Lacerations

Assess:
-size (<4-6 cm)
-foreign body?
-neurovascular intact?
-infectious risk (tetanus, rabies)

Anesthesia:
- Child Life Specialist
- 1% lidocaine
   – w/ epi (max= 7 mg/kg) Lido 1% has 10 mg/ml, 2% has 20 mg/ml
   – w/o epi (max= 5 cc/kg)
- LET (4% lidocaine, 1:2000 epi, 0.5% tetracaine)
   – max= 7mg lidocaine/ kg (0.2cc/kg)
   – use for open wounds – leave 15-20 min onset 5-10 min with duration 20-30 min
- Lorazepam 0.05 mg/kg PO w/ sedation protocol

Irrigation:
NS, tap water

Suturing:
- Deep – absorbable monofilament (vicryl)
- Superficial – nonabsorbable monofilament (prolene, ethilon, dermalon)

Dressing:
- steristrips
- bacitracin
- sterile gauze

Suture Type and time of Removal: (see chart for more details)

Location		Anesthetic	Deep Suture	Superficial Suture	Dressing	Suture Removal	Special Considera-tions
Scalp	1% lido w/ epi or LET		5-0 vicryl	staples	Bacitracin, air	10-12 days	Pressure dressing if early hematoma
Pinna (ear)	1% lido		5-0 vicryl in perichondrium	6-0 prolene vs fast absorbing gut.	Bacitracin, light pressure dressing	5 days
Eyelid/Eyebrow	1% lido		5-0 vicryl	6-0/ 5-0 prolene vs fast absorbing gut	Bacitracin, air	4-5 days	Donâ€™t shave hair
Lip	1% lido w/ epi		5-0 vicryl	6-0 prolene vs fast absorbing gut	Air		Vermillion border
Face Forehead	1% lido w/ epi		5-0 vicryl	6-0 fast absorbing gut	Bacitracin, air	4-6 days	Facial Nerve
Neck	1% lido w/ epi		4-0 vicryl	5-0 prolene		6-8 days	Through platysma
Trunk	1% lido w/ epi		4-0 vicryl	5-0/ 4.0 prolene	Bacitracin	7-10 days	r/o abd path
Extremities/ Buttocks	1% lido w/ epi		4-0 vicryl 5-0 vicryl	4-0 prolene 3-0 for over joints 5-0 prolene (rapid)		7-10 days 10-14 days if over joint	Check if NV infact
Hands	1% lido		None	6-0/ 6-0 prolene 5-0 or 6-0 chromic gut		7-10 days 10-14 days if over joint
Nailbeds	1% lido		None	6-0 chromic gut	Bacitracin/ splint/ xeroform gauze		If amputation, splint + antiobiotics
Feet/sole	1% lido		None	5-0/ 4-0 chromic gut	Bacitracin, xeroform	10-14 days
Scrotum	1% lido		None	5-0 vicryl or 5-0 glut	Bacitracin, air, 4X4, fluff
Penis	1% lido			5-0 prolene		6-8 days

Dermabond:
- A replacement for sutures in linear lacs that approximate well and are not under stress(joints, etc). Apply at least 6 layers.

Contraindications to Use of Skin Adhesives:
- Jagged or stellate lacerations
- Bites, punctures or crush wounds
- Contaminated wounds
- Mucosal surfaces
- Axillae and perineum (high-moisture areas)
- Hands, feet and joints (unless kept dry and immobilized)

Steps in Use of Dermabond:
1. Apply topical anesthetic as needed.
2. Prepare wound with antiseptic.
3. Oppose wound edges.
4. Crush Dermabond vial and invert.
5. Gently brush adhesive over laceration.
6. Avoid pushing adhesive into wound.
7. Apply six layers of adhesive.

If desired may be removed with acetone or the application of antibiotic ointment or petroleum jelly for 30 minutes will loosen the polymer for removal.

The adhesive will spontaneously peel off in five to 10 days. No topical antibiotics should be applied to the closed wound because this would break down the adhesive and cause early peeling.

There is a great video located on NEJM.com that shows proper technique for laceration repair.

Here is the link:

Laceration Repair

Or, if you prefer text and pictures, here is a link to the PDF:

Laceration Repair