Key Feature 7a: In treating a patient with a laceration: Ask about immunization status for tetanus. 
Skill: Clinical Reasoning
Phase: History

Key Feature 7b: In treating a patient with a laceration: Immunize the patient appropriately. 
Skill: Clinical Reasoning
Phase: Treatment

In any patient with a significant skin wound (ex: laceration, puncture wound such as from a bite or needle stick, crush injury, or others such as avulsions or abrasions) it is important to confirm tetanus status. All patients who receive their routine childhood immunizations will have received tetanus immunisation (DTaP), often with the last routine dose in grade 9 (Tdap). So all children will be covered if they've received all of the routine vaccinations, period. Tetanus immunization lasts up to 10 years, so it is recommended that a tetanus vaccine (Td) be readministered every 10 years. 

UpToDate provides a table advising what to do if a patient presents with a clean or possibly contaminated dermal injury, depending on whether or not the patient has been fully immunised against tetanus and when the most recent vaccination was. The first 3 doses are given as part of the routine childhood series at 2, 4, and 6 months of age. At least that is how it happens in Canada. If administration of the tetanus immune globulin is indicated, this basically provides passive immunity (the immunoglobulins that the body would make that defend against tetanus are instead just immediately delivered - this provides immediate protection, but it doesn't provide long-term protection as these get broken down and eliminated by the body with a half-life of 23 days).

Key Feature 4: Identify wounds at high risk of infection (ex: puncture wounds, some bites, some contaminated wounds), and do not close them. 
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Treatment

Key Feature 5: When repairing lacerations in children, ensure appropriate analgesia (ex: topical anesthesia) and/or sedation (ex: procedural sedation) to avoid physical restraints. 
Skill: Clinical Reasoning
Phase: Treatment

Key Feature 6: When repairing a laceration, allow for and take adequate time to use techniques that will achieve good cosmetic results (ex: layer closure, revision if necessary, use of regional rather than local anesthesia). 
Skill: Clinical Reasoning
Phase: Treatment

A few days ago, a kiddo came into the children's ED with scalp lacerations from an eagle attack! He was in a lot of pain, but the reassurance of having his parents next to him appeared to be a major analgesic. We also injected the area surrounding the laceration with local anesthesia. We then proceeded to irrigate the wound (there was no visible debris and so only moderate quantities of fluid and pressure was needed, and in this healthy child without risk increased risk factors for infection, we did not need to use sterile solution). There was no devitalised tissue so debridement was not needed. Once clean and frozen, with his parents holding both of his hands, my attending and I put his scalp back together with staples.

What wounds are at increased risk of infection, and what type of closure is warranted? According to the UpToDate article, "Minor wound preparation and irrigation" (2018), "The decision of whether to perform primary closure, allow a wound to heal by secondary intention, or perform a tertiary (ie, delayed primary) closure is dependent upon the age of the injury as well as the mechanism and degree of contamination. Absolute contraindications to wound closure are signs of inflammation (redness, warmth, swelling, pain). In the absence of these findings, the decision to close a wound must be made based upon clinical judgment." 

Basically, primary closure is indicated unless a reason is found that puts the patient at increased risk of wound infection. Such factors include factors on history (mechanism of injury increasing risk of wound contamination, time from injury, patient risk factors [ex: advanced age, diabetes mellitus, renal impairment, poor nutrition, smoking, obesity, chronic steroid use]) or physical exam (location on body, degree of contamination, presence or possibility of foreign body). This patient with the eagle lacerations did not have risk factors on history or physical exam that suggested primary closure was contraindicated, and so we closed the lacerations to control bleeding and improve cosmesis. 

Again, stay tuned for my future procedure posts on wound management, in which I will go through in more detail the reasons to opt for different wound closures more specifically, as well as technique to best promote healing and cosmesis. While it takes time to develop the skills of wound repair, and while it takes extra time during the procedure to ensure best results, as a cardiac surgeon once told me when he was operating, "Slow is smooth and smooth is fast." In other words, if you slow things down and work more deliberately, things tend to go smoother and ironically faster. There is less need for revising previous repairs, and the outcome tends to be much better.

The child with the eagle lacerations had two very supportive parents, and he was old enough to be able to understand how important it was to stay still despite pain while we injected the local anesthesia so we could do a good job cleaning and fixing his scalp wounds. He was a brave boy. Not all children and not all adult even will be able to be so "mind over matter." Once a minor wound is frozen, generally speaking, most patients will be able to tolerate the process of irrigation, debridement as needed, and wound closure. I will go through freezing options and how to administer them in a future procedural post. In some settings, local anesthesia may not suffice, and procedural sedation with the assistance of an anesthesiologist may be warranted to be able to properly provide wound care.

Key Feature 1: When managing a laceration, identify those that are more complicated and may require special skills for repair (ex: a second- versus third-degree perineal tear, lip or eyelid lacerations involving margins, arterial lacerations).
Skill: Clinical Reasoning, Selectivity
Phase: Diagnosis, Physical

Key Feature 2: When managing a laceration, look for complications (ex: flexor tendon lacerations, open fractures, bites to hands or face, neurovascular injury, foreign bodies) requiring more than simple suturing.
Skill: Clinical Reasoning
Phase: Diagnosis, Physical

Key Feature 3: Given a deep or contaminated laceration, thoroughly clean with copious irrigation and debride when appropriate, before closing. 
Skill: Clinical Reasoning
Phase: Treatment

As a primary care clinician, I am expected to be competent at simple laceration repairs. This is great for me, because I find this fun! Well, most of the time. There are some situations in which the difficult and sensitive location and extent of a laceration may make me feel too uncomfortable to enjoy a challenge of making things look better again. In these situations, it is warranted to call in a specialist, or to at least have special training for the type of complicated laceration at hand. These situations include lacerations involving the lip or eyelid margins, third-degree perineal tears (involving the anal sphincter), and arterial lacerations. I tried to look up a broader list of indications when special training in laceration repair is indicated, and I was unsuccessful after a reasonable time suck. So I am going to go with my gut on this one, that sense that if it seems at all more complicated than my training has prepared me for, it's time to call in someone who has had that training. It's not worth my stress or increased risk of harm to the patient from subpar laceration management. 

If a laceration appears as though it is in a location and to an extent that I have been trained to repair, there are still some important factors I must assess for when determining the approach to management/repair. Complicating factors to assess include:

• Signs and symptoms of damage to underlying structures beyond the skin or mucosa, such as to arteries, nerves, muscles/tendons/ligaments, or bones. 
• Signs and symptoms of foreign body deposition or risk factors on history
• Whether the injury is reported to be from an animal bite

When any of these factors are identified, more than just simple laceration repair is warranted. In the case of damage to underlying structures, consultation with an appropriate specialist is warranted. If history or physical exam suggests possible foreign body deposition, then the wound will need to be thoroughly explored and irrigated +/- debridement, perhaps even so much so as to require this being done under anaesthesia in the operating room. When the laceration is from an animal bite, thorough exploration and irrigation +/- debridement is indicated, but primary wound closure is also contraindicated because there is an increased risk of infection when doing so. 

Stay tuned for my eventual posts on wound debridement and laceration repair, which will go more into depth on the details of how to manage lacerations. Here I will just conceptually touch on  an important principle in the management of lacerations: wound decontamination. 

General laceration management stand of care includes cleaning the wound before closure. This may involve irrigation and possibly debridement if there is any devitalised tissue. Per the UpToDate article, "Minor wound preparation and irrigation" (2018), "Irrigation is the most important means of decreasing the incidence of wound infection because soil or small foreign bodies that remain in a wound reduce the inoculum of bacteria required to cause infection." Irrigation and debridement are done after anaesthesia has been provided. Some factors to think about when planning to irrigate a laceration include: choice of irrigation solution, irrigation pressure, and volume needed.

1. Irrigation solution
   1. For healthy patients with relatively clean wounds, in places with high water quality, tap water can be the choice of solution. Studies of tap water vs normal saline in these settings revealed no difference in rates of wound infection.
   2. In a patient who has risk factors for infection (ex: immunocompromised), or who sustained a dirty mechanism of injury (ex: animal bite), or with apparent wound contamination on exam, consider a dilute antiseptic solution (ex: 1:10 mixture of povidone/iodine solution with isotonic saline).
2. Irrigation pressure
   1. There is no ideal irrigation pressure, but in a highly contaminated wound, higher pressures may be desirable. This may be more effective at removing foreign debris and reducing bacterial load, but it does come at the risk of increased tissue damage from the elevated pressure. In a relatively clean wound, the risk of injury to tissue outweighs the benefit in using higher pressure irrigation.
   2. For standard lower pressure wound irrigation, UpToDate suggests using a 19-gauge syringe or catheter on a 60 mL syringe for moderate pressure, or bulb syringe irrigation if very low pressures are acceptable.
3. Irrigation volume
   1. This depends on location and extent of the wound. Small, clean wounds in areas with good blood supply (decreases risk of infection) may not need as much irrigation, whereas more volume is required in larger, dirtier wounds with poor blood supply. There is no evidence to suggest just how much volume is indicated, so it is a clinical judgment.