At the Bedside

• Primary survey first if trauma mechanism suggests associated injuries.
• History: mechanism, time since injury, contamination (soil, saliva, water, bites), foreign body concern, tetanus status, anticoagulants/immunosuppression, diabetes, prior poor healing.
• Exam: wound depth, length, gaping, devitalized tissue, tendon/nerve/vascular injury, joint involvement, exposed bone, contamination, signs of infection, foreign body, cosmetic subunits (face, lips, eyelid, ear, hand).
• Neurovascular/tendon exam: distal pulses, cap refill, 2-point discrimination if relevant, motor testing across tendon groups before anesthesia if possible.
• Imaging:
• X-ray for glass/metal/stone foreign body, fracture, joint penetration, gas, or deep wounds near bone/joint.
• Ultrasound can help locate radiolucent foreign bodies (wood, plastic) and guide removal.
• CT if deep penetrating injury, suspected retained foreign body not seen on XR/US, or complex facial/hand wounds.
• Irrigation:
• The single most important infection-prevention step.
• Copious normal saline or potable tap water is appropriate for most wounds.
• Use enough volume to visibly clear debris; for contaminated wounds often 50–100 mL/cm or more is used in practice.
• Avoid routine antiseptics inside the wound bed; they can impair healing.
• Debridement: remove devitalized tissue and obvious contaminants; preserve viable tissue.
• Closure choice:
• Primary closure for clean, well-vascularized wounds within an acceptable time window.
• Delayed primary closure for contaminated wounds or those with higher infection risk after serial reassessment.
• Secondary intention for small superficial wounds, puncture-type wounds, heavily contaminated wounds, or when tissue loss prevents approximation.
• High-risk wounds usually not closed primarily: human/animal bites (especially hand), grossly contaminated wounds, puncture wounds, infected wounds, wounds with devitalized tissue, and some crush injuries.
• Special locations:
• Face: close early for cosmesis if clean.
• Hands/joints/tendons: low threshold for specialist involvement.
• Scalp: often requires hemostasis first; staples are efficient.
• Tetanus prophylaxis: update based on wound type and immunization status.
• Antibiotics: not needed for most simple lacerations. Consider for bites, open fractures, gross contamination, immunocompromised patients, hand wounds, and wounds involving cartilage/joints.
• Disposition: discharge if hemostatic, NV intact, foreign body excluded/removed, tetanus addressed, and follow-up arranged. Consult plastics/hand/ortho/ophtho as needed.

Study Directive

• Draw a closure decision tree from memory: primary vs delayed vs secondary intention.
• Memorize tetanus prophylaxis rules for clean vs dirty wounds.
• Practice a full laceration exam script: bleeding, foreign body, tendon, nerve, vessel, joint.
• Review the 5 most common foreign bodies and which imaging best detects them.
• Rehearse dosing for lidocaine with and without epinephrine.
• Do 10 wound images/case stems and decide closure type, imaging, and antibiotics.