Contraindications to epinepherine?
Intranasal or Oral midazolam 20 min prior to procedure
- Simple skin laceration or abrasion
- Complex anatomical location (auricle, intraoral, eyelid involvement, genital or rectal involvement)
- Deep muscle, tendon or neurovascular involvement
- Deep puncture wounds
- Animal or human bites
- High tension skin areas
- Active signs of infection
- Complex nature of wound
Hemostatis obtained?
Will patient need tetanus prophylaxis?
Consult advanced provider in wound repair
Sutures
- Determine suturing technique
- Determine type of suture material
- Place sutures
- Determine need for antibiotics
- Apply topical antibiotics and bandage
Tissue adhesive
- Ensure complete hemostasis & skin is dry
- Approximate skin margins with forceps or fingers
- Apply a thin strip along the wound
- Allow to dry for 30-40 sec while holding skin
- Repeat process 3 - 4 times
Patient to require sedation?
Patient to require anxiolysis?
Irrigate and clean area with clean tap water, apply topical antibiotics if indicated, sunscreen advice, consider delayed closure
Contraindications to LET
- Lacerations of mucous membranes
- Lacerations to areas of potential vascular compromise (eg, digits, penis, ear, nose)
- Grossly contaminated wounds
- Patients with allergy to amide or ester local anesthetics
- Lacerations > 5cm
Risk for concerning foreign body?
Patient to benefit from regional nerve block?
Perform regional nerve block
Contraindications to LET?
Clean the area around the wound with providone-iodine or chlorhexidine. Do not scrub the wound itself with these solutions.
Inadequate analgesia?
Contraindications to midazolam
- History of adverse event
- Current disease process causing myocardial depression
- Patients at risk for hypoventilation
Contraindications to lidocaine with epinephrine
- Peripheral vascular disease
- History of hypersensitivity to local anesthetics of the amide type
- Patient with disease process that make them susceptible to epinephrine (HTN, CV disease, etc.)
- Dirty or contaminated wounds
Wound irrigation and preparation. Start primary closure.
Wound closure tapes
- Dry area around wound site
- Place central strip first (pinch wound)
- Place tapes 1/8 inch (3mm) apart
- Add parallel strips to reduce tension
Staples
- Approximate skin margins with forceps or fingers
- Place central staple first
- Place staples 0.5 - 1 cm apart along wound
- Apply topical antibiotics and bandage
Techniques to achieve hemostatis
- Constant Pressure for 10-15 min
- Injection of 1% lidocaine with epinephrine
- Absorbable gelatin foam
- Use of a BP cuff at 10 mmHg above systolic pressure applied to proximal end of extremity with wound after elevating the extremity for 1 min to allow venous drainage.
- Large extremity tourniquets (30-60 min)
- Digital tourniquets (20-30 min)
Contraindications to tissue adhesive
- High skin tension
- Complex wounds (stellate, crush)
- Wounds over joints unless immobilized
- Mucosal surfaces
- Hairy areas unless trimmed
- Concern for infection (bites, punctures, etc.)
- Allergy or sensitivity
Contraindications to nitrous oxide
- History of adverse event
- Vomiting
- Pregnancy
- Gas within body cavities (SBO, Pneumothorax, Otitis Media, etc)
Consider x-ray to identify radiopaque materials
Wound will need primary closure?
Hair removal
- Hair should only be gently combed or trimmed away from wound margins.
Hair apposition
- Appose hair across the wound
- Rotate 2 -3 times
- Apply small drop of tissue adhesive
- Repeat along the length of the wound
Place LET 30-45 min prior to procedure
1% lidocaine field block
1% lidocaine with epinephrine field block
