Lacerations
Lacerations - Summary
A laceration is a tearing or splitting of the skin commonly caused by blunt trauma, or an incision of the skin caused by a sharp object, such as a knife or broken glass.
Infection is the most common complication of a laceration. However, there may be injuries to the nerves, blood vessels, muscles, bone, and tendons.
The risk of infection is increased further with factors such as:
Diabetes.
Visible contamination.
Increasing age.
Increasing time from injury to repair.
Increasing depth, length, and width of the laceration.
Management of a laceration with low risk of infection involves:
Disinfecting the skin around the wound with an antiseptic and closing the laceration appropriately (local anaesthetic may be required for large or deep lacerations).
Applying an appropriate dressing after closing the laceration.
Offering follow up as appropriate to remove sutures.
Management of infected lacerations or lacerations at high risk of developing infection involves:
Not closing the laceration initially.
Covering the laceration with a non-adherent, absorbent dressing.
Taking a detailed history and ascertaining whether the wound was originally contaminated with high-risk material (soil, faeces, bodily fluids, or purulent exudates).
Reviewing 3–5 days after presentation and closing the laceration if there are no signs of infection.
If symptoms and signs of infection develop after closure of the laceration: removing sutures or adhesive strips and incising the laceration if it is not draining. Taking swabs from any discharge for microbiological investigation - and initiating empirical antibiotic therapy while awaiting results.
Treating contaminated lacerations with co-amoxiclav (or erythromycin plus metronidazole in penicillin allergy).
Treating clean lacerations (no history or evidence of contamination or foreign bodies) with flucloxacillin (erythromycin or clarithromycin in penicillin allergy).
If signs of infection persist, reviewing the swab results, changing the antibiotics if indicated, and arranging further review.
Referring people who have a tetanus-prone wound which is at high risk of contamination to hospital for treatment with human tetanus immunoglobulin, regardless of tetanus immunization status.
Checking the person's tetanus immunization status and administer a booster dose of tetanus vaccine if needed.
Referral to A&E is recommended if:
There is vascular, nerve, or tendon damage.
It is a facial laceration.
It is a laceration of the palm of the hand with any signs of infection.
There is associated marked cellulitis over a joint.
There is a possible foreign body remaining in the wound after cleaning, including all injuries caused by glass.
The laceration is complex, widely gaping, or extensively devitalized.
There is a tetanus-prone wound.
Admission to hospital should be arranged if the person has signs or symptoms of tetanus (generalized rigidity and spasm of skeletal muscles, including lockjaw) and has had a laceration in the previous days or weeks.
People with lacerations should be advised to:
Seek medical attention if they develop infection.
Take paracetamol or ibuprofen for pain relief, if needed.
Keep the wound dry.
Have I got the right topic?
This CKS topic covers the management of lacerations in primary care.
There are separate CKS topics on Bites - human and animal and Burns and scalds.
The target audience for this CKS topic is healthcare professionals working within the NHS in the UK and providing first contact or primary health care.
How up-to-date is this topic?
How up-to-date is this topic?
Changes
February 2013 — minor update. The 2013 QIPP options for local implementation have been added to this topic [NICE, 2013].
October 2012 — minor update. The 2012 QIPP options for local implementation have been added to this topic [NPC, 2012].
August 2012 — reviewed. A literature search was conducted in August 2012 to identify evidence-based guidelines, UK policy, systematic reviews, and key RCTs published since the last revision of this topic. No major changes to recommendations have been made.
Previous changes
July 2011 — minor update. More exact paracetamol dosing for children has been introduced by the Medicines and Healthcare products Regulatory Agency [MHRA, 2011]. Prescriptions have been updated to reflect the revised dosing. Issued in July 2011.
May 2011 — minor update. The 2010/2011 QIPP options for local implementation have been added to this topic [NPC, 2011]. Issued in June 2011.
October 2010 — topic structure revised to ensure consistency across CKS topics — no changes to clinical recommendations have been made.
August 2009 — minor update. Advice from the National Institute for Health and Clinical Excellence guideline on when to suspect child maltreatment has been added to this topic [NICE, 2009c]. Issued in August 2009.
July to October 2007 — converted from CKS guidance to CKS topic structure. The evidence-base has been reviewed in detail, and recommendations are more clearly justified and transparently linked to the supporting evidence.
More detailed information has been included on how to assess and manage a laceration at high risk of infection.
October 2006 — minor update. Analgesia prescriptions updated because new doses of ibuprofen for children are recommend by the British National Formulary. Issued in October 2006.
October 2005 — minor technical update. Issued in November 2005.
July 2005 — minor correction to reference list. Issued in July 2005.
September 2004 — updated to include the new combined tetanus vaccines Pediacel, Repevax, and Revaxis. Issued in September 2004.
March 2004 — reviewed. Validated in May 2004 and issued in July 2004.
May 2001 — reviewed. Validated in July 2001 and issued in October 2001.
August 1998 — written.
Update
New evidence
Evidence-based guidelines
No new evidence-based guidelines since 1 August 2012.
HTAs (Health Technology Assessments)
No new HTAs since 1 August 2012.
Economic appraisals
No new economic appraisals relevant to England since 1 August 2012.
Systematic reviews and meta-analyses
No new systematic reviews or meta-analyses published since 1 August 2012.
Primary evidence
No new randomized controlled trials published in the major journals since 1 August 2012.
New policies
No new national policies or guidelines since 1 August 2012.
New safety alerts
No new safety alerts since 1 August 2012.
Changes in product availability
No changes in product availability since 1 August 2012.
Goals and outcome measures
Goals
To support primary healthcare professionals:
To reduce risk of infection
To treat any established infection
To achieve satisfactory wound healing with good cosmetic outcome
To prevent tetanus
QIPP — Options for local implementation
QIPP — Options for local implementation
Non-steroidal anti-inflammatory drugs (NSAIDs)
Review the appropriateness of NSAID prescribing widely and on a routine basis, especially in people who are at higher risk of both gastrointestinal (GI) and cardiovascular (CV) morbidity and mortality (e.g. older patients).
If initiating an NSAID is obligatory, use ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).
Review patients currently prescribed NSAIDs. If continued use is necessary, consider changing to ibuprofen (1200 mg per day or less) or naproxen (1000 mg per day or less).
Review and, where appropriate, revise prescribing of etoricoxib to ensure it is in line with MHRA advice and the NICE clinical guideline on osteoarthritis [CSM, 2005; NICE, 2008].
Co-prescribe a proton pump inhibitor (PPI) with NSAIDs for people with osteoarthritis, rheumatoid arthritis, or low back pain (for people over 45 years) in accordance with NICE guidance [NICE, 2008; NICE, 2009a; NICE, 2009b].
Take account of drug interactions when co-prescribing NSAIDs with other medicines (see Summaries of Product Characteristics). For example, co-prescribing NSAIDs with ACE inhibitors or angiotensin receptor blockers (ARBs) may pose particular risks to renal function; this combination should be especially carefully considered and regularly monitored if continued.
Antibiotic prescribing — especially quinolones and cephalosporins
Review and, where appropriate, revise current prescribing practice and use implementation techniques to ensure prescribing is in line with Health Protection Agency (HPA) guidance.
Review the total volume of antibiotic prescribing against local and national data.
Review the use of quinolones and cephalosporin prescribing against local and national data.
Background information
Definition
What is it?
A laceration is a tearing or splitting of the skin commonly caused by blunt trauma, or an incision of the skin caused by a sharp object, such as a knife or broken glass.
Prevalence
How common is it?
Lacerations account for approximately 10% of attendances at Accident and Emergency departments.
In a prospective study of 5521 people with laceration presenting at an Accident and Emergency department:
More than 70% were male.
The mean age was 23.1 +/– 18.3 years.
Complications
Injuries to important structures, such as nerves, blood vessels, muscles, bones, and tendons, are commonly associated with lacerations.
Infection is the most common complication of a laceration. In a prospective study of 5521 people presenting to an Accident and Emergency department [Hollander et al, 2001]:
Approximately 3.5% developed a wound infection.
The risk of infection was increased further with:
Diabetes.
Foreign body in the wound.
Visible contamination.
Jagged wound margins.
Increasing age.
Increasing time from injury to repair.
Increasing depth, length, and width of the laceration.
The risk of infection was reduced in people with lacerations on the head or neck.
Assessment
Assessment of lacerations
Assessment
How should I assess a person with a laceration?
For people with a laceration not requiring specialist referral, decide whether it is:
Delayed presentation with erythema spreading from the laceration.
Possible general malaise, fever, rigors and lymphadenopathy.
A laceration at high risk of infection:
The risk of infection is high in people with a laceration contaminated with soil, faeces, body fluids, or pus.
The risk of infection for all other lacerations is judged by assessing the number and severity of risk factors. The risk of infection is increased with each of the following risk factors:
Diabetes.
Oral steroid therapy and other causes of immunosuppression.
Age older than 65 years.
Foreign body present before cleaning of wound.
Stellate shape or jagged wound margins.
Visible contamination with substances other than soil, faeces, bodily fluids, or pus.
Presentation more than 6 hours after injury.
Wounds longer than 5 cm.
The risk of infection is reduced in people with a laceration on the head or neck.
The risk assessment requires clinical judgement, but as a guide:
A person with a single risk factor, unless it is unusually severe, is not likely to be at high risk of infection.
A person with two or more risk factors for infection, unless these risk factors are unusually mild, is likely to be at high risk of infection.
A laceration at low risk of infection:
All wounds that are assessed not to be infected or at high risk of infection.
Although rare, suspect child maltreatment if:
A child has lacerations, abrasions or scars and the explanation is unsuitable.
Examples include lacerations, abrasions or scars:
On a child who is not independently mobile.
That are multiple.
With a symmetrical distribution.
On areas usually protected by clothing (such as the back, chest, abdomen, axilla, genital area).
On the eyes, ears, or sides of face.
On the neck, ankles, or wrists that look like ligature marks.
Note: Many risk factors require judgement on the degree of risk they represent for an individual. For example, the degree of jaggedness of the wound edge might be slight, moderate, or severe, or diabetes might be well controlled or poorly controlled.
Basis for recommendation
Basis for recommendation
These criteria are a guide to the most important factors to consider when deciding whether a laceration should be managed as having high or low risk of infection. They are based on the best available evidence of the most significant risk factors for a laceration developing infection. They are not a validated assessment tool and should not be used in place of clinical judgement.
Experts recommend that lacerations at high risk of infection be managed differently from those that are not.
CKS could not find published criteria that clearly determined which people with a laceration should be managed as having high risk and who should be managed as having low risk of infection.
CKS has provided specific criteria to guide the decision when to manage a person as having high or low risk of infection. These criteria are based on two considerations:
Some experts consider a 10% or greater risk of infection in a laceration to be high risk [Edlich and Reddy, 2001].
Evidence from two large prospective trials found factors that increase the risk of infection:
Wounds contaminated with material that contains a high bacterial count have a very high risk of infection; the wound should be classified and managed as having high risk of infection on this basis alone. This practice is widely supported by expert opinion.
Several factors, when considered alone, do not confer sufficient increased risk of infection to justify managing the wound as high risk. When two or more factors are present, however, the risk of infection is increased. If these risk factors are judged to be of moderate to high severity, the risk of infection is likely to be high enough to justify managing the laceration as having high risk of infection.
Direct evidence is lacking that immunosuppression due to causes other than corticosteroids increases the risk of infection in a laceration. However, it seems reasonable to assume that this is the case.
The recommendations on when to suspect child maltreatment are based on guidelines from the National Institute for Health and Clinical Excellence [NICE, 2009c].
Management
Management
Scenario: Laceration - low infection risk: covers the management of people who have a laceration that is not presently infected or at high risk of infection.
Scenario: Laceration - high infection risk: covers the management of people who have a laceration that is not presently infected but is at high risk of infection.
Scenario: Laceration - infected: covers the management of a laceration that is already infected on presentation.
Scenario: Laceration - low infection risk
Scenario: Laceration - low risk of infection
When to refer
When should I refer a person with a laceration?
Refer to an Accident and Emergency department if:
There is vascular damage — arterial bleeding from wound, loss of pulse, or poor perfusion distal to the injury.
There is nerve damage — loss of light touch or motor function distal to the injury.
There is injury to a tendon, including injury to the sheath.
It is a facial laceration for which a good cosmetic repair is important, particularly a laceration that crosses the margins of lips, nose, or ears.
It is a laceration of the palm of the hand with any signs of infection.
The laceration is associated with marked cellulitis over a joint.
There is a possible foreign body remaining in the wound after cleaning, including all injuries caused by glass.
The laceration is complex, widely gaping, or extensively devitalized.
Basis for recommendation
Basis for recommendation
These criteria are widely recommended by experts to determine when a laceration requires secondary care management [Cole, 2003].
How to clean the laceration
How should I clean a laceration before closure?
Disinfect the skin around the wound with an antiseptic, but avoid getting antiseptic into the wound.
Keep hair out of the wound — minimize hair removal by clipping with scissors around the wound edges and by applying simple ointment to flatten the hair away from the wound.
Anaesthetize the laceration before cleaning if debriding or exploring the wound. The pain from infiltrating local anaesthetic can be reduced by:
Using a 25–gauge needle.
Warming the anaesthetic before infiltration.
Infiltrating through the cut edge of the wound into the subdermal tissue.
Infiltrating slowly.
Debride devitalized tissue and pick out as much foreign material as possible — if glass may be present, refer for radiography.
Irrigate the wound with normal saline, drinking-quality water, or cooled boiled water.
For lacerations that are not visibly contaminated, low-pressure irrigation using a syringe is sufficient.
For lacerations that are visibly contaminated, irrigate at high pressure with a syringe and a green needle, to remove visible debris from the wound.
Basis for recommendation
Basis for recommendation
Basis for cleaning the laceration before closing the wound
There is evidence from two large prospective studies that devitalized tissue, foreign bodies, and visible contamination of a laceration increase the risk of wound infection [Cruse and Foord, 1980; Hollander et al, 2001].
Although there is a lack of direct evidence for the effectiveness of measures to clean the wound (removal of hair and foreign bodies, disinfection of the surrounding skin, debridement and irrigation of the wound) in reducing infection rates in lacerations, they are practical recommendations that are widely recommended [NGC, 2007].
There is evidence from a Cochrane systematic review that drinkable tap water, boiled and cooled water, and normal saline are all comparable wound cleansing agents. Using drinkable tap water to clean acute wounds does not appear to increase the infection rate [Fernandez and Griffiths, 2012].
Specific recommendations about hair removal, anaesthetizing the laceration, and irrigating the laceration are from a consensus of expert opinion [Edlich and Reddy, 2001].
How to close the laceration
How should I close the laceration?
Sutures (with local anaesthetic) are preferred for all lacerations longer than 5 cm, or those 5 cm or shorter when:
Deep dermal sutures are required, to allow low-tension apposition of the wound edges.
The wound is subject to excessive flexing, tension, or wetting.
Tissue adhesives or adhesive strips should be used to close wounds 5 cm or shorter when there are no risk factors for infection, and the wound edges are easily apposed without leaving any dead space, and the wound is not subject to excessive flexing, tension, or wetting:
Tissue adhesives are not suitable if any risk factors for infection are present.
Always use adhesive strips on pretibial flaps (not tissue adhesives or sutures).
For further details on anaesthesia, choice of suturing material, suturing technique, skin tissue adhesives, and skin closure strips, see Additional information.
Additional information
Additional information
The pain from infiltrating local anaesthetic can be reduced by [Edlich and Reddy, 2001]:
Using a 25–gauge needle.
Warming the anaesthetic before infiltration.
Infiltrating through the cut edge of the wound into the subdermal tissue.
Infiltrating slowly.
Choice of suturing material [Castille, 1998; Whiteside and Moorehead, 1998]:
Synthetic monofilament materials, such as nylon or polypropylene, are inert and are preferable to silk, which may cause a tissue reaction.
For small, simple wounds, the most frequently used sizes of suture material range from 3/0 (large) to 6/0 (fine). As a general guide:
Trunk and lower limbs — 3/0.
Scalp — 3/0, 4/0.
Upper limbs — 4/0.
Face — 5/0, 6/0.
Reduce the recommended adult sizes by one size when suturing children's wounds.
Suturing technique [Castille, 1998; Wilson et al, 2000]:
Lacerations that gape by more than 5 mm require deep dermal absorbable sutures to eliminate any potential dead space and bring the surface edges of the wound in close apposition. Refer to Accident and Emergency if this is beyond the competency of the clinician.
The first surface suture is placed centrally to ensure equal apposition of wound edges.
Sutures are placed 5 mm from the laceration edge at right angles to the wound.
The closed wound should have a slightly everted edge with modest tension on the sutures.
Record the number of sutures used to inform the person removing the sutures how many need to be removed.
Skin tissue adhesives [Hollander and Singer, 1999]:
Tissue adhesive is painted on top of the skin while the edges of the laceration are held in apposition. If significant tension is required to appose the edges of the laceration, use of a tissue adhesive is inappropriate.
Three or four layers of adhesive are applied to provide adequate strength for the wound closure. Allow heat to dissipate between each application.
Skin closure strips [Richardson, 2003]:
Skin must be clean and dry before applying the strip.
Place the first strip centrally to align the wound edges properly.
Place subsequent strips with 3 mm gaps between each one.
If necessary, strips can be placed parallel to the wound to strengthen the closing strips.
Basis for recommendation
Basis for recommendation
A Cochrane review found that tissue adhesives are an acceptable alternative to standard closure techniques for people with simple lacerations shorter than 5 cm that are not subject to flexing or tension. They produce similar cosmetic results but are quicker to apply and are less painful [Farion et al, 2002]. A further literature search for this Cochrane systematic review in 2007 did not find any new evidence to necessitate an update to these conclusions.
Evidence from a randomized controlled trial (n = 100) indicates that skin closure strips have very similar outcomes as tissue adhesives when used to close simple facial lacerations in children [Zempsky et al, 2004].
Skin closure strips are preferred to close lacerations 5 cm or shorter that have a risk factor for infection, because they are easily removed to allow drainage.
CKS does not recommend the use of staples in primary care because [Cole, 2003]:
They produce a poorer cosmetic result than other methods of closure.
Although they are quicker to use than other methods of closure, which is a significant benefit in a busy casualty department, this is rarely a significant factor in primary care.
Specific recommendations on anaesthesia [Edlich and Reddy, 2001], choice of suturing material [Castille, 1998; Whiteside and Moorehead, 1998], suturing technique [Castille, 1998; Wilson et al, 2000], skin tissue adhesives [Hollander and Singer, 1999], and skin closure strips [Richardson, 2003] are based on expert opinion.
How to dress the laceration
How should an uninfected laceration be dressed after closure?
Apply a dressing after closing the laceration.
For lacerations with minimal exudate, dress with a clear vapour-permeable dressing.
For lacerations with modest exudate, dress with a low-adherence, absorbent, perforated dressing with an adhesive border. These are also available with a plastic film covering to protect dressings from getting wet.
Types of dressing
Types of dressing
CKS recommends the use of different categories of dressing, but not specific dressings. The terms used for the different categories of dressings follows those used in the British National Formulary (BNF). Within each category listed in the BNF, there are dressings with slightly different properties. The dressing used will depend on personal preference and experience.
Non-adherent, absorbent, perforated dressings are placed in contact with the wound and are available in various forms:
With an adhesive border, which allows the dressing to be used alone.
With an adhesive border, which allows the dressing to be used alone, and a clear plastic backing to protect it from wetting.
Without an adhesive border, for when it must be combined with a secondary dressing to keep it in place.
Impregnated with soft yellow paraffin, to reduce the risk of adhesion to the wound surface.
Impregnated with povidone–iodine, which has antimicrobial activity.
Basis for recommendation
Basis for recommendation
These recommendations are based on information in the British National Formulary [BNF 63, 2012].
Vapour–permeable film dressings are recommended for use with wounds with low levels of exudate because:
They are waterproof and protect the wound from becoming infected or wet during normal daily activities.
They maintain a moist environment for optimal wound healing.
They are comfortable and convenient to use.
They allow the wound to be visually inspected for infection without the dressings being removed.
Low-adherence, absorbent, perforated dressings are recommended for wounds with moderate amounts of exudate because:
They can absorb moderate amounts of exudate, which prevents the wound from becoming macerated but maintains a moist environment for optimal wound healing.
Exudate from the wound discolours the dressing and is easily seen. This allows some monitoring of the wound without removing the dressing.
Advice
What advice should I give to a person with a laceration at low risk of infection?
Advise people to seek medical attention if they develop infection. Symptoms and signs to look out for include:
Increasing pain, redness, or swelling spreading from the laceration.
Fever or general malaise.
Advise people to take simple analgesia, such as paracetamol or ibuprofen, if the wound is painful or is likely to become painful. These drugs can be prescribed or bought over the counter.
Advise people to keep the wound dry. Waterproof dressings, such as vapour-permeable dressings, allow light wetting (as from showering) without the dressing separating or the wound becoming wet. Non-waterproof dressings must be protected from wetting at all times.
Provide written information to back-up this advice.
Basis for recommendation
Basis for recommendation
These recommendations are pragmatic advice based on narrative reviews of laceration repair and management [Hollander and Singer, 1999; Wilson et al, 2000].
Tetanus prophylaxis
When should I give tetanus prophylaxis to a person with a laceration at low risk of infection?
Check the person's tetanus immunization status.
A fully immunized person will have had a primary course of three vaccines followed by two boosters spaced 10 years apart.
For further details, see the CKS topic on Immunizations - childhood.
Administer a booster dose of tetanus vaccine if needed.
Fully immunized — booster not required.
Primary immunization complete, boosters incomplete but up to date — booster not required, but administer if the next dose is due soon and it is convenient to do so.
Primary immunization incomplete or boosters not up to date — administer a reinforcing dose and continue with the recommended schedule.
Not immunized or immunization status unknown or uncertain — give an immediate dose of vaccine and continue with the full five-dose schedule.
For details on giving a booster dose of Td/IPV, see the section on Tetanus booster in Prescribing information.
Prophylaxis with tetanus immunoglobulin is not necessary in a wound that is unlikely to become infected.
Basis for recommendation
Basis for recommendation
These recommendations are based on Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2009].
A wound that is unlikely to be infected is also unlikely to be tetanus-prone. However, presentation of a laceration provides an opportunity to check and reinforce the immunization schedule if necessary.
Follow up
How should I follow up a person following closure of a laceration?
If symptoms and signs of infection develop after closure of the laceration, see Scenario: Laceration - infected for the course of action.
Remove sutures after 3–5 days on the head, 10–14 days over joints, and 7–10 days at other sites.
Advise people with lacerations closed by adhesive strips to remove these themselves after 3–5 days for wounds on the head and 7–10 days for wounds at other sites.
Tissue adhesive does not need to be removed, as it will slough off naturally after 7–10 days.
Dressings should be removed at the same time as sutures or adhesive strips. Low-adherence absorbent dressings should be replaced if the exudate has caused significant wetting of the dressing.
Basis for recommendation
Basis for recommendation
These recommendations are based on widely accepted practice supported by experts [Singer et al, 1997].
Scenario: Laceration - high infection risk
Scenario: Laceration - high risk of infection
When to refer
When should I refer a person with a laceration?
Refer to an Accident and Emergency department if:
There is vascular damage — arterial bleeding from wound, loss of pulse, or poor perfusion distal to the injury.
There is nerve damage — loss of light touch or motor function distal to the injury.
There is injury to a tendon, including injury to the sheath.
It is a facial laceration for which a good cosmetic repair is important, particularly a laceration that crosses the margins of lips, nose, or ear.
It is a laceration of the palm of the hand with any signs of infection.
The laceration is associated with marked cellulitis over a joint.
There is a possible foreign body remaining in the wound after cleaning, including all injuries caused by glass.
The laceration is complex, widely gaping, or extensively devitalized.
There is a tetanus-prone wound (see Tetanus prophylaxis).
Basis for recommendation
Basis for recommendation
These criteria are widely recommended by experts to determine when a laceration requires secondary care management [Cole, 2003].
How to clean the laceration
How should I clean a laceration at high risk of infection?
Disinfect the skin around the wound with an antiseptic, but avoid getting antiseptic into the wound.
Keep hair out of the wound — minimize hair removal by clipping with scissors around the wound edges and by applying simple ointment to flatten the hair away from the wound.
Anaesthetize the laceration before cleaning if debriding or exploring the wound. The pain from infiltrating local anaesthetic can be reduced by:
Using a 25–gauge needle.
Warming the anaesthetic before infiltration.
Infiltrating through the cut edge of the wound into the subdermal tissue.
Infiltrating slowly.
Debride devitalized tissue and pick out as much foreign material as possible — if glass may be present, refer for radiography.
Irrigate the wound with normal saline, drinking-quality water, or cooled boiled water.
For lacerations that are not visibly contaminated, low-pressure irrigation using a syringe is sufficient.
For lacerations that are visibly contaminated, irrigate at high pressure with a syringe and a green needle, to remove visible debris from the wound.
Basis for recommendation
Basis for recommendation
Basis for cleaning the laceration before closing the wound
There is evidence from two large prospective studies that devitalized tissue, foreign bodies, and visible contamination of a laceration increase the risk of wound infection [Cruse and Foord, 1980; Hollander et al, 2001].
Although there is a lack of direct evidence for the effectiveness of measures to clean the wound (removal of hair and foreign bodies, disinfection of the surrounding skin, debridement and irrigation of the wound) in reducing infection rates in lacerations, they are practical recommendations that are widely recommended [NGC, 2007].
There is evidence from a Cochrane systematic review that drinkable tap water, boiled and cooled water, and normal saline are all comparable wound cleansing agents. Using drinkable tap water to clean acute wounds does not appear to increase the infection rate [Fernandez and Griffiths, 2012].
Specific recommendations about hair removal, anaesthetizing the laceration, and irrigating the laceration are from a consensus of expert opinion [Edlich and Reddy, 2001].
How to dress and pack the laceration
How should I dress and pack an open laceration at high risk of developing infection?
Dress but do not close lacerations at high risk of infection.
Prevent apposition of the wound edges by packing with a non-adherent dressing.
Cover all lacerations at high risk of infection with a non-adherent, absorbent dressing.
For lacerations with small quantities of exudate, dress with a non-adherent dressing alone or cover the non-adherent dressing with a vapour-permeable dressing.
For lacerations with more exudate, cover the non-adherent dressing with an alginate dressing or with a foam dressing held in place with a vapour-permeable dressing.
For details on types of dressing available, see Types of dressing.
Types of dressing
Types of dressing
CKS recommends the use of different categories of dressing, but not specific dressings. The terms used for the different categories of dressings follows those used in the British National Formulary (BNF). Within each category listed in the BNF, there are dressings with slightly different properties. The dressing used will depend on personal preference and experience.
Non-adherent, absorbent, perforated dressings are placed in contact with the wound and are available in various forms:
With an adhesive border that allows the dressing to be used alone.
With an adhesive border that allows the dressing to be used alone, and a clear plastic backing to protect it from wetting.
Without an adhesive border, for when it must be combined with a secondary dressing to keep it in place.
Impregnated with soft yellow paraffin, to reduce the risk of adhesion to the wound surface.
Impregnated with povidone–iodine, which has antimicrobial activity.
Alginate dressings vary in their absorbance according to the product used. They must be covered with a further dressing, such as a vapour-permeable film, to retain the dressing.
Foam dressings vary in their absorbency according to the product used.
Basis for recommendation
Basis for recommendation
These recommendations are based on information in the British National Formulary [BNF 63, 2012].
Low adherence, absorbent dressings are recommended for wounds with small quantities of exudate because:
They can absorb small quantities of exudate, which prevents the wound from becoming macerated but maintains a moist environment for optimal wound healing.
Exudate from the wound discolours the dressing and is easily seen. This allows some monitoring of the wound without removing the dressing.
Alginate or foam dressing is recommended for wounds with moderate or heavier quantities of exudate because these have a greater capacity to absorb exudate.
Which antibiotic to prescribe
Which antibiotic should I prescribe for a person at high risk of infection in a laceration?
Take a detailed history and ascertain whether the wound was originally contaminated with high-risk material (soil, faeces, bodily fluids, or purulent exudates).
Treat contaminated lacerations with co-amoxiclav. If the person is allergic to penicillin, treat with erythromycin combined with metronidazole (clarithromycin is an alternative if erythromycin is poorly tolerated).
Treat clean lacerations (no history or evidence of contamination or foreign bodies) with flucloxacillin. Use erythromycin (or clarithromycin) if the person is allergic to penicillin.
For further information on the suitability and adverse effects of antibiotics, see Prescribing information.
Basis for recommendation
Basis for recommendation
CKS could find no national guidelines or reviews on which antibiotic should be prescribed for lacerations. Consequently, these recommendations are based on the common use of antibiotics in the UK and the known antibiotic sensitivities of bacteria likely to present in a contaminated or susceptible wound.
CKS could find no evidence from controlled trials that any antibiotic is superior to another. Antibiotics have not been found to be effective in the prevention of infection in general populations of people with lacerations, but they are indicated for people with risk factors.
Co-amoxiclav is a broad-spectrum antibiotic which provides coverage against most species of bacteria found in contaminated wounds [ABPI Medicines Compendium, 2012].
Wounds that are, or may have been, contaminated with potentially infectious material (soil, faeces, body fluids, or pus) require a broad-spectrum antibiotic to cover the large number of species of bacteria which may be involved.
Co-amoxiclav is licensed for the treatment of skin and soft-tissue infections. It is effective against many species of Gram-positive and Gram-negative bacteria, as well as many anaerobes. It is also effective against penicillinase-producing bacteria, including resistant Staphylococcus aureus and S. epidermis (which commonly colonize skin).
Flucloxacillin has a narrow spectrum of activity but is potent against species normally found in the skin as commensals, which are the most likely causative pathogens in a 'clean' wound that becomes infected. It is therefore suitable for treatment of clean wounds at higher risk of infection.
Flucloxacillin is licensed for the treatment of infected wounds [ABPI Medicines Compendium, 2010a].
Human skin contains up to 1 million bacteria per square centimetre, depending on the location (i.e. how dry the surface is). The most common bacteria involved in pathogenesis are S. aureus and S. epidermis [Edlich and Reddy, 2001], both of which are susceptible to flucloxacillin, making it a suitable choice.
Flucloxacillin diffuses well into most tissues and is therefore suitable for skin and soft-tissue infections, including those in lacerations [Finch et al, 2003].
Erythromycin has a broad spectrum of activity and is a suitable alternative to flucloxacillin and co-amoxiclav (when combined with metronidazole).
Erythromycin is licensed for the treatment of soft-tissue infections [ABPI Medicines Compendium, 2010b].
The spectrum of activity of erythromycin includes activity against most sensitive Gram-positive cocci (including S. aureus and S. epidermis) and some Gram-negative cocci and anaerobes [Finch et al, 2003].
Clarithromycin has a similar spectrum of activity as erythromycin, but is reputed to cause fewer adverse effects [DTB, 1991a]. The perceived superior adverse effect profile of clarithromycin compared with erythromycin is mainly theoretical, although there are some limited data from randomized controlled trials to corroborate it [Aronson, 2006].
Metronidazole provides additional coverage for anaerobes that are not susceptible to erythromycin. It is licensed for various deep soft-tissue infections, in which anaerobes are likely to proliferate [ABPI Medicines Compendium, 2011].
Tetanus prophylaxis
When should I give tetanus prophylaxis to a person with a laceration at high risk of infection?
Refer people who have a tetanus-prone wound which is at high risk of contamination to hospital for treatment with human tetanus immunoglobulin, regardless of tetanus immunization status. A tetanus-prone wound that is at high risk of tetanus is either a wound that has extensive devitalization, or a wound that has heavy contamination with material likely to contain tetanus spores (e.g. soil or manure) and:
Requires surgical intervention (i.e. closure) that has been delayed by 6 hours or more.
Has significant devitalization or is a puncture type injury.
Has a foreign body.
Check the person's tetanus immunization status and administer a booster dose of tetanus vaccine if needed (a fully immunized person will have had a primary course of three vaccines followed by two boosters spaced 10 years apart, see CKS topic on Immunizations - childhood).
Fully immunized — booster not required.
Primary immunization complete, boosters incomplete but up to date — booster not required, but administer if the next dose is due soon and it is convenient to do so.
Primary immunization incomplete or boosters not up to date — administer a reinforcing dose and continue with the recommended schedule.
Not immunized or immunization status unknown or uncertain — give an immediate dose of vaccine and continue with the full five-dose schedule.
For details on giving a booster dose, see the section on Tetanus booster in Prescribing information.
If both human tetanus immunoglobulin and and a booster are required, separate injection sites should be used.
Basis for recommendation
Basis for recommendation
These recommendations are based on Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2009].
Human tetanus immunoglobulin is unlikely to be available in primary care and will usually require referral to Accident and Emergency.
The use of immunoglobulins is a precautionary recommendation, since evidence to support other alternatives is insufficient.
Tetanus vaccine given at the time of a tetanus-prone injury may not boost immunity early enough to give additional protection if a tetanus-prone wound is present. However, it provides an opportunity to check and reinforce the immunization schedule if necessary.
Advice
What advice should I give to a person with lacerations at high risk of infection?
Advise people to seek medical attention if they develop infection. Symptoms and signs include:
Increasing pain, redness, or swelling spreading from the laceration.
Fever or general malaise.
Advise people to take simple analgesia, such as paracetamol or ibuprofen, if the wound is painful or is likely to become painful. These drugs can be prescribed or bought over the counter.
Advise people to keep the wound dry. Waterproof dressings, such as vapour-permeable dressings, allow light wetting (as from showering) without the dressing separating or the wound becoming wet. Non-waterproof dressings must be protected from wetting at all times.
Provide written information to back-up this advice.
Basis for recommendation
Basis for recommendation
These recommendations are pragmatic advice based on narrative reviews of laceration repair and management [Hollander and Singer, 1999; Wilson et al, 2000].
When and how to close the laceration
When and how should I close a laceration at high risk of infection?
Review 3–5 days after presentation and close if there are no signs of infection. If infection has developed, see Scenario: Laceration - infected.
Sutures (with local anaesthetic) are preferred for all lacerations longer than 5 cm, or those 5 cm or shorter when:
Deep dermal sutures are required, to allow low-tension apposition of the wound edges.
The wound is subject to excessive flexing, tension or wetting.
Adhesive strips should be used to close wounds 5 cm or shorter when there are no risk factors for infection, and the wound edges are easily apposed without leaving any dead space, and the wound is not subject to excessive flexing, tension, or wetting. Adhesive strips are also appropriate for use in pretibial flaps.
Apply a dressing after closing the laceration. For lacerations with minimal exudate, dress with a clear vapour-permeable dressing. For lacerations with modest exudate, dress with a low adherence, absorbent, perforated dressing with an adhesive border.
For further details on anaesthesia, choice of suturing material, suturing technique, skin tissue adhesives, and skin closure strips, see Additional information.
Additional information
Additional information
The pain from infiltrating local anaesthetic can be reduced by:
Using a 25–gauge needle.
Warming the anaesthetic before infiltration.
Infiltrating through the cut edge of the wound into the subdermal tissue.
Infiltrating slowly.
Choice of suturing material:
Synthetic monofilament materials, such as nylon or polypropylene, are inert and are preferable to silk, which may cause a tissue reaction.
For small, simple wounds, the most frequently used sizes of suture material range from 3/0 (large) to 6/0 (fine). As a general guide:
Trunk and lower limbs — 3/0.
Scalp — 3/0, 4/0.
Upper limbs — 4/0.
Face — 5/0, 6/0.
Reduce the recommended adult sizes by one size when suturing children's wounds.
Suturing technique:
Lacerations that gape by more than 5 mm require deep dermal absorbable sutures to eliminate any potential dead space and bring the surface edges of the wound in close apposition. Refer to Accident and Emergency if this is beyond the competency of the clinician.
The first surface suture is placed centrally to ensure equal apposition of wound edges.
Sutures are placed 5 mm from the laceration edge at right angles to the wound.
The closed wound should have a slightly everted edge with modest tension on the sutures.
Record the number of sutures used to inform the person removing the sutures how many need to be removed.
Skin closure strips:
Skin must be clean and dry before applying the strip.
Place the first strip centrally to align the wound properly.
Place subsequent strips with 3 mm gaps between each one.
If necessary, strips can be placed parallel to the wound to strengthen the closing strips.
Basis for recommendation
Basis for recommendation
When to close a laceration at high risk of infection
Experts widely recommend delayed closure when lacerations are at high risk of infection [Hollander and Singer, 1999; Edlich and Reddy, 2001; Richardson, 2003]. This is largely based upon the experience of surgeons managing contaminated battlefield wounds and is supported by a study of delayed closure of wounds in the Vietnam war and from animal experiments [Edlich et al, 1969].
How to close a laceration at high risk of infection
Tissue adhesives are not recommended for delayed closure of lacerations at high risk of infection because they are not easily removed to allow drainage.
Skin closure strips are recommended because they are easily removed if infection develops and have been shown to be an effective method of closing simple lacerations in children compared with tissue adhesives [Zempsky et al, 2004].
CKS does not recommend the use of staples in primary care because [Cole, 2003]:
They produce a poorer cosmetic result than other methods of closure.
Although they are quicker to use than other methods of closure, which is a significant benefit in a busy casualty department, this is rarely a significant factor in primary care.
Choice of dressing after closing the laceration
These recommendations are based on expert opinion. Dressings for acute lacerations have not been assessed in randomized controlled trials [Dale, 1997].
Vapour-permeable film dressings are recommended for use in wounds with low levels of exudate because:
They are waterproof and protect the wound from becoming infected or wet during normal daily activities.
They maintain a moist environment for optimal wound healing.
They are comfortable and convenient to use.
They allow the wound to be visually inspected for infection without the dressings being removed.
Low-adherence, absorbent, perforated dressings are recommended for wounds with moderate amounts of exudate because:
They can absorb moderate amounts of exudate, which prevents the wound from becoming macerated but maintains a moist environment for optimal wound healing.
Exudate from the wound discolours the dressing and is easily seen. This allows some monitoring of the wound without removing the dressing.
Specific recommendations on anaesthesia [Edlich and Reddy, 2001], choice of suturing material [Castille, 1998; Whiteside and Moorehead, 1998], suturing technique [Castille, 1998; Wilson et al, 2000], skin tissue adhesives [Hollander and Singer, 1999], and skin closure strips [Richardson, 2003] are based on expert opinion.
Follow up after closing laceration
How should I follow up after closing a laceration that has been infected?
If symptoms and signs of infection develop after closure of the laceration.
Remove sutures or adhesive strips and incise if it is not draining.
Take swabs from any discharge for microbiological investigation, and start empirical antibiotic therapy while awaiting results.
See Scenario: Laceration - infected for more information.
Remove sutures after 3–5 days on the head, 10–14 days over joints, and 7–10 days at other sites.
Advise people with lacerations closed by adhesive strips to remove these themselves after 3–5 days for wounds on the head and 7–10 days for wounds at other sites.
Remove dressings when sutures or adhesive strips are due to be removed. Low-adherence absorbent dressings should be replaced if exudate has caused significant wetting of the dressing.
Basis for recommendation
Basis for recommendation
These recommendations are based on widely accepted practice supported by experts [Singer et al, 1997].
Scenario: Laceration - infected
Scenario: Laceration - infected
When to refer
When should I refer a person with a laceration?
Refer to an Accident and Emergency department if:
There is vascular damage — arterial bleeding from wound, loss of pulse, or poor perfusion distal to the injury.
There is nerve damage — loss of light touch or motor function distal to the injury.
There is injury to a tendon, including injury to the sheath.
It is a facial laceration for which a good cosmetic repair is important, particularly a laceration that crosses the margins of lips, nose, or ears.
It is a laceration of the palm of the hand with any signs of infection.
The laceration is associated with marked cellulitis over a joint.
There is a possible foreign body remaining in the wound after cleaning, including all injuries caused by glass.
The laceration is complex, widely gaping, or extensively devitalized.
There is a tetanus-prone wound (see Tetanus prophylaxis).
Admit if the person has signs or symptoms of tetanus (generalized rigidity and spasm of skeletal muscles, including lockjaw) and has had a laceration in the previous days or weeks.
Basis for recommendation
Basis for recommendation
These criteria are widely recommended by experts to determine when a laceration requires secondary care management [Cole, 2003].
Tetanus has an incubation period of 4–21 days. Any symptoms or signs of tetanus in a person who has received a tetanus-prone wound during this interval should be treated as an emergency [DH, 2009].
How to clean the laceration
How should I clean an infected laceration?
Disinfect the skin around the wound with an antiseptic, but avoid getting antiseptic into the wound.
Keep hair out of the wound — minimize hair removal by clipping with scissors around the wound edges and by applying simple ointments to flatten the hair away from the wound.
Anaesthetize the laceration before cleaning if debriding or exploring the wound. The pain from infiltrating local anaesthetic can be reduced by:
Using a 25–gauge needle.
Warming the anaesthetic before infiltration.
Infiltrating through the cut edge of the wound into the subdermal tissue.
Infiltrating slowly.
Debride devitalized tissue and pick out as much foreign material as possible — if glass may be present, refer for radiography.
Irrigate the wound with normal saline, drinking-quality water, or cooled boiled water.
For lacerations that are not visibly contaminated, low-pressure irrigation using a syringe is sufficient.
For lacerations that are visibly contaminated, irrigate at high pressure with a syringe and a green needle, to remove visible debris from the wound.
Basis for recommendation
Basis for recommendation
Basis for cleaning the laceration before closing the wound
There is evidence from two large prospective studies that devitalized tissue, foreign bodies, and visible contamination of a laceration increase the risk of wound infection [Cruse and Foord, 1980; Hollander et al, 2001].
Although there is a lack of direct evidence for the effectiveness of measures to clean the wound (removal of hair and foreign bodies, disinfection of the surrounding skin, debridement and irrigation of the wound) in reducing infection rates in lacerations, they are practical recommendations that are widely recommended [NGC, 2007].
There is evidence from a Cochrane systematic review that drinkable tap water, boiled and cooled water, and normal saline are all comparable wound cleansing agents. Using drinkable tap water to clean acute wounds does not appear to increase the infection rate [Fernandez and Griffiths, 2012].
Specific recommendations about hair removal, anaesthetizing the laceration, and irrigating the laceration are from a consensus of expert opinion [Edlich and Reddy, 2001].
How to dress an infected laceration
How should I dress an infected laceration?
Dress but do not close a laceration that is infected.
Prevent apposition of the wound edges by packing the laceration with a non-adherent, absorbent dressing.
Cover all infected lacerations with a non-adherent, absorbent dressing.
For lacerations with small quantities of exudate, dress with a non-adherent dressing alone, or cover the non-adherent dressing with a vapour-permeable dressing.
For lacerations with more exudate, cover a non-adherent dressing with an alginate or foam dressing.
For details on types of dressing available, see Types of dressing.
Types of dressing
Types of dressing
CKS recommends the use of different categories of dressing, but not specific dressings. The terms used for the different categories of dressings follows those used in the British National Formulary (BNF). Within each category listed in the BNF, there are dressings with slightly different properties. The dressing used will depend on personal preference and experience.
Non-adherent, absorbent, perforated dressings are placed in contact with the wound and are available in various forms:
With an adhesive border that allows the dressing to be used alone.
With an adhesive border that allows the dressing to be used alone, and a clear plastic backing to protect it from wetting.
Without an adhesive border, for when it must be combined with a secondary dressing to keep it in place.
Impregnated with soft yellow paraffin, to reduce the risk of adhesion to the wound surface.
Impregnated with povidone–iodine, which has antimicrobial activity.
Alginate dressings vary in their absorbance according to the product used. They must be covered with a further dressing, such as a vapour-permeable film, to retain the dressing.
Foam dressings vary in their absorbency according to the product used.
Basis for recommendation
Basis for recommendation
These recommendations are based on information in the British National Formulary [BNF 63, 2012].
Low adherence, absorbent dressings are recommended for wounds with small quantities of exudate because:
They can absorb small quantities of exudate, which prevents the wound from becoming macerated but maintains a moist environment for optimal wound healing.
Exudate from the wound discolours the dressing and is easily seen. This allows some monitoring of the wound without removing the dressing.
Alginate or foam dressing is recommended for wounds with moderate or heavier quantities of exudate because these have a greater capacity to absorb exudate.
Which antibiotic to prescribe
Which antibiotic should I prescribe for an infected laceration?
Take a detailed history and ascertain whether the wound was originally contaminated with high-risk material (soil, faeces, saliva, or purulent exudates).
Treat contaminated lacerations with co-amoxiclav. If the person is allergic to penicillin, treat with erythromycin combined with metronidazole (clarithromycin is an alternative if erythromycin is poorly tolerated).
Treat clean lacerations (no history or evidence of contamination or foreign bodies) with flucloxacillin. Use erythromycin (or clarithromycin) if the person is allergic to penicillin.
For further information on the suitability and adverse effects of antibiotics, see Prescribing information.
Basis for recommendation
Basis for recommendation
CKS could find no national guidelines or reviews on which antibiotic should be prescribed for infected lacerations. Consequently, these recommendations are based on the common use of antibiotics in the UK and the known antibiotic sensitivities of bacteria likely to present in an infected wound.
CKS could find no evidence from controlled trials that one antibiotic is superior to another (antibiotics have not been found to be effective in the prevention of infection in general populations of people with lacerations but are indicated for people with risk factors or existing infection).
Co-amoxiclav is a broad-spectrum antibiotic which will provide coverage against most species of bacteria found in infected wounds that have been exposed to potentially infectious material [ABPI Medicines Compendium, 2012].
Wounds that are, or may have been, contaminated with potentially infectious material (soil, faeces, body fluids, or pus) require a broad-spectrum antibiotic to cover the large number of species of bacteria which may be involved.
Co-amoxiclav is licensed for the treatment of skin and soft-tissue infections. It is effective against many species of Gram-positive and Gram-negative bacteria, as well as many anaerobes. It is also effective against penicillinase-producing bacteria, including resistant Staphylococcus aureus and S. epidermis (which commonly colonize skin).
Flucloxacillin has a narrow spectrum of activity but is potent against species normally found in the skin as commensals, which are the most likely causative pathogens in a 'clean' wound that has become infected.
Flucloxacillin is licensed for the treatment of infected wounds [ABPI Medicines Compendium, 2010a].
Human skin contains up to 1 million bacteria per square centimetre, depending on the location (i.e. how dry the surface is). The most common bacteria involved in pathogenesis are S. aureus and S. epidermis [Edlich and Reddy, 2001], both of which are susceptible to flucloxacillin.
Flucloxacillin diffuses well into most tissues, so is suitable for skin and soft tissue infections including lacerations [Finch et al, 2003].
Erythromycin has a broad spectrum of activity and is suitable as an alternative to flucloxacillin and co-amoxiclav when combined with metronidazole.
Erythromycin is licensed for the treatment of skin and soft-tissue infections [ABPI Medicines Compendium, 2010b].
The spectrum of activity of erythromycin includes activity against most sensitive Gram-positive cocci (including S. aureus and S. epidermis) and some Gram-negative cocci and anaerobes [Finch et al, 2003].
Clarithromycin has a similar spectrum of activity as erythromycin, but is reputed to cause fewer adverse effects [DTB, 1991a]. The perceived superior adverse effect profile of clarithromycin compared with erythromycin is mainly theoretical, although there are some limited data from randomized controlled trials to corroborate it [Aronson, 2006].
Metronidazole provides additional coverage for anaerobes that are not susceptible to erythromycin. It is licensed for various deep soft-tissue infections in which anaerobes are likely to proliferate [ABPI Medicines Compendium, 2011].
Tetanus prophylaxis
When should I give tetanus prophylaxis to a person with an infected laceration?
Refer people who have a tetanus-prone wound which is at high risk of contamination to hospital for treatment with human tetanus immunoglobulin, regardless of tetanus immunization status. A tetanus-prone wound that is at high risk of tetanus is either a wound that has extensive devitalization, or a wound that has heavy contamination with material likely to contain tetanus spores (e.g. soil or manure) and:
Requires surgical intervention (i.e. closure) that has been delayed by 6 hours or more.
Has significant devitalization or is a puncture type injury.
Has a foreign body.
Check the person's tetanus immunization status and administer a booster dose of tetanus vaccine if needed (a fully immunized person will have had a primary course of three vaccines followed by two boosters spaced 10 years apart, see CKS topic on Immunizations - childhood).
Fully immunized — booster not required.
Primary immunization complete, boosters incomplete but up to date — booster not required, but administer if the next dose is due soon and it is convenient to do so.
Primary immunization incomplete or boosters not up to date — administer a reinforcing dose and continue with the recommended schedule.
Not immunized or immunization status unknown or uncertain — give an immediate dose of vaccine and continue with the full five-dose schedule.
For details on giving a booster dose, see the section on Tetanus booster in Prescribing information.
If both human tetanus immunoglobulin and and a booster are required, separate injection sites should be used.
Basis for recommendation
Basis for recommendation
These recommendations are consistent with those in Immunisation against infectious disease (the 'Green Book'), published by the Department of Health [DH, 2009].
Tetanus has an incubation period of 4–21 days. Any symptoms or signs of tetanus in a person who has received a tetanus-prone wound during this interval should be treated as an emergency.
There are no specific guidelines on when to treat a visibly infected wound with human tetanus immunoglobulin. However, the Department of Health recommends all wounds requiring surgical intervention that have been contaminated with material likely to contain tetanus spores and are older than 6 hours should receive treatment.
The use of immunoglobulins is a precautionary recommendation since there is insufficient evidence to support other alternatives.
Tetanus vaccine given at the time of a tetanus-prone injury may not boost immunity early enough to give additional protection if a tetanus-prone wound is present. However, it provides an opportunity to check and reinforce the immunization schedule if necessary.
Advice
What advice should I give to a person with an infected laceration?
Advise people to seek medical attention if they develop infection. Symptoms and signs include:
Increasing pain, redness, or swelling spreading from the laceration.
Fever or general malaise.
Advise people to take simple analgesia, such as paracetamol or ibuprofen, if the wound is painful or is likely to become painful. These drugs can be prescribed or bought over the counter.
Advise people to keep the wound dry. Waterproof dressings, such as vapour-permeable dressings, allow light wetting (as from showering) without the dressing separating or the wound becoming wet. Non-waterproof dressings must be protected from wetting at all times.
Provide written information to back-up this advice.
Basis for recommendation
Basis for recommendation
These recommendations are pragmatic advice based on narrative reviews of laceration repair and management [Hollander and Singer, 1999; Wilson et al, 2000].
When and how to close the laceration
When and how should I close an infected laceration?
If signs of infection persist, review the swab results, change the antibiotics if indicated, and arrange further review.
Sutures (with local anaesthetic) are preferred for all lacerations longer than 5 cm, or those 5 cm or shorter when:
Deep dermal sutures are required, to allow low-tension apposition of the wound edges.
The wound is subject to excessive flexing, tension, or wetting.
Adhesive strips should be used to close wounds 5 cm or shorter when there are no risk factors for infection, and the wound edges are easily apposed without leaving any dead space, and the wound is not subject to excessive flexing, tension, or wetting. Adhesive strips are also appropriate for use in pretibial flaps.
Apply a dressing after closing the laceration:
For lacerations with minimal exudate, dress with a clear vapour-permeable dressing.
For lacerations with modest exudate, dress with a low-adherence, absorbent, perforated dressing with an adhesive border. These are also available with a plastic film covering to protect dressings that are likely to get wet.
For further details on anaesthesia, choice of suturing material, suturing technique, skin tissue adhesives, and skin closure strips, see Additional information.
Additional information
Additional information
The pain from infiltrating local anaesthetic can be reduced by:
Using a 25–gauge needle.
Warming the anaesthetic before infiltration.
Infiltrating through the cut edge of the wound into the subdermal tissue.
Infiltrating slowly.
Choice of suturing material:
Synthetic monofilament materials, such as nylon or polypropylene, are inert and are preferable to silk, which may cause a tissue reaction.
For small, simple wounds, the most frequently used sizes of suture material range from 3/0 (large) to 6/0 (fine). As a general guide:
Trunk and lower limbs — 3/0.
Scalp — 3/0, 4/0.
Upper limbs — 4/0.
Face — 5/0, 6/0.
Reduce the recommended adult sizes by one size when suturing children's wounds.
Suturing technique:
Lacerations that gape by more than 5 mm require deep dermal absorbable sutures to eliminate any potential dead space and bring the surface edges of the wound in close apposition. Refer to Accident and Emergency if this is beyond the competency of the clinician.
The first surface suture is placed centrally to ensure equal apposition of wound edges.
Sutures are placed 5 mm from the laceration edge at right angles to the wound.
The closed wound should have a slightly everted edge with modest tension on the sutures.
Record the number of sutures used to inform the person removing the sutures how many need to be removed.
Skin closure strips:
Skin must be clean and dry before applying the strip.
Place the first strip centrally to align the wound properly.
Place subsequent strips with 3 mm gaps between each one.
If necessary, strips can be placed parallel to the wound to strengthen the closing strips.
Basis for recommendation
Basis for recommendation
Closure techniques
Tissue adhesives are not recommended for delayed closure of infected lacerations because they are not easily removed to allow drainage.
Skin closure strips are recommended because they are easily removed if infection develops and have been shown to be effective for closing simple lacerations in children compared with tissue adhesives [Zempsky et al, 2004].
CKS does not recommend the use of staples in primary care because [Cole, 2003]:
They produce a poorer cosmetic result than other methods of closure.
Although they are quicker to use than other methods of closure, which is a significant benefit in a busy casualty department, this is rarely a significant factor in primary care.
Choice of dressing after closing the laceration
These recommendations are based on expert opinion. Dressings for acute lacerations have not been assessed in randomized controlled trials [Dale, 1997].
Vapour-permeable film dressings are recommended for use with wounds with low levels of exudate because:
They are waterproof and protect the wound from becoming infected or wet during normal daily activities.
They maintain a moist environment for optimal wound healing.
They are comfortable and convenient to use.
They allow the wound to be visually inspected for infection without the dressings being removed.
Low-adherence, absorbent, perforated dressings are recommended for wounds with moderate amounts of exudate because:
They can absorb moderate amounts of exudate, which prevents the wound from becoming macerated but maintains a moist environment for optimal wound healing.
Exudate from the wound discolours the dressing and is easily seen. This allows some monitoring of the wound without removing the dressing.
Specific recommendations on anaesthesia [Edlich and Reddy, 2001], choice of suturing material [Castille, 1998; Whiteside and Moorehead, 1998], suturing technique [Castille, 1998; Wilson et al, 2000], skin tissue adhesives [Hollander and Singer, 1999], and skin closure strips [Richardson, 2003] are based on expert opinion.
Follow up after closing laceration
How should I follow up after closing a laceration that has been infected?
Advise people to reconsult at any time if they develop symptoms or signs of wound infection after closure of the wound.
Remove sutures or adhesive strips from areas where a collection is forming beneath the wound or where the wound is discharging.
Swab any discharge and start antibiotic therapy.
Advise people with lacerations closed with adhesive strips to remove these themselves after 3–5 days if the wound is on the head, or 7–10 days if the wound is at another site.
Arrange a follow-up appointment to remove sutures after 3–5 days on the head, 10–14 days over joints, or 7–10 days for other sites.
Remove dressings when sutures or adhesive strips are due to be removed. Low-adherence absorbent dressings should be replaced if exudate has caused significant wetting of the dressing.
Basis for recommendation
Basis for recommendation
These recommendations are based on widely accepted practice supported by experts [Singer et al, 1997].
Important aspects of prescribing information relevant to primary healthcare are covered in this section specifically for the drugs recommended in this CKS topic. For further information on contraindications, cautions, drug interactions, and adverse effects, see the electronic Medicines Compendium (eMC) (http://medicines.org.uk/emc), or the British National Formulary (BNF) (www.bnf.org).
Co-amoxiclav
Co-amoxiclav for lacerations
CKS recommends the higher British National Formulary dose of co-amoxiclav (i.e. 500 mg amoxicillin component three times daily in adults) [BNF 63, 2012] when it is used to prevent infection of lacerations or to treat infection that is already present [Edlich and Reddy, 2001].
Even a small amount of inoculum can cause clinical infection. In addition, the physiological process of wound healing may inhibit the distribution of antibiotic in the wound. Therefore, it is logical to use the highest tolerable dose, to maximize tissue absorption and efficacy.
A 5-day course is usually sufficient but can be extended if necessary.
Co-amoxiclav should not be taken by people who have true penicillin allergy. Gastrointestinal adverse effects alone (i.e. nausea, vomiting, or diarrhoea) do not constitute an allergy to penicillin. Co-amoxiclav should also be used with caution in people with hepatic impairment [BNF 63, 2012].
Adverse effects are uncommon with co-amoxiclav, even at the higher dose.
As with all broad-spectrum antibiotics, it may cause gastrointestinal adverse effects, such as nausea, vomiting, and diarrhoea. These effects are usually mild. If they are severe, consider trying an alternative antibiotic; flucloxacillin or a cephalosporin may be suitable. If in doubt, seek expert advice.
Co-amoxiclav may in rare cases cause cholestatic jaundice during or shortly after its use. This is more common in men, in people older than 65 years, and with long courses of treatment (more than 14 days) [CSM, 1997].
Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of co-amoxiclav [FSRH, 2011].
However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.
Erythromycin
Erythromycin
CKS recommends that erythromycin be given at a dosage of 500 mg four times daily for 5 days. This dosage should be sufficient to prevent infection in 'clean' wounds.
Erythromycin may inhibit the metabolism of some drugs, which may enhance their effects. Consider an alternative antibiotic if the person is taking theophylline, carbamazepine, warfarin, or a statin (which may increase the risk of myopathy). Avoid erythromycin if drugs that may prolong the QT interval are being taken concomitantly (e.g. antiarrhythmics, antipsychotics, tricyclic antidepressants) [Baxter, 2006].
Erythromycin is a broad-spectrum antibiotic and may cause gastrointestinal adverse effects, such as nausea, vomiting, and diarrhoea. These effects are usually mild. If they are severe, consider trying an alternative macrolide, such as clarithromycin or azithromycin, which cause less gastrointestinal effects than erythromycin [MeReC, 1992].
Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of erythromycin [FSRH, 2011].
However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.
Metronidazole
Metronidazole
Metronidazole should be taken with erythromycin at a dose of 400 mg three times daily for 5 days.
Single courses of metronidazole can be taken during pregnancy or breastfeeding. Although there are theoretical safety concerns, several studies have shown no conclusive evidence that metronidazole use during pregnancy increases the risk of malformations [Schaefer et al, 2007].
Common adverse effects of metronidazole include a metallic taste and gastrointestinal irritation (in particular, nausea and vomiting) [BNF 63, 2012]. These effects are more common with higher doses.
Some people taking oral metronidazole experience disulfiram-like reactions to alcohol (flushing, increased respiratory rate, increased pulse rate). Although no conclusive evidence supports an interaction between metronidazole and alcohol, people taking metronidazole should be advised of the possible consequences of drinking alcohol [Baxter, 2006].
Oral hormonal contraception — additional contraceptive precautions are not required during or after courses of metronidazole [FSRH, 2011].
However, women should be advised about the importance of correct contraceptive practice if they experience vomiting or diarrhoea. For further information, see the section on Antibiotics in the CKS topic on Contraception - assessment.
Tetanus booster
Tetanus booster
Ensure that the person is up to date with their vaccinations. For children over 10 years of age and adults who have not been vaccinated, give:
A primary course: three doses of vaccine (as Td/IPV), 1 month apart.
Two booster doses: the first 5–10 years after the last dose of the primary course, and the second 10 years later.
For children under 10 years of age who have not been vaccinated, see the CKS topic on Immunizations - childhood.
Confirmed anaphylaxis occurs extremely rarely. Data from the UK, Canada, and the US indicate rates of 0.65–3 anaphylaxis events per million doses of vaccine given. However, it is recommended that tetanus vaccine should not be given if the person:
Has had a confirmed anaphylactic reaction to a previous dose of tetanus vaccine.
Has had a confirmed anaphylactic reaction to neomycin, streptomycin, or polymyxin B (which may be present in trace amounts).
Avoid tetanus vaccine if the person has a current severe febrile illness (wait for the illness to subside).
Pain, swelling, or redness at the injection site are common and may occur more frequently following subsequent doses. A small painless nodule may form at the injection site; this usually disappears and is of no consequence.
[DH, 2009]
Analgesia (paracetamol or ibuprofen)
Analgesia (paracetamol or ibuprofen)
Paracetamol and ibuprofen are well tolerated when used for short periods.
Paracetamol is licensed for the relief of pain and fever. Some experts suggest that people who drink excessive quantities of alcohol should not use it.
Ibuprofen is licensed for the relief of pain and fever from 3 months of age. People with known hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs, people with renal complications, or people with a known risk of gastrointestinal bleeding should avoid ibuprofen. Paracetamol is often a safer option in older people.
Paracetamol and ibuprofen rarely cause adverse effects when used in the short-term (e.g. management of the symptoms of the common cold).
Paracetamol has no notable adverse effects when used at the correct dosage.
Ibuprofen may occasionally cause gastrointestinal adverse effects, such as discomfort, nausea, and diarrhoea.
Evidence
Evidence
Supporting evidence
Risk factors for laceration infections
Evidence on risk factors for laceration infections
Several prospective studies have identified risk factors for infection in people with traumatic lacerations. These studies could not determine the effect of chronic health problems on the risk of infection, because most traumatic lacerations occur in young people, among whom prevalence of these problems is low.
The effect of chronic health problems and wound contamination on the risk of wound infection was extensively studied in a large prospective trial of people following surgery. The conclusions from these studies have been widely extrapolated in the literature to inform the management of people with traumatic lacerations.
A prospective study of 5521 people presenting to an Emergency department examined factors associated with development of wound infection in people with traumatic lacerations [Hollander et al, 2001]. The overall infection rate was 3.5%.
Factors associated with an increased infection rate:
Diabetes (RR 3.9, 95% CI 0.8 to 12.7).
Foreign body (RR 2.9, 95% CI 1.5 to 5.2).
Visible contamination (RR 1.8, 95% CI 1.1 to 2.8).
Jagged wound margins (RR 1.7, 95% CI 1.3 to 2.4).
Increasing age (per year) (OR 1.01, 95% CI 1.003 to 1.02).
Increasing time between injury and repair.
Increasing depth, length, and width of the laceration.
Factors associated with reduced risk of infection:
Lacerations on the head or neck (OR 0.3, 95% CI 0.18 to 0.45).
A prospective study of 14,800 people following surgery examined the risk of wound infection with chronic health problems [Howard et al, 1964]. A significantly increased risk of infection was reported for people:
Older than 65 years (RR 2.2 compared with people younger than 14 years).
With diabetes (RR 1.46).
Taking oral corticosteroids (RR 2.25).
The risk of wound infection strongly correlated with the risk of contamination in a study of 62,939 people with surgical wounds [Cruse and Foord, 1980]. The overall infection rate was less than 5%. Surgical procedures were categorized by their risk of wound contamination. Infection rates were:
Less than 2% for clean surgical wounds (defined as no infection encountered, no break in aseptic technique, and no hollow muscular organ opened).
Less than 9% for surgical wounds categorized as clean contaminated (defined as a hollow muscular organ entered with no spillage of contents).
Up to 15% for contaminated wounds (defined as a hollow organ entered with spillage of contents, a traumatic wound less than 4 hours old, or a major break in aseptic technique).
Up to 40% for dirty surgical wounds (defined as a traumatic wound 4 or more hours old, pus encountered at operation, or a perforated viscus encountered).
Wound cleansing agents
Wound cleansing agents
There is evidence from a number of trials that drinkable tap water, boiled and cooled water, and normal saline are all comparable wound cleansing agents. Using drinkable tap water to clean acute wounds does not appear to increase the infection rate.
A Cochrane systematic review (search date November 2011) compared rates of infection and healing in wounds cleaned with water and normal saline [Fernandez and Griffiths, 2012].
Three randomized controlled trials (n = 1514) were identified which compared infection rates in acute wounds cleaned with water or normal saline. In adults, drinkable tap water appeared to be more effective than saline at reducing the infection rate (RR 0.63, 95% CI 0.40 to 0.99; p = 0.05), but these findings may have been influenced by differences between the temperatures of the water and saline used in one trial. In children, there was no statistically significant difference in infection rates between the two groups (RR 1.07, 95% CI 0.43 to 2.64; p = 0.88).
In an arm of a separate trial included in the Cochrane systematic review (n = 51), the use of cooled boiled water for cleansing open fractures was not found to cause a statistically significant difference in infection rates when compared with normal saline (RR 0.83, 95% CI 0.37 to 1.87).
Antibiotics to treat lacerations
Evidence on antibiotics to treat lacerations
There is no evidence from randomized controlled trials (RCTs) that antibiotics are effective at preventing infection in general populations of people with lacerations. However, so far RCTs have not been designed or powered to investigate the effect of antibiotics in people who are considered to be at high risk of infection:
A systematic review (search date: December 1993) identified seven RCTs (n = 1701) that compared the use of systemic antibiotics with placebo or no treatment in people with lacerations. The quality of the included studies was variable, with limited blinding and follow up, and intention-to-treat analysis was not used (the trials dated back to the 1970s and early 1980s, when study design was generally less robust). Antibiotics used in the active intervention were penicillin based or cephalosporins, and some were penicillinase-resistant.
The results were as follows (after the data was combined as a meta-analysis):
On average, 6.0% of people in the control groups developed infection (95% CI 4.5 to 8.0%). People treated with antibiotics had a slightly greater risk of infection, with a non-significant odds ratio of 1.16 (95% CI, 0.77 to 1.78).
The authors conducted sensitivity analysis to detect factors that might influence the results or individual studies that might have had an influence (e.g. unblinded studies, using the presence of pus as an end point). This included limiting the studies to those that investigated sutured wounds, hand wounds, oral antibiotics, parenteral antibiotics, and penicillinase-resistant antibiotics. No subgroup analysis found significant benefit from either antibiotics or control.
The authors concluded that the available evidence provides little justification for the routine use of antibiotics in the management of simple, non-bite wounds. However, they noted that the available studies did not allow analysis of the impact of various factors on wound infection, such as the type of injury, the age of the person, or the presence of diabetes. Some studies actively excluded lacerations with visible signs of infections.
CKS found two subsequent controlled trials that investigated the role of antibiotics in preventing wound infection.
One prospective, controlled, allocated trial (n = 250) found that the number of people who developed infection with co-amoxiclav was 5.0%, compared with 3.2% for the control (no treatment). This difference was not significant [Cassell and Ion, 1997].
One RCT of people with minor limb lacerations (n = 100) found no significant difference in infection rate between people receiving co-amoxiclav (12%) and those who did not (20%, p > 0.10). However, diabetes, laceration length, and ragged appearance of the laceration were found to significantly increase the risk of infection [Stamou et al, 1999].
For information on the evidence of the influence of risk factors on the chance of developing wound infections, see Risk factors for laceration infections.
Search strategy
Scope of search
A literature search was conducted for guidelines, systematic reviews and randomized controlled trials on primary care management of lacerations.
Search dates
2007 - August 2012.
Key search terms
Various combinations of searches were carried out. The terms listed below are the core search terms that were used for Medline and these were adapted for other databases. Further details are available on request.
exp Lacerations/, laceration$.tw.
Table 1. Key to search terms.| Search commands | Explanation |
|---|---|
| / | indicates a MeSh subject heading with all subheadings selected |
| .tw | indicates a search for a term in the title or abstract |
| exp | indicates that the MeSH subject heading was exploded to include the narrower, more specific terms beneath it in the MeSH tree |
| $ | indicates that the search term was truncated (e.g. wart$ searches for wart and warts) |
Sources of guidelines
National Institute for Health and Clinical Excellence (NICE)
Scottish Intercollegiate Guidelines Network (SIGN)
Royal College of General Practitioners
National Guidelines Clearinghouse
Guidelines International Network
NHS Scotland National Patient Pathways
Agency for Healthcare Research and Quality
Institute for Clinical Systems Improvement
National Health and Medical Research Council (Australia)
Royal Australian College of General Practitioners
British Columbia Medical Association
University of Michigan Medical School
Michigan Quality Improvement Consortium
National Resource for Infection Control
UK Ambulance Service Clinical Practice Guidelines
RefHELP NHS Lothian Referral Guidelines
Medline (with guideline filter)
Driver and Vehicle Licensing Agency
NHS Health at Work (occupational health practice)
Sources of systematic reviews and meta-analyses
Systematic reviews
Protocols
Database of Abstracts of Reviews of Effects
Medline (with systematic review filter)
EMBASE (with systematic review filter)
Sources of health technology assessments and economic appraisals
NIHR Health Technology Assessment programme
NHS Economic Evaluations
Health Technology Assessments
Canadian Agency for Drugs and Technologies in Health
International Network of Agencies for Health Technology Assessment
Sources of randomized controlled trials
Central Register of Controlled Trials
Medline (with randomized controlled trial filter)
EMBASE (with randomized controlled trial filter)
Sources of evidence based reviews and evidence summaries
Central Services Agency COMPASS Therapeutic Notes
Sources of national policy
Health Management Information Consortium (HMIC)
Patient experiences
Patient.co.uk - Patient Support Groups
Sources of medicines information
The following sources are used by CKS pharmacists and are not necessarily searched by CKS information specialists for all topics. Some of these resources are not freely available and require subscriptions to access content.
British National Formulary (BNF)
electronic Medicines Compendium (eMC)
European Medicines Agency (EMEA)
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