Trauma

Lacerations: General Management Information

Background

1. Irrigation
   • Cleanse wound with normal saline - other solutions, including dilute iodine, may not be necessary
     • Tap water is equally safe and effective as sterile NS in reducing infection rate (Go to BEEM)
   • Pressure irrigation
     • Shown to decrease infection rate
     • Use a 30-60 mL syringe with an 18 GA needle
     • Remove any visible foreign material with forceps
     • May need to anesthetize wound prior to irrigation if pain
   • Avoid epinephrine on distal areas
     • Fingers
     • Nose
     • Penis
     • High-risk wounds
2. Local Anesthesia
   • Small wounds
     • Lidocaine 1%
     • Bupivacaine 0.25%
     • Topical: EMLA cream
   • Large wounds
     • May require regional block
3. Debridement and Exploration
   • Debride devitalized tissue
   • Explore all wounds through entire ROM to remove foreign bodies and assess extent of injury
     • If unsure about foreign bodies, consider X-rays (though many foreign bodies will not be visualized) and CT in very few select wounds
   • Do NOT close puncture wounds and most bite wounds d/t risk of infection
   • Do NOT close wounds older than 8-12 hr, though some facial wounds can be closed up to 24 hrs
   • Large wounds of trunk, scalp, and extremities (not face or hands) can be closed more quickly w/staples
4. Prophylaxis
   • Tetanus prophylaxis, if indicated by history
   • PO antibiotics in high-risk wounds
     • Cat bite
     • Human bite
     • Open fx
     • Open tendon injury
     • Through-through intraoral wounds
     • Select dog bite
     • Severely contaminated wounds
   • Consider PO Abx in compromised host
     • Diabetic
     • CRF
     • Immunosuppressant use
5. Consult Surgery
   • Deep wounds of the hand or foot
   • Full thickness lacerations of eyelid, lip or ear
   • Injury involving arteries, nerves, joints
   • Severely contaminated wounds
6. Discharge/Follow-up instructions
   • Patient education should clearly explain signs of infection in return precautions
   • Ensure 24 hr follow-up in high-risk wounds
   • No proven benefit to topical or PO antibiotics for other wounds not listed above

Avulsion Injuries

1. Document size and location
2. Allow to heal by secondary intention if < 1-2 cm
3. Consider skin graft to cover on hand if > 1 cm
4. Undermine edges and primary closure if
   • Clean appearing
   • Less than 8 hr old
   • In area of body with loose/excess skin
5. Dressing changes
6. 36-48 hr wound check follow-up
7. No proven benefit to topical Abx

Dressings

1. Nonadherent dressing w/topical antiseptic
2. Sterile gauze layer on top
3. Cover and hold in place w/Kling and Kerlix or
4. Cover and hold w/ACE wrap, if compression desired
5. Patient should change dressing in 24 hr
6. Patient to examine wound at 24 hr, return if signs of infection

Steri-Strips (Butterfly Bandages)

1. To approximate wound edges in wounds > 12 hr, not sutured
2. Closure of very thin flaps
3. Reinforcement of wounds w/sutures just removed
4. Application of benzoin to skin prolongs attachment
5. Avoid water contact for first 3-4 d
6. Pt to trim strips as they loosen from edges

1. Quick application
   • Multiple trauma victims
   • Uncooperative (intoxicated) patients
2. Thick skin on extremities, trunk, scalp
3. Not for wounds involving face, neck, hands, feet
4. Avoid if patient to undergo computed tomography (CT)
   • MRI is relatively safe

Stitches Out

1. Following are guidelines, healing rates vary
2. Pts on steroids, w/renal failure and DM may heal more slowly
3. Sutures left too long will produce local reaction: erythema, pruritis, increased scarring
4. Sutures removed too early may allow wound to reopen
5. Sutured wounds under tension (extensor surfaces) may need to stay in slightly longer
6. Days to removal:
   • Scalp: 6-9 days
   • Face: 3-5 days
   • Forehead: 4-5 days
   • Eyelid: 4-5 days
   • Nose: 4-5 days
   • Lip: 4-5 days
   • Ear: 4-5 days
   • Arm: 8-12 days
   • Hand: 9-10 days
   • Digits: 9-10 days
   • Fingertip: 10-12 days
   • Chest: 8-10 days
   • Abdomen: 8-10 days
   • Back: 12-14 days
   • Foot: 12-14 days
   • Legs: 8-12 days
7. Note: add 2-3 days for involvement of joint extensor surfaces

Wound Check

1. Diagnostics
   • Pain, swelling, erythema
   • Drainage of pus, lymphangitis
   • Separation of edges
   • Post-surgical excision wound (View image)
2. Treatment
   • Remove one or two sutures, separate edges to allow drainage of pus
   • Localized infection
     • Oral anti-Staph/Strep Abx
     • Re-examine in 24 hr
   • Generalized (lymphangitis, fever)
     • Culture pus
     • Admit for IV Abx
   • Consider possible retained foreign body

References

1. Trott A. Wounds and Lacerations: Emergency Care and Closure, 4th ed., Philadelphia, PA;Elsevier Health Sciences, 2012;Chapters 14, 22
2. Braen GR, Jenkins JL, Basior J, Cloud S, DeFazio C, McCormack R. Manual of Emergency Medicine, 6th ed., Lippincott Williams & Wilkins, 2012;Chapter 48
3. In: Trott AT; (eds). Wounds and Lacerations: Emergency Care and Closure, 4th ed., Philadelphia, PA:Elsevier-Saunders, 2012;pp.73-108
4. Centers for Disease Control and Prevention (CDC). Emergency Wound Management for Healthcare Professionals. Available at: https://www.cdc.gov/disasters/emergwoundhcp.html. [Accessed December 2021]
5. Nicks BA, Ayello EA, Woo K, Nitzki-George D, Sibbald RG. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med. Aug 27, 2010;3(4):399-407
6. Prevaldi C, Paolillo C, Locatelli C, et al. Management of traumatic wounds in the Emergency Department: position paper from the Academy of Emergency Medicine and Care (AcEMC) and the World Society of Emergency Surgery (WSES). World J Emerg Surg. 2016;11:30
7. Tap water as Effective as Normal Saline for Wound Irrigation

Contributor(s)

1. Ballarin, Daniel, MD

Updated/Reviewed: December 2021