Lacerations

See also Adult Lacerations

Initial Evaluation

1. Determine mechanism of injury
2. Check vital signs for hypotension or tachycardia
3. Hours since injury
4. Foreign bodies
   • X-ray to R/O fracture or metallic foreign body (FB)
   • US or CT if glass or wood FB suspected

Wound Preparation

1. Prepare site
   • High-pressure irrigation with normal saline as needed
     • Pressure should exceed 8 psi
     • Use 35 mL syringe with 19G needle
   • Debride devitalized tissue
2. Anesthesia as needed
   • 1-2% Lidocaine, +/- epinephrine
     • NO EPINEPHRINE in areas of limited vascularity, (e.g. finger/ toes, ear, penis)
   • Benadryl can be injected locally if allergic to local agents
     • BEWARE - potential for tissue necrosis
   • Topical anesthetics
     • LET (lidocaine, epinephrine, tetracaine)
     • TAC (tetracaine, adrenaline, cocaine)
       • DO NOT use on mucous membranes
     • EMLA: Topical agent

Wound Closure

1. Examine wound for
   • Depth
   • Structures involved (e.g. tendon, bone, vasculature)
     • Recommended Ortho or Plastics consult
       • Orthopedics if tendon or joint involvement
       • Plastic surgery if facial wound
   • Presence of foreign body
2. Close superficial wounds with little or no tension via:
   • Steri strips and tincture of benzoin
   • Cyanoacrylates
     • Octyl-2-cyanoacrylate (2-OCA)
     • Surround wound with antibiotic ointment "dam" to prevent adhesive runoff
3. Close deep wounds with sutures
   • Absorbable stitches for deep tissue as needed
   • Vertical mattress sutures if there is any wound tension
4. Antibiotics:
   • Not usually indicated
   • Consider if:
     • Grossly contaminated wound
     • Injury present more than 6-8 hours
     • Immunocompromised patient
     • Poor vascularity at wound site
       • Keflex or oral Amoxicillin-clavulanate
     • Cat or Human bite wounds:
       • IV Ampicillin sulbactam or oral Amoxicillin-clavulanate
5. Tetanus prophylaxis as needed
6. Special concerns
   • Longer than 12 hours since injury
     • Consider leaving open
   • Deep puncture wounds
     • Leave open
     • Nu-gauze drain may be helpful
   • Bite Wounds
     • Human
     • Cat
     • Dog

Disposition

1. Admit PRN severe trauma, open fracture or severe blood loss
2. Discharge with suture removal as an outpatient
   • 5 days for face or scalp
   • 7 days for arms or anterior trunk
   • 10-14 days for legs or posterior trunk

References

1. Kazzi MG, Silverberg M. Pediatric Tongue Laceration Repair Using 2-Octyl Cyanoacrylate (Dermabond). The Journal of emergency medicine. Jul 1 2013. Website: http://www.ncbi.nlm.nih.gov/pubmed/23827167
2. Lowe DA, Monuteaux MC, Ziniel S, Stack AM. Predictors of parent satisfaction in pediatric laceration repair. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. Oct 2012;19(10):1166-1172. Website: http://www.ncbi.nlm.nih.gov/pubmed/23036013
3. Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG. Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatric emergency care. Aug 2012;28(8):767-770. Website: http://www.ncbi.nlm.nih.gov/pubmed/22858745
4. Sobieraj G, Bhatt M, LeMay S, Rennick J, Johnston C. The effect of music on parental participation during pediatric laceration repair. The Canadian journal of nursing research = Revue canadienne de recherche en sciences infirmieres. Dec 2009;41(4):68-82. Website: http://www.ncbi.nlm.nih.gov/pubmed/20191714
5. Madhok M, Teele M. Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics. Sep 2006;118(3):1321; author reply 1321-1322. Website: http://www.ncbi.nlm.nih.gov/pubmed/16951038
6. Sinha M, Christopher NC, Fenn R, Reeves L. Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics. Apr 2006;117(4):1162-1168. Website: http://www.ncbi.nlm.nih.gov/pubmed/165853111.
7. Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG. Intranasal ketamine for procedural sedation in pediatric laceration repair: a preliminary report. Pediatric emergency care. Aug 2012;28(8):767-770. Website: http://www.ncbi.nlm.nih.gov/pubmed/22858745

Updated/Reviewed: September, 2013