosuppression, implanted devices (artificial heart valves) 2
• Facial wounds closed beyond 8 hours 1
• Open fractures: administer as soon as possible for maximum 48-72 hours (unless proven infection develops) 2

When NOT to Use Antibiotics

• Do not give antibiotics if patient presents ≥24 hours after bite with no infection signs 2
• Clean wounds within 8-hour window do not require prophylaxis 1
• Universal prophylaxis for all bite wounds is not recommended 2

Antibiotic Selection

• First-line: Amoxicillin-clavulanate or cephalosporins for traumatic wounds 2
• Beta-lactam allergy: Clindamycin plus gentamicin 2
• Duration: 3-5 days for prophylaxis 2
• For open fractures: maximum 48-72 hours unless infection proven 2

Special Considerations

Anticoagulation Therapy

• Assess bleeding risk and ensure adequate hemostasis before closure 2
• May require longer observation period post-procedure 2

Diabetes

• Evaluate arterial perfusion before repair as diabetic vascular disease affects smaller below-knee vessels 2, 3
• Aggressive revascularization approach is warranted as there is no true microvascular occlusive disease in diabetic foot 3
• Ensure meticulous glucose control during healing period 2
• Higher infection risk (6-44% for open fractures vs 1% for closed) 2

Vascular Disease

• Peripheral arterial disease increases risk of ischemic complications 2
• May require vascular surgery consultation for revascularization 2
• Debridement may be contraindicated in primarily ischemic wounds 2

Pressure Off-Loading (for lower extremity wounds)

• Relieve pressure from wound site using total contact cast (gold standard), removable cast walker, or other off-loading device 2
• This is vital for diabetic foot wound healing 2

Follow-Up

Immediate Post-Procedure

• Elevate injured body part if swollen to accelerate healing 1
• Provide wound care instructions and signs of infection to watch for 2

Scheduled Follow-Up

• Follow-up within 24 hours by phone or office visit for significant wounds 1
• Monitor for infectious complications: septic arthritis, osteomyelitis, subcutaneous abscess, tendonitis, bacteremia 1
• Pain disproportionate to injury severity near bone or joint suggests periosteal penetration 1
• Hand wounds require closer monitoring as they are often more serious than wounds to fleshy areas 1

Delayed Primary Closure Follow-Up

• Plan surgical revision at 2-5 days for contaminated extremity wounds managed with delayed closure 1
• Reassess wound for viability, infection signs, and readiness for closure 1

Critical Pitfalls to Avoid

• Do not use tourniquets for bleeding control unless direct pressure fails, as they risk nerve/muscle injury and systemic complications 2
• Do not elevate or use pressure points for bleeding control as these are ineffective and compromise direct pressure 2
• Do not apply ice directly to wounds as it causes tissue ischemia 2
• Do not close wounds with purulent material, significant contamination, or devitalized tissue 1
• Do not give prolonged antibiotic prophylaxis beyond 48-72 hours for open fractures without proven infection 2
• Do not ignore vascular assessment in diabetic patients before wound repair 2