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Laceration Management, Emergency Medicine

Basics

Description

- Exploration and removal of foreign body: - Indications for removal of a foreign body include: - Potential or actual injury to tendons, nerves, vasculature - Toxic substance or reactive agent - Continued pain

- Try to avoid shaving hair. Clip if necessary: - Increased skin infection rate after shaving - Never shave or clip eyebrow as it may not grow back with a normal appearance

- Multiple-layered closure: - Closes deep tissue dead space - Lessens tension at the epidermal level, improves cosmetic result - Buried interrupted absorbable suture, simple or running nonabsorbable sutures for epidermis

- Suture materials: - Absorbable: - For use in mucous membranes and buried muscle/fascial layer closures - Natural: Dissolve <1 wk, poor tensile strength, local inflammation: Plain gut, chromic gut, fast-absorbing gut (for certain facial lacerations where cosmesis is important) - Synthetic braided: Tensile strength diminishing over 1 mo, mild inflammation: Polyglycolic acid (Dexon), polyglactin 910 (Vicryl) - Synthetic monofilament: Tensile strength 70% at 1 mo: Polydioxanone (PDS), polyglyconate (Maxon)

- Wounds at risk for infection or poor healing require a wound check within 48 hr. - Time of suture removal dependent on location and peripheral perfusion: - Scalp: 7 " 10 days - Face: 3 " 5 days - Oral: 7 days - Neck: 4 " 6 days - Abdomen, back, chest, hands, feet: 7 " 10 days - Upper extremity: 7 " 10 days - Lower extremity: 10 " 14 days - Overlying joints: 10 " 14 days

  • A laceration is a disruption in skin integrity most often resulting from trauma.
  • May be single or multiple layered

Etiology

Multiple causes

Diagnosis

Signs and Symptoms

Lacerations may be accompanied by:

  • Bleeding
  • Tissue foreign bodies
  • Hematoma
  • Pain or numbness
  • Loss of motor function
  • Diminished pulses, delayed capillary refill

History

  • Mechanism and circumstances of injury
  • Time of injury
  • History of foreign body (glass, splinter, teeth)
  • Tetanus immunization
  • Comorbid condition or medications that may impede wound healing

Physical Exam

  • Evaluate nerve and motor function.
  • Document associated neurovascular injury.
  • Assess presence of devitalized tissue, debris from foreign materials, bone or joint violation, tendon injury:Avoid digital exploration if the object is believed to be sharp.

Essential Workup

  • Consider repair in OR if unable to be performed safely within the ED, especially for children requiring deep sedation.
  • Consider surgical consultation for complex lacerations, especially involving eyes and face.

Assess for possible nonaccidental trauma.

Diagnosis Tests & Interpretation

Imaging

  • Evaluation for possible foreign bodies
  • Plain radiography:Soft-tissue views may aid in visualization.Objects with the same density as soft tissue may not be seen (wood, plants).
  • US
  • CT scan
  • MRI with metal precautions

Differential Diagnosis

  • Skin avulsion
  • Contusion
  • Abrasion

Treatment

Pre-Hospital

  • Obtain hemostasis, or control of bleeding with direct pressure.
  • Straighten any flaps of skin whose blood supply may be strangulated.
  • Apply splint if needed.
  • Universal precautions

Initial Stabilization/Therapy

  • Airway, breathing, and circulation management (ABCs)
  • Control hemostasis.
  • Remove rings or jewelry if needed. Swollen fingers with rings can become ischemic.

Ed Treatment/Procedures

  • Time of onset:Lacerations may be closed primarily ≤8 hr old in areas of poorer circulation.Lacerations may be closed ≤12 hr old in areas of normal circulation.On face, lacerations may be closed ≤24 hr if clean and well irrigated.If not closed, wound may heal by secondary intention or by delayed primary closure (DPC) in 3 " 5 days.
  • Analgesia and conscious sedation:Adequate analgesia is crucial for good wound management.Conscious sedation may be required (see "Conscious Sedation " ).
  • Local anesthetics:Topical:TAC (tetracaine, adrenaline, cocaine)EMLA (eutectic mixture, lidocaine, prilocaine)LET (lidocaine, epinephrine, tetracaine)Local/regional:Lidocaine, bupivacaineEpinephrine will cause vasoconstriction and improve duration of action of anesthetic.Avoid epinephrine in the penis, digits, toes, ears, eyelids, tip of nose, skin flaps (necrosis), and severely contaminated wounds (impairs defense).For patient comfort, inject slowly with small-gauge needle; buffer every 9 mL of 1% lidocaine with 1 mL 8.4% sodium bicarbonate.Consider a 1% diphenhydramine solution in the lidocaine-allergic patient.
  • Exploration and removal of foreign body:Indications for removal of a foreign body include:Potential or actual injury to tendons, nerves, vasculatureToxic substance or reactive agentContinued pain
  • Irrigation and debridement:Surrounding intact skin may be cleaned with an antiseptic solution (povidone-iodine, chlorhexidine):Do not use antiseptic solution within the wound itself because it may impair healing.Scrub with a fine-pore sponge only if significant contamination or particulate matter.Irrigation with ≥200 mL of normal saline (NS):Optimal pressure (5 " 8 psi) generated with 30-mL syringe through 18 " 20G needleTry to avoid shaving hair. Clip if necessary:Increased skin infection rate after shavingNever shave or clip eyebrow as it may not grow back with a normal appearanceDebride devitalized and contaminated tissue.
  • Wound repair:Universal precautionsWounds that cannot be cleaned adequately should heal by secondary intention or DPC.Reapproximate all anatomic borders carefully (e.g., skin " vermilion border of lip).Consider tissue adhesive for wounds with clean borders, low tension.
  • Single-layered closure:Simple interrupted sutures:Avoid in lacerations under tension.Horizontal mattress sutures (running or interrupted):Edematous finger and hand woundsIdeal in skin flaps where edges at risk for necrosisVertical mattress:For wounds under greater tension1 stitch that provides both deep and skin closureHalf-buried horizontal mattress sutures:Ideal for closing the vertex of a v- or y-shaped laceration where ischemia is a concern
  • Multiple-layered closure:Closes deep tissue dead spaceLessens tension at the epidermal level, improves cosmetic resultBuried interrupted absorbable suture, simple or running nonabsorbable sutures for epidermis
  • Dressing:Dress wound with antibiotic ointment and nonadherent semiporous dressing.Inform patient about scarring and risk for infection, use of sunscreen.Apply splint if needed.
  • Antimicrobial agents:Uncomplicated lacerations do not need prophylactic antibiotics.If antibiotics are used, initiate before wound manipulation or as early as possible.Lacerations with high likelihood of infection:Animal, human bites, especially to hand (see "Hand Infection " )Contaminated with dirt, bodily fluids, fecesTetanus immunization

Medication

  • See "Conscious Sedation. "
  • Tetanus (Tdap/Td for adolescents " adults, DTap for peds): 0.5 mL IM
  • Local anesthetics:Topical, applied directly to wound with cotton, gauze:EMLA (eutectic mixture, 5% lidocaine, and prilocaine): Apply for 60 min. Note: each g of EMLA contains 2.5 g of lidocaine, do not exceed 3 mg/kg lidocaineTAC (0.5% tetracaine, 1:2,000 adrenaline, 11.8% cocaine): Apply for 20 " 30 min. Apply from 2 " 5 mL to woundLET (4% lidocaine, 1:1,000 epinephrine, 0.5% tetracaine): Apply for 20 " 30 min. Apply 1 " 3 mL. Do not exceed 3 mg/kg lidocaine.
  • Injected:Bupivacaine (max.: 2 mg/kg; duration 3 " 10 hr)Lidocaine (max.: 4.5 mg/kg; duration 1.5 " 3.5 hr)
  • Suture materials:Absorbable:For use in mucous membranes and buried muscle/fascial layer closuresNatural: Dissolve <1 wk, poor tensile strength, local inflammation: Plain gut, chromic gut, fast-absorbing gut (for certain facial lacerations where cosmesis is important)Synthetic braided: Tensile strength diminishing over 1 mo, mild inflammation: Polyglycolic acid (Dexon), polyglactin 910 (Vicryl)Synthetic monofilament: Tensile strength 70% at 1 mo: Polydioxanone (PDS), polyglyconate (Maxon)Nonabsorbable:Greatest tensile strengthMonofilament: Nylon (Ethilon, Dermalon), polypropylene (Prolene), polybutester (Novafil) can stretch with wound edema, polyethylene (stainless steel)Multifilament: Cotton, Dacron, silk (local inflammation)Needle types:Cutting (cuticular and plastic) types are most often used in outpatient wound repair.
  • Staples:For linear lacerations of scalp, torso, extremitiesAvoid in hands, face, and areas requiring CT or MRI.
  • Adhesive tapes (Steri-Strips):For lacerations that are clean, small, and under minimal tensionAvoid in wounds that have potential to become very swollen.Pretreat wound edges with tincture of benzoin to improve adhesion.
  • Tissue adhesives:Good cosmetic results have been achieved in simple lacerations with low skin tension.An alternative to sutures/staples, especially in children

Follow-Up

Disposition

Admission Criteria

  • Few lacerations by themselves necessitate admission unless they require significant debridement or ongoing IV antibiotics, or are complicated by extensive wound care issues or comorbid processes (head injury, abdominal trauma).
  • It is unsafe for a child to return home when nonaccidental trauma is suspected.

Discharge Criteria

  • Wounds at risk for infection or poor healing require a wound check within 48 hr.
  • Time of suture removal dependent on location and peripheral perfusion:Scalp: 7 " 10 daysFace: 3 " 5 daysOral: 7 daysNeck: 4 " 6 daysAbdomen, back, chest, hands, feet: 7 " 10 daysUpper extremity: 7 " 10 daysLower extremity: 10 " 14 daysOverlying joints: 10 " 14 days

Issues for Referral

  • Lacerations of the eye where tear duct injury is suspected require immediate referral.
  • Complicated lacerations (tendon involvement) may require further repair in the outpatient surgical office.
  • Be sure to discuss temporary skin closure and splinting with your surgical consultant.
  • Specific follow-up should be arranged prior to patient discharge.

Additional Reading

  • Beam JW. Tissue adhesives for simple traumatic lacerations. J Athl Train. 2008;43(2):222 " 224.
  • Chisolm C, Howell JM. Soft tissue emergencies. Emerg Med Clin North Am. 1992;10(4):665 " 705.
  • Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999;34(3):356 " 367.
  • Roberts PA, Lamacraft G. Techniques to reduce the discomfort of paediatric laceration repair. Med J Aust. 1996;164(1):32 " 35.
  • Trott A. Wounds and Lacerations: Emergency Care and Closure. 4th ed. Philadelphia, PA: Saunders, Elsevier; 2012.

See Also (Topic, Algorithm, Electronic Media Element)

Hand Infection

Codes

ICD9

  • 879.8 Open wound(s) (multiple) of unspecified site(s), without mention of complication
  • 882.0 Open wound of hand except finger(s) alone, without mention of complication
  • 883.0 Open wound of finger(s), without mention of complication
  • 873.40 Open wound of face, unspecified site, without mention of complication
  • 873.50 Open wound of face, unspecified site, complicated
  • 879.9 Open wound(s) (multiple) of unspecified site(s), complicated
  • 882.1 Open wound of hand except finger(s) alone, complicated
  • 883.1 Open wound of finger(s), complicated
  • 883.2 Open wound of finger(s), with tendon involvement

ICD10

  • S61.219A Laceration w/o fb of unsp finger w/o damage to nail, init
  • S61.419A Laceration without foreign body of unsp hand, init encntr
  • T14.8 Other injury of unspecified body region
  • S01.81XA Laceration w/o foreign body of oth part of head, init encntr
  • S01.82XA Laceration w foreign body of oth part of head, init encntr
  • S61.229A Laceration w fb of unsp finger w/o damage to nail, init
  • S61.429A Laceration with foreign body of unsp hand, init encntr

SNOMED

  • 312608009 Laceration - injury (disorder)
  • 274172008 Laceration of finger (disorder)
  • 284549007 Laceration of hand (disorder)
  • 370247008 Facial laceration (disorder)
  • 211463006 Foreign body in skin wound (disorder)
  • 301453009 tendon laceration (disorder)