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Lacerations are the single best opportunity to demonstrate your procedural skills during your clerkship!!!

To Close or Not To Close?

  • Closing a wound with sutures, etc = Healing by “primary intention”
    • INCREASES risk of infection but DECREASES scar
  • Leaving a wound open = Healing by “secondary intention”
    • DECREASES risk of infection but INCREASES scar

Step 1: History

  • Does patient have comorbidities that increase risk of infection/poor healing?
    • Diabetes
    • Renal Failure
    • Obesity
    • Smoking
    • Immunosuppression
  • How long since injury happened?
  • Any concern for foreign body?

Step 2: Identify Tetanus Status

  • Has patient EVER been immunized against tetanus?
  • Has it been >5 years since last tetanus shot?

Step 3: Tetanus Prophylaxis

  • Give tetanus booster (Tdap) if >5 years since last tetanus shot
  • Give tetanus immunoglobulin (IG) if patient has never had tetanus immunization

Step 4: Give Specific, Objective Description of Laceration

  • EXACT length
    • Must use a ruler
    • Most important BILLING categories
      • 2.5 cm or less
      • 2.6 cm to 7.5 cm
      • 7.6 cm to 12.5 cm
  • Description
    • Shape
      • Linear
      • Stellate
      • Flap
    • Depth
      • Superficial
      • Muscle
      • Bone
  • Neurovascular exam
    • Sensation
    • Motor
    • Cap refill

Step 5: Rule Out Foreign Body

  • Consider X-Ray
    • Not all foreign bodies will show up on x-ray
      • Especially organic material, clothing, etc
  • Consider bedside ultrasound
    • (You are not expected to know how to do this, only to consider this)

Additional Reading