Priority Topic: Lacerations

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.