Clinical Management of Acute Minor Wounds and Lacerations: A Guide for Emergency Practitioners

Executive Summary

Acute wound management in the emergency department (ED) focuses on two primary goals: avoiding infection and achieving a functional, cosmetically acceptable scar. Effective management requires a deep understanding of the physiological phases of wound healing—hemostasis, inflammation, proliferation, and maturation. Practitioners must distinguish between wounds suitable for primary closure and those requiring secondary or delayed primary closure based on wound age, mechanism of injury, and patient-risk factors.

Critical takeaways for the experienced practitioner include:

Healing Dynamics: Wounds typically regain 80% of their original tensile strength by six weeks, though full maturation can take up to 180 days.
The "Golden Period": Most clean, simple lacerations can be closed up to 12–18 hours after injury, with head/neck wounds extending to 24 hours due to high vascularity.
Preparation is Paramount: Irrigation remains the most effective method for decreasing infection. Pressures of 5–8 PSI are ideal for most minor wounds.
Suture Selection: Use the thinnest suture feasible (e.g., 6-0 for face, 4-0/5-0 for extremities). Deep dermal sutures should utilize absorbable materials like Polyglactin 910 to reduce surface tension.

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Relevant Anatomy for Wound Repair

Skin Layers and Architecture

Understanding the depth of injury is critical for classification and repair strategy:

Epidermis: The superficial barrier layer. Epithelialization across this layer normally completes within 48 hours in primarily closed surgical wounds.
Dermis: The structural layer containing collagen fiber bundles. This layer provides the tensile strength for the wound. Deep dermal sutures are placed here to reduce static tension.
Subcutaneous Tissue: Contains fat and vessels. Deep wounds involving this layer often require multi-layer closure to eliminate dead space.

Skin Tension Lines

Relaxed Skin Tension Lines (RSTL) / Langer’s Lines: These lines run parallel to the predominant direction of collagen fiber bundles in the dermis.
Clinical Significance: Incisions or lacerations parallel to these lines have a lower tendency to gape and result in superior cosmetic outcomes. Wounds oriented perpendicular to these lines are at higher risk for significant scarring.

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Local Anaesthetic Options

Effective anaesthesia is required prior to wound exploration and irrigation.

Topical Anaesthesia (LET)

While the source context refers generally to the "clinical use of topical anesthetics in children," these are preferred for needle-phobic patients and to provide initial numbing before infiltration.

Application: Applied directly to the wound edges.
Benefits: Facilitates painless irrigation and reduces the need for subsequent painful infiltration.

Subcutaneous Infiltration

Standard Agent: 1% Lidocaine.
Lidocaine with Epinephrine: Often used to provide hemostasis for persistent bleeding.
Safety Note: Epinephrine should be used judiciously in areas with terminal circulation, though digital nerve blocks with epinephrine are referenced as a documented procedure.
Technique: Infiltration should occur through the wound edges rather than the intact skin to minimize pain, unless the wound is grossly contaminated.

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Step-by-Step Instructions for Wound Management

1. Initial Evaluation and Neurovascular Assessment

History: Determine mechanism (sharp vs. blunt), wound age, and allergies (local anaesthetics, latex).
Physical Exam: Assess circulation, sensation (two-point discrimination for hands), and motor function (tendon integrity) prior to anaesthesia.
Imaging: Obtain plain radiographs if the wound was caused by glass or if the base cannot be visualized. Ultrasound is an adjunct for non-radiopaque foreign bodies.

2. Hemostasis

Direct Pressure: Apply for 10–15 minutes.
Tourniquets: Use sphygmomanometer (20–30 mmHg above systolic) for extremities (max 30–60 mins) or digital tourniquets for digits (max 20–30 mins).
Topical Agents: Gelfoam may be used but avoid at skin closure sites as it delays healing.

3. Irrigation

Volume: Dependent on location and contamination (e.g., 200 mL for clean forehead wound; >500 mL for contaminated leg wound).
Solution: Isotonic (normal) saline or running tap water. Additives like Betadine are generally unnecessary and may impede healing.
Pressure: 5–8 PSI is recommended. Achieve this using a 19-gauge needle or catheter on a 60 mL syringe.

4. Debridement

Method: Sharp excisional debridement using a scalpel or scissors is preferred over enzymatic/biologic methods.
Goal: Remove all devitalized tissue, which acts as a nidus for infection. Trim extruding subcutaneous fat if it interferes with edge apposition.

5. Wound Closure Selection

Type of Closure	Indications	Timing
Primary Closure	Clean, sharp objects; minimal contamination.	Up to 12–18 hrs (trunk/limbs); 24 hrs (face).
Delayed Primary	Contaminated wounds; presentation after "golden period."	Debride initially; close 4–5 days later.
Secondary Intention	Abscesses, punctures, animal bites (non-cosmetic).	Healing by granulation/epithelialization.

6. Suturing Technique

Deep Dermal Sutures: Use absorbable 3-0 or 4-0 (Vicryl/Polysorb). Bury the knot by starting deep-to-superficial then superficial-to-deep. Pull knots tight perpendicular to the wound.
Simple Interrupted: The standard for most repairs. Start in the middle of long lacerations to avoid "dog ears."
Horizontal Mattress: Useful for high-tension wounds or as a temporary "assistant" to hold edges together during meticulous repair.
Vertical Mattress: Preferred for wound edge eversion.

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Suture Material Reference Guide

Material	Type	Absorption/Strength	Common ED Use
Nylon (Ethilon)	Non-absorbable Monofilament	15-20% degradation/yr	Standard skin closure.
Polypropylene (Prolene)	Non-absorbable Monofilament	Permanent	Skin; areas with dark hair (blue color).
Polyglactin 910 (Vicryl)	Absorbable Braided	50% loss at 3 wks	Deep dermal sutures; not for skin.
Fast-Absorbing Gut	Absorbable Natural	Strength for 5-7 days	Facial lacerations.
Chromic Gut	Absorbable Natural	Strength for 10-14 days	Oral mucosa; nail bed repair.
Silk	Non-absorbable Braided	Gradual loss	Securing tubes/lines; high inflammation.

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Example Electronic Health Record (EPIC Template)

Laceration Repair Note

Wound Characteristics:
- Location: [e.g., Right forearm]
- Length: [e.g., 4 cm]
- Type: [e.g., Simple, Stellate, Linear]
- Contamination: [e.g., None, Moderate soil]
- Age: [e.g., 4 hours]
Neurovascular Status:
- Distal Sensation: [e.g., Intact to light touch/Two-point discrimination]
- Distal Circulation: [e.g., Capillary refill <2 seconds]
- Tendon/Motor Function: [e.g., Intact throughout range of motion]
Procedure:
- Anaesthesia: [e.g., LET topical applied, followed by 5 mL 1% Lidocaine with Epinephrine infiltration]
- Irrigation: [e.g., 500 mL Normal Saline via 19g splash shield at 8 PSI]
- Debridement: [e.g., Sharp excision of devitalized margins]
- Foreign Body: [e.g., None identified on exploration; X-ray negative]
- Closure: [e.g., 2 x 4-0 Vicryl deep dermal sutures; 6 x 5-0 Nylon simple interrupted sutures]
Tetanus Status: [e.g., Up to date/Tdap administered today]
Plan/Disposition:
- Dressing: [e.g., Simple dressing with antibiotic ointment]
- Follow-up: [e.g., Suture removal in 7–10 days]

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References

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