Laceration repair: Difference between revisions
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==Indications== | ==Indications== | ||
Skin or mucosal laceration. | *Skin or mucosal [[laceration]]. | ||
==Contraindications== | ==Contraindications== | ||
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===Irrigation=== | ===Irrigation=== | ||
*High pressure irrigation is best (can be achieved with 18 gauge syringe) | *High pressure irrigation is best (can be achieved with 18 gauge syringe) | ||
*Tap water is as effective as sterile water/ normal saline | *Tap water is as effective as sterile water/ normal saline<ref>Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007 May;14(5):404-9</ref><ref>Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013 Jan 16;3(1).</ref><ref>Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD003861. </ref> | ||
**Pressure from tap is ~45 psi, higher than syringe<ref>Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998 Nov;5(11):1076-80.</ref> | |||
*Irrigation optional for face/scalp wound as long as: | *Irrigation optional for face/scalp wound as long as: | ||
**Not a bite wound | **Not a bite wound | ||
**Not a contaminated wound | **Not a contaminated wound | ||
**Not older than 6 hours | **Not older than 6 hours | ||
===Anesthesia=== | ===Anesthesia=== | ||
*Can be topical or injected. | *Can be topical or injected. | ||
*Topical | *Topical | ||
**LET for open wound, EMLA for intact skin | **LET for open wound, EMLA for intact skin | ||
***EMLA needs to be left on 1-2 hours <ref name=aafp>[https://www.aafp.org/afp/2002/0701/p99.html KUNDU S, et. al. Principles of Office Anesthesia: Part II. Topical Anesthesia Am Fam Physician. 2002 Jul 1;66(1):99-102.]</ref> | |||
***LET onset is 20-30 minutes<ref name=aafp></ref> | |||
*Evaluate motor/sensation before giving local anesthesia | *Evaluate motor/sensation before giving local anesthesia | ||
*To decrease pain of injection: | *To decrease pain of injection: | ||
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===Exploration=== | ===Exploration=== | ||
*See [[Soft tissue foreign body]] | |||
*Explore to base of wound | *Explore to base of wound | ||
*Ideally done in bloodless field | *Ideally done in bloodless field | ||
*Look for foreign bodies, tendon injury, or fracture | *Look for foreign bodies, tendon injury, or fracture | ||
*Possible glass in wound = get | *Possible glass in wound = get XR or US to evaluate | ||
===Suturing=== | ===Suturing=== | ||
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**Irrigate and explore wound, then pack with non-adherent or vaseline gauze | **Irrigate and explore wound, then pack with non-adherent or vaseline gauze | ||
**Re-check in 3 days - may suture at that point if wound appears clean. | **Re-check in 3 days - may suture at that point if wound appears clean. | ||
{{Suture chart}} | |||
===Steri-Strips=== | |||
*Just as good a suturing according to this <ref name=Esmailian>[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5887701/ Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds' Scar. Adv Biomed Res. 2018;7:49. Published 2018 Mar 27. doi:10.4103/abr.abr_148_16]</ref> and other articles. Picture on how to do it property from the same article <ref name=Esmailian></ref> which is under CC BY-NC-SA 4.0 license: | |||
[[File:Steri-strips.png|thumb|Steri-Strips]] | |||
===Scalp Laceration=== | |||
*Scalp laceration can be done with staples or if the patient has enough hair with [https://lacerationrepair.com/techniques/alternative-wound-closure/hair-apposition-technique/ Hair Apposition Technique] by twisting hair together and using dermabond. | |||
===Aftercare=== | ===Aftercare=== | ||
*Consider antibiotics for | *Consider [[antibiotics]] for | ||
**Wounds contaminated by debris or feces | **Wounds contaminated by debris or feces | ||
**Caused by punctures or bites | **Caused by punctures or [[animal bites|bites]] | ||
**Tissue destruction or in avascular areas | **Tissue destruction or in avascular areas | ||
**Neglected wounds | **Neglected wounds | ||
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*Splinting | *Splinting | ||
**Wounds over flexor surfaces or tension | **Wounds over flexor surfaces or tension | ||
*Tetanus | *[[Tetanus prophylaxis]] | ||
**Tdap 0.5cc IM to patients >7y with no booster within 5 yr | **Tdap 0.5cc IM to patients >7y with no booster within 5 yr | ||
**Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given | **Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given | ||
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**48-72 hrs ONLY if high risk wound | **48-72 hrs ONLY if high risk wound | ||
***No point in checking before 48hr (takes this long for infection to occur) | ***No point in checking before 48hr (takes this long for infection to occur) | ||
==Billing== | |||
*Anatomical location of wound | |||
*Size of wound | |||
**Length (cm) <2.5, 2.6-5.0, 5.1-7.5, 7.6-12.5, 12.5-20.0, 20.1-30.0, >30.0 | |||
*Complexity | |||
**Simple, intermediate, or complex (depends on debridement, layers, complex stitch, drain, etc.) | |||
*Type and number of sutures | |||
==See Also== | ==See Also== | ||
*[[Soft Tissue Foreign Body]] | |||
*[[Sutures]] | *[[Sutures]] | ||
*[[Lip Laceration]] | *[[Lip Laceration]] | ||
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*[[Eyelid Laceration]] | *[[Eyelid Laceration]] | ||
*[[Tongue Laceration]] | *[[Tongue Laceration]] | ||
*[[Nailbed laceration]] | |||
*[[Conjunctival laceration]] | |||
*[[Bites]] | *[[Bites]] | ||
*[[LET]] | *[[LET]] | ||
==References== | ==References== | ||
<references/> | |||
[[Category:Trauma]] | [[Category:Trauma]] | ||
[[Category:Procedures]] | [[Category:Procedures]] |
Revision as of 14:12, 12 December 2019
Indications
- Skin or mucosal laceration.
Contraindications
- Body laceration >12 hours old
- Face/scalp wounds >24 hours old
Management
Wound Preparation
- Debridement is most important step in reducing infection/ promoting healing
- Avoid betadine/chlorhexadine in wound
- Not necessary to remove hair (if do, avoid using razor)
Irrigation
- High pressure irrigation is best (can be achieved with 18 gauge syringe)
- Tap water is as effective as sterile water/ normal saline[1][2][3]
- Pressure from tap is ~45 psi, higher than syringe[4]
- Irrigation optional for face/scalp wound as long as:
- Not a bite wound
- Not a contaminated wound
- Not older than 6 hours
Anesthesia
- Can be topical or injected.
- Topical
- Evaluate motor/sensation before giving local anesthesia
- To decrease pain of injection:
- Buffer lidocaine with bicarbonate (1mL bicarb:9mL lidocaine)
- Inject slowly
Maximum Doses of Anesthetic Agents
Agent | Without Epinephrine | With Epinephrine | Duration | Notes |
Lidocaine | 5 mg/kg (max 300mg) | 7 mg/kg (max 500mg) | 30-90 min |
|
Mepivicaine | 7 mg/kg | 8 mg/kg | ||
Bupivicaine | 2.5 mg/kg (max 175mg) | 3 mg/kg (max 225mg) | 6-8 hr |
|
Ropivacaine | 3 mg/kg | |||
Prilocaine | 6 mg/kg | |||
Tetracaine | 1 mg/kg | 1.5 mg/kg | 3hrs (10hrs with epi) | |
Procaine | 7 mg/kg | 10 mg/kg | 30min (90min with epi) |
Exploration
- See Soft tissue foreign body
- Explore to base of wound
- Ideally done in bloodless field
- Look for foreign bodies, tendon injury, or fracture
- Possible glass in wound = get XR or US to evaluate
Suturing
- See Sutures
- If laceration not closed immediately secondary to age of wound:
- Irrigate and explore wound, then pack with non-adherent or vaseline gauze
- Re-check in 3 days - may suture at that point if wound appears clean.
Laceration Areas and Their Common Suture Type and Duration
Area | Size | Type | Days to Removal |
---|---|---|---|
Scalp | Staples or 4-0 or 5-0 | non absorbable | 7 |
Ear | 6-0 | non absorbable (absorbable for cartilage repair) | 5-7 |
Eyelid | 6-0 or 7-0 | absorbable or nonabsorbable | 5-7 |
Eyebrow | 5-0 or 6-0 | absorbable or nonabsorbable | 5-7 |
Nose | 6-0 | absorbable or nonabsorbable | 5-7 |
Lip | 6-0 | absorbable | NA |
Oral mucosa | 5-0 | absorbable | NA |
Other face / forehead | 6-0 | absorbable or nonabsorbable | 5 |
Chest/abdomen | 4-0 or 5-0 | non absorbable | 12-14 |
Back | 4-0 or 5-0 | non absorbable | 7-10 |
Extremities | 4-0 or 5-0 | non absobrable | 7-10 |
Hand | 5-0 | non absorbable | 7-10 |
Foot / Sole | 4-0 | non absorable | 12-14 |
Joint (Extensor) | 4-0 | non absorable | 10-14 |
Joint (Flexor) | 4-0 | non absorbable | 7-10 |
Vagina | 4-0 | absorbable | NA |
Penis | 5-0 | non absorbable | 7-10 |
Scrotum | 5-0 | non absorbable | 7-10 |
Note: consider use of Fast Absorbing Gut (5-0/6-0) on Ear, Eyelid, Eyebrow, Nose, Lip and Face if anticipated difficulty with suture removal
Note: Favor absorbable sutures for facial repair especially in children
Steri-Strips
- Just as good a suturing according to this [6] and other articles. Picture on how to do it property from the same article [6] which is under CC BY-NC-SA 4.0 license:
Scalp Laceration
- Scalp laceration can be done with staples or if the patient has enough hair with Hair Apposition Technique by twisting hair together and using dermabond.
Aftercare
- Consider antibiotics for
- Wounds contaminated by debris or feces
- Caused by punctures or bites
- Tissue destruction or in avascular areas
- Neglected wounds
Wounds contaminated by fresh water and plantar puncture wounds through athletic shoes should include Pseudomonas coverage
- Splinting
- Wounds over flexor surfaces or tension
- Tetanus prophylaxis
- Tdap 0.5cc IM to patients >7y with no booster within 5 yr
- Hypertet 250 u IM at diff site from Tdap if NO history of Td or < 3 doses given
- Require follow up Tdap at 1mo & 1 yr; age>60 = high risk of poor immunization
- Dressing
- Keep moist, not wet
- Bandaid, xeroform, or ointment
- Keep moist, not wet
- Wound check
- 48-72 hrs ONLY if high risk wound
- No point in checking before 48hr (takes this long for infection to occur)
- 48-72 hrs ONLY if high risk wound
Billing
- Anatomical location of wound
- Size of wound
- Length (cm) <2.5, 2.6-5.0, 5.1-7.5, 7.6-12.5, 12.5-20.0, 20.1-30.0, >30.0
- Complexity
- Simple, intermediate, or complex (depends on debridement, layers, complex stitch, drain, etc.)
- Type and number of sutures
See Also
- Soft Tissue Foreign Body
- Sutures
- Lip Laceration
- Fingertip Laceration
- Eyelid Laceration
- Tongue Laceration
- Nailbed laceration
- Conjunctival laceration
- Bites
- LET
References
- ↑ Moscati RM, Mayrose J, Reardon RF, Janicke DM, Jehle DV. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007 May;14(5):404-9
- ↑ Weiss EA, Oldham G, Lin M, Foster T, Quinn JV. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013 Jan 16;3(1).
- ↑ Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012 Feb 15;(2):CD003861.
- ↑ Moscati RM, Reardon RF, Lerner EB, Mayrose J. Wound irrigation with tap water. Acad Emerg Med. 1998 Nov;5(11):1076-80.
- ↑ 5.0 5.1 KUNDU S, et. al. Principles of Office Anesthesia: Part II. Topical Anesthesia Am Fam Physician. 2002 Jul 1;66(1):99-102.
- ↑ 6.0 6.1 Esmailian M, Azizkhani R, Jangjoo A, Nasr M, Nemati S. Comparison of Wound Tape and Suture Wounds on Traumatic Wounds' Scar. Adv Biomed Res. 2018;7:49. Published 2018 Mar 27. doi:10.4103/abr.abr_148_16