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:
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.
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