Lacerations are a pattern of injury in which skin and the underlying tissues are cut or torn. Healthcare providers encounter lacerations regularly. It was reported in 2005 the nearly 12% of all ER visits or 13.8 million visits occurred for laceration care. Lacerations can be managed in the outpatient setting as well depending on the location and severity of the injury.
The clinical presentation of lacerations can be highly variable based on location, depth, width, and length. Due to this highly variable presentation, the healthcare team must have a strong understanding of the critical history and physical exam items each laceration requires.
When approaching a laceration, a basic understanding of the anatomy of the skin can aid in understanding the depth of lacerations. Also, a knowledge of the stages of wound healing will assist in patient education and follow up care.
The skin is made up of three layers:
The four stages of wound healing are:
To best assess the future care requirements of any laceration, the healthcare team must first review the patient's history as well do a complete physical examination of the wound and nearby structures.
Pertinent history items include:
Keys to a good physical exam of lacerations:
Contraindications to the repair of a laceration include:
The equipment required for the closure of lacerations can vary depending on the location and characteristics of the wound. Necessary supplies required for any laceration repair include but are not limited to the local anesthetic drawn up with a small gauge needle (greater than 27 gauge), needle holders, forceps, scissors, gauze, and the appropriate closure device (suture, staple, glue) for the wound.
The selection of local anesthetic is dependant on patient allergies, accessibility, and location of the injury. True allergies to anesthetics are rare. If there is a concern for amide allergies, the use of ester anesthetics or preservative-free amides should are options as reactivity is thought to be due to the preservatives. The use of epinephrine with local anesthetic was previously cautioned in fingers, toes, nose, penis, and ears. However, current research shows the concerns of local ischemia to be unsupported.
The selection of repair material varies based on the location, depth, length, and width of the laceration. The decision between absorbable and nonabsorbable sutures will depend on the depth and method planned for closure. Current studies have shown that the selection of absorbable gut vs. nonabsorbable suture materials in the external closure of lacerations produce similar infection rates and aesthetic outcomes over the long term.
The use of staples for the closure of scalp lacerations is a quick and secure method of care.
The use of staples for the closure of scalp lacerations is a quick and secure method of care. Due to the higher risk of scarring, staples should only be used in thicker skin and when appropriate, follow up can be obtained for their removal. The use of tissue adhesives can be an option when the laceration overlies an area with minimal tension and is easily approximated. The most significant concern for their use is successful closure of the wound, which hinges on appropriate cleaning and preparation of the wound. Steri-strips are another alternative for primary closure of lacerations with no tension and not overlying a joint, but due to the requirement of added adhesives such as benzoin, there is a risk of local skin reaction that reduces their functionality for lacerations care.
Also of note, the use of sterile vs. nonsterile gloves has been examined by many studies and found that due to the contaminated nature of lacerations at presentation there is no statistical difference in infection with the use of nonsterile gloves.
The personnel requirements of the primary closure of a laceration vary based on the complexity of the wound. In the most basic of repairs, a single provider can perform the technique alone. As the complexity of the laceration increases, there may be an increased need for other personnel to hold pressure, manage supplies, and reduce tension across the wound.
A helpful mnemonic in preparing for any laceration is LACERATE:L - Look at the wound to assess repair optionsA - Anesthetize the woundC - Clean the woundE - Equipment setupR - Repair the woundA - Assess the results, anticipate complicationsT - Tetanus ImmunizationE - Educate patient about wound care
Careful step by step planning of the procedure and gathering of all the required supplies ahead of time can aid in reducing the duration and difficulty of any closure. Preparation of the room in which the procedure will take place by turning on lights, moving trays and tables, positioning patients bed, and localizing waste receptacles all aid in reducing the risk of contamination during the procedure.
Local anesthesia is used to clean and repair lacerations appropriately. Selection of the anesthetic, as stated previously, will depend on patient allergies and accessibility at the care facility. Several steps can be taken to reduce patient discomfort while administering the local anesthetic, such as:
After local anesthesia, the next step is irrigation of the wound to remove any foreign objects and clotted blood, allowing for complete visualization of the laceration. Most commonly performed utilizing a saline solution, some research has shown that in simple lacerations on healthy immunocompetent patients tap water can be utilized to irrigate the wound.
Following irrigation, the laceration can now be closed using whichever method best suits its location and size. If suturing, there is no specific guide for which technique to use, but general technique recommendations are as follows:
Following primary closure, placement of either antibiotic ointment or petroleum infused gauze over the sutures with overlying gauze affixed by tape is advised.  Educate patients on keeping the wound clean and give follow up instructions for when they can have the sutures removed. General guidelines for removal vary depending on the location of repair, the complexity of repair, and suture utilized. Sutures left in place too long can increase the risk of infection and scarring.
Lacerations are a common chief complaint of patients, and their management must be well understood by the healthcare team to provide appropriate care to patients.
Lacerations are seen and managed by many clinicians, including nurse practitioners. However, only those professionals with anatomical and basic surgical knowledge should close lacerations. Even the most simple laceration can become infected or develop into a keloid. Before closing any laceration, the wound must be clean.
Laceration presentation can vary drastically, and while the primary care team can manage simple lacerations, the below guidelines should aid team decision making on when to consult general surgery or other specialty services.
There are many instances where a laceration may not be safe to close, and in such situations, a wound care nurse should be involved to follow the patient. These patients require education about wound care and dressing changes. If the nurse notices complications such as infection or dehiscence, they should refer the patient back to the clinician.
Nursing can work with applying and/or changing wound dressings and administer medication for pain control and antimicrobial agents. Pharmacists can make antibiotic recommendations as well as for pain, and perform medication reconciliation. If the would becomes infected, the pharmacist should make antibiotic recommendations to the clinician based on local resistance as well as custom and practice.
The outcomes of laceration repair depend on the mechanism, location, and complexity. For optimal outcomes, prompt consultation with a specialist is recommended, and an interprofessional team approach must be leveraged for the best patient care and good outcomes. [Level V]
The prompt collection and dissemination of pertinent patient history can aid the healthcare team in assessing the severity of the laceration. The understanding of how to appropriately aid in hemostasis through direct pressure can significantly aid in the complete assessment of the patient. Nurses also play a vital role in the dressing change, wound care, and timely removal of sutures/staples.
Nurses should monitor patients for the following signs:
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