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Emergency and Acute Medicine – Laceration ManagementBasic description
A laceration is a disruption in skin integrity, most commonly resulting from trauma. Lacerations may involve single or multiple tissue layers and can be associated with deeper structural injury depending on mechanism and location.
Etiology
Lacerations result from multiple mechanisms including sharp objects, blunt trauma, crushing injuries, and bites.
Diagnosis: signs and symptoms
Lacerations may present with bleeding, pain, hematoma, retained foreign bodies, tissue loss, numbness, loss of motor function, diminished pulses, or delayed capillary refill. History should include mechanism and circumstances of injury, time of injury, possible foreign body exposure (glass, wood, teeth), tetanus immunization status, and comorbidities or medications that impair wound healing. Physical examination focuses on careful assessment of neurovascular status, tendon and motor function, and evaluation for devitalized tissue, contamination, joint or bone involvement, and tendon injury. Sharp objects should not be digitally explored if there is risk of further injury.
Essential workup
Consider operative repair if safe wound management cannot be achieved in the emergency department, particularly in children requiring deep sedation. Early surgical consultation is recommended for complex wounds, especially those involving the face, eyes, hands, or joints. Pediatric patients should be assessed for possible nonaccidental trauma.
Diagnostic tests and interpretation
Imaging is used when foreign bodies are suspected. Plain radiographs may identify radiopaque objects but will not reliably detect wood or plant material. Ultrasound can identify radiolucent foreign bodies. CT or MRI may be required for deep or complex injuries, with metal precautions as appropriate.
Differential diagnosis
Skin avulsion, abrasion, contusion, and crush injury should be considered.
Treatment: prehospital care
Initial care includes bleeding control with direct pressure, gentle realignment of skin flaps to preserve perfusion, splinting when indicated, and adherence to universal precautions.
Initial stabilization and therapy
Airway, breathing, and circulation are addressed first. Hemostasis is achieved, rings and constricting jewelry are removed to prevent ischemia, and the wound is protected.
Emergency department treatment and procedures
Primary closure timing depends on wound age and location. Most wounds may be closed within 8–12 hours, facial wounds up to 24 hours if clean and well irrigated. Older or contaminated wounds may require delayed primary closure or healing by secondary intention. Adequate analgesia is essential, using topical, local, or regional anesthesia, with procedural sedation when necessary. Wounds are irrigated with copious normal saline under appropriate pressure, avoiding antiseptics inside the wound. Devitalized tissue is debrided. Foreign bodies are removed when they pose risk of infection, toxicity, or functional impairment. Closure technique is selected based on wound tension, location, and depth, with careful reapproximation of anatomic landmarks. Dressings include antibiotic ointment and nonadherent coverings, and splinting is applied when needed. Prophylactic antibiotics are not required for uncomplicated wounds but are considered for high-risk injuries such as bites or heavily contaminated wounds. Tetanus prophylaxis is updated as indicated.
Medications
Local anesthetics include lidocaine and bupivacaine, with topical agents such as LET, EMLA, or TAC when appropriate. Tetanus immunization is administered according to age and immunization status. Analgesics are provided as needed.
Follow-up and disposition
Most lacerations do not require admission unless associated with major injury, infection risk requiring IV antibiotics, or social concerns such as suspected abuse. Discharge requires clear wound care instructions, infection precautions, and follow-up planning. Wound checks are recommended within 48 hours for high-risk injuries. Suture removal timing varies by anatomic location and perfusion.
Issues for referral
Immediate referral is required for suspected tear duct injuries, complex facial wounds, tendon or nerve involvement, and wounds requiring specialized surgical repair.
Pearls and pitfalls
Careful neurovascular examination before and after repair is essential. Inadequate irrigation and missed foreign bodies increase infection risk. Always consider deeper structural injury, especially in hand and joint lacerations, and maintain a low threshold for consultation when cosmetic or functional outcomes may be compromised.
A laceration is a disruption in skin integrity, most commonly resulting from trauma. Lacerations may involve single or multiple tissue layers and can be associated with deeper structural injury depending on mechanism and location.
Etiology
Lacerations result from multiple mechanisms including sharp objects, blunt trauma, crushing injuries, and bites.
Diagnosis: signs and symptoms
Lacerations may present with bleeding, pain, hematoma, retained foreign bodies, tissue loss, numbness, loss of motor function, diminished pulses, or delayed capillary refill. History should include mechanism and circumstances of injury, time of injury, possible foreign body exposure (glass, wood, teeth), tetanus immunization status, and comorbidities or medications that impair wound healing. Physical examination focuses on careful assessment of neurovascular status, tendon and motor function, and evaluation for devitalized tissue, contamination, joint or bone involvement, and tendon injury. Sharp objects should not be digitally explored if there is risk of further injury.
Essential workup
Consider operative repair if safe wound management cannot be achieved in the emergency department, particularly in children requiring deep sedation. Early surgical consultation is recommended for complex wounds, especially those involving the face, eyes, hands, or joints. Pediatric patients should be assessed for possible nonaccidental trauma.
Diagnostic tests and interpretation
Imaging is used when foreign bodies are suspected. Plain radiographs may identify radiopaque objects but will not reliably detect wood or plant material. Ultrasound can identify radiolucent foreign bodies. CT or MRI may be required for deep or complex injuries, with metal precautions as appropriate.
Differential diagnosis
Skin avulsion, abrasion, contusion, and crush injury should be considered.
Treatment: prehospital care
Initial care includes bleeding control with direct pressure, gentle realignment of skin flaps to preserve perfusion, splinting when indicated, and adherence to universal precautions.
Initial stabilization and therapy
Airway, breathing, and circulation are addressed first. Hemostasis is achieved, rings and constricting jewelry are removed to prevent ischemia, and the wound is protected.
Emergency department treatment and procedures
Primary closure timing depends on wound age and location. Most wounds may be closed within 8–12 hours, facial wounds up to 24 hours if clean and well irrigated. Older or contaminated wounds may require delayed primary closure or healing by secondary intention. Adequate analgesia is essential, using topical, local, or regional anesthesia, with procedural sedation when necessary. Wounds are irrigated with copious normal saline under appropriate pressure, avoiding antiseptics inside the wound. Devitalized tissue is debrided. Foreign bodies are removed when they pose risk of infection, toxicity, or functional impairment. Closure technique is selected based on wound tension, location, and depth, with careful reapproximation of anatomic landmarks. Dressings include antibiotic ointment and nonadherent coverings, and splinting is applied when needed. Prophylactic antibiotics are not required for uncomplicated wounds but are considered for high-risk injuries such as bites or heavily contaminated wounds. Tetanus prophylaxis is updated as indicated.
Medications
Local anesthetics include lidocaine and bupivacaine, with topical agents such as LET, EMLA, or TAC when appropriate. Tetanus immunization is administered according to age and immunization status. Analgesics are provided as needed.
Follow-up and disposition
Most lacerations do not require admission unless associated with major injury, infection risk requiring IV antibiotics, or social concerns such as suspected abuse. Discharge requires clear wound care instructions, infection precautions, and follow-up planning. Wound checks are recommended within 48 hours for high-risk injuries. Suture removal timing varies by anatomic location and perfusion.
Issues for referral
Immediate referral is required for suspected tear duct injuries, complex facial wounds, tendon or nerve involvement, and wounds requiring specialized surgical repair.
Pearls and pitfalls
Careful neurovascular examination before and after repair is essential. Inadequate irrigation and missed foreign bodies increase infection risk. Always consider deeper structural injury, especially in hand and joint lacerations, and maintain a low threshold for consultation when cosmetic or functional outcomes may be compromised.
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