Haemorrhage is stopped by firm pressure on the wound, although occasionally
a tourniquet (applied for no longer than 15 minutes at a time above
systolic blood pressure) may be required. Vasoconstrictors such
as epinephrine can be used, avoiding areas with end organ blood
supply such as fingers, nose, penis and toes.
Wound cleansing, Irrigation
All lacerations should be considered contaminated by the time of
evaluation in the Emergency Department. The rate of wound infection
in sutured lacerations is 1-30%, depending on the study series.
Antibiotic administration does not substitute for the proper cleaning
Wound cleansing is of paramount importance and cannot be overemphasised.
Wound irrigation should be copious. High pressure irrigation is more
effective than low-pressure irrigation in reducing bacterial wound
counts and wound infection rates. Most authorities recommend impact
pressures generated by a 30-60cc syringe and a 18-gauge needle.
Normal saline is the most common choice of solution and should be
used until the wound appears clean. Hydrogen peroxide and poviodine
should NOT be used for irrigation.
Devitalised pieces of skin and subcutaneous tissue are excised. Viable
tissue should be conserved and this is especially important in
the face and hands.
Prior to the administration of local anaesthetics, check the sensory
and motor nerve response, and for allergy (very rare). The pediatric
literature supports the use of a topical anesthetic such as LET
(a combination of lidocaine, epinephrine and tetracaine) prior
to needle infiltration to reduce the pain. Slow injection by a
small needle (such as a 25 Gauge) will reduce the pain of infiltration.
Picture of injecting anesthetic
Wound Closure - Choice of suture material
Absorbable suture material is utilised below the skin (except dermal
sutures may be used for high tension lacerations), inside the mouth
for example, or in other awkward areas where suture removal would
be difficult. Plain catgut has high tissue reactivity. Chromic
catgut is less problematic and is absorbed in about 10-14 days.
Dexon or Vicryl last 90-120 days.
Non-absorbable suture material is used for most skin closures. The
synthetics are likely best as these have less tissue reactivity.
Monofilaments, for example, nylon (Ethilon, Prolene) or braided materials
(Ethibond, Surgilon) may be used. Knots must be “well locked”,
and there should be only minimal tension on the tissues themselves.
A suture size of 5:0 or 6:0 is used on the face, whereas 4:0 or
sometimes 3:0 (if more strength is required) is used on the trunk
The application of staples is more rapid than sutures and staples
are useful for scalp, trunk, and some extremity wounds.
Wound Closure - Suturing techniques
All of the sterile equipment required for simple wound care procedures
in the emergency department is available in a “suture tray”.
Picture of equipment tray and list of equipment and single shots
of needle driver holding needle properly and the right tweezers
Simple interrupted suture
This style of suture is used most frequently in the emergency department.
In the Procedures Lab, you will be asked to repair a laceration
similar to the laceration of the thigh above using simple interrupted
sutures. Remember to always use universal
The laceration is 3 hours old and sustained from the clean edge
of a metal shelf. You have already used lidocaine 1% to anesthetize
the area, have cleaned the wound well, and have placed several subcutaneous
sutures. You are now ready to place your skin sutures.
Wound examination and repair should always be conducted with good
Accurate layer by layer repair is the key.
The goal is to approximate the margins of the wound as exactly as
possible. The goal is a slightly elevated and everted wound closure
margin that over time will flatten to a more attractive scar. For
deeper lacerations, a subcuticular closure with absorbable suture
will minimise tension on the skin layer itself.
simple knot techniques in this animation.
can review the placement of sutures and a simple instrument tie of
a simple interrupted suture in this video.
Approximation and slight eversion of the wound margins is difficult in certain
wounds, especially if the wound margins are already retracted or rolled inwards.
A vertical mattress suture is useful in this situation.
Wound Closure - Skin adhesives
Tissue adhesives are used
in small lacerations. The time to close the wound is much faster
using tissue adhesives. The wound must
be cleansed carefully.
Tissue adhesive should not be placed within the wound, or used on
areas of high tension or repetitive movements, such as joints. Application
is rapid and relatively painless. Warn the patient of an exothermic
reaction as the adhesive polymerises. Tissue adhesives will slough
off in 5-10 days.
Step-by-step approach on using skin adhesives
Exact approximation of the wound margins
Tissue adhesives should be applied over a bloodless field.
Exact adaptation of wound
Application of Histoacryl
Avoid placing the glue in the wound or between the wound margins.
Three to four coats should be applied.
Application of Histoacryl
Hold the wound margins together for several seconds until
Hold wound edges in place for 1 minute
Wound dressings and follow-up
Dressings are important to maintain sterility and absorb blood and
serum. Moisture improves the rate of epithiliazation. The goal is
a state of optimal hydration of the wound margins – not too
wet or too dry. Sutured or stapled lacerations should be covered
with a nonadherent dressing for the first 1 to 2 days to also allow
sufficient epithelization to prevent gross contamination.
There is some suggestion that topical antibiotic ointments, such
as Polysporin or bacitracin, are helpful in reducing infection of
the wound. However, these are NOT used if a tissue adhesive is applied
as the glue is weakened.
Abrasions are treated in much the same way
as burns. An occlusive or semi-occlusive antibiotic or Vaseline
dressing will minimize pain
and help prevent infection. Some full thickness abrasions may require
skin grafting, and Plastic Surgery should be consulted.
is a potential “dead space” in a wound, then
a pressure bandage – a bolus dressing of gauze held firmly
by tape, can be used to minimize serum and blood collection in
space” by putting pressure on the wound area.
injuries, other than minor ones, should be splinted in a position
of function following repair. Elevation of an extremity
will reduce swelling for those injuries with concomitant soft
Instructions to the patient are important. The repaired
laceration should be kept clean and dry. After 1 to 2 days, patients
gently clean the area with soap and water and blot the area
that have been closed with glue should not be kept wet for
long – showering
is fine but bathing and swimming should be avoided or dehiscence
of the wound may occur. Again, the wound should be pat dried
to avoid stress on the wound margins and dehiscence. The symptoms
of infection (including redness and streaking, heat, the discharge
of pus, swelling, and increasing pain) must be explained to the
patient and documented on the chart. A handout for wound care
for the patient to take home but the details must be explained
to the patient.
Sutured or stapled lacerations should be covered with a protective
and nonadherent dressing for 24 to 48 hours. Thereafter, exposed
wound lines should be gently washed with soap and water daily. Scrubbing
or soaking is to be avoided. Topical antibiotic ointments such as
Polysporin may help reduce the wound infection rate. Maintenance
of a moist wound margin with such topicals also increases the rate
However, such topicals should not be used with
tissue adhesives as the glue may slough. These patients can shower
but should avoid bathes
or swims. Prolonged exposure to water loosens the glue.
should understand the frequency of dressing changes and also be
instructed on the signs of infection and to seek medical
if these develop. A handout for patients is useful but the handout
must be explained.
The timing of suture removal is variable. As a general principle,
suture marks (sinus tracts) may be permanent if the stitches are
left in place for 7 days or more. The table below contains suggestions
for the optimal time for suture removal. Before removing the sutures,
the wound margins should appear to be healing and appear closed.
A ridge of healing tissue may be felt. It may be prudent to apply “steristrips” to
strengthen the wound if the area is under tension and the sutures
are being removed “early” for cosmetic reasons. Coexisting
illnesses, such as diabetes and renal failure, may prolong healing
times and should also be considered.
Optimal time for suture removal
Chest and extremities
High tension (joints, hands)
Adapted from Management of lacerations in the emergency
department. O. Capellan and J. Hollander Emergency Medicine Clinics
of North America.
Volume 21, Number 1, February 2003
The infection rate of most wounds is not decreased
with the use of oral, IV or IM antibiotics. Certain exceptions
exist, particularly when
with mammalian bites and some other situations. These wounds are
seldom closed primarily. See Medications/Antibiotics and Special