Essential Tips on Laceration Repair for ER Physicians

OVERVIEW

Laceration repair is not uncommon in the emergency department. In this episode, we get some expert tips for emergency physicians from a plastic surgery colleague. Join Dr. Kimberly Fiscella of Albany Medical Center and host Dr. Blythe Fiscella of ChristianaCare to pick up some essential pearls on suturing and skin/soft tissue injury management in the ER.

Pearls & Pitfalls

• Take your time. Ask for help. Get more supplies than you think you'll need. Identify the laceration. This often means spending time with good lighting, warm water, a washcloth, and persistence if the wound is in the scalp.
  • Don't be afraid to cut hair out of your way if needed! Get good exposure and identify the extent of the wound to determine the type of repair required.
  • If gaping or any evidence of deeper structures like muscle, tendon, or nerve, you likely need a layered closure.
• Irrigate the laceration, ideally after you have numbed the area with lidocaine and epinephrine. Inject from within the wound to avoid causing more trauma and pain.
  • Give the anesthetic plenty of time to take effect (~10 minutes) and consider using part bicarbonate if you have a lot of surface area to cover and want to minimize burning. Use SafeLocal to check your math and ensure safe lidocaine and bupivacaine dosing.
  • Use safe technique to ensure you are not injecting the anesthetic directly into vessels: pull back on the syringe plunger once you advance the needle and check for blood return before instilling the solution. Be patient and use a small syringe (3-5 mL is best) and small needle (ideally 25G or smaller) to slow the rate at which you are injecting the lidocaine. This minimizes pain for the patient.
• Select the right size suture (usually 5.0 or 6.0 on the face) and select non-braided suture for most ER repairs.
  • The usual best selection in the ER for buried sutures is an absorbable monofilament like poliglecaprone 25 (Monocryl™).
  • The usual best selection for most ER for top layer sutures is polypropylene (Prolene™).
  • If the patient cannot come back to have the sutures removed or if they require sedation for the placement of sutures, you can use absorbable suture like Plain/Fast Gut on the skin for the top layer (warning the patient that the cosmetic result could be slightly worse than with non-absorbable suture) so they won't have to come back. Still use Monocryl for deep sutures in those patients (Plain/Fast Gut is very inflammatory if used as a buried stitch).