Laceration Repair (abx credit from WikEM)

#Laceration, repaired

Laceration was repaired.
Laceration was cleaned with copious irrigation
Explored wound in a clean, bloodless field with good lighting and explored (which was not limited by pain), no retained foreign body was found
Laceration repaired with good approximation of wound edges. Hemostatic after repair.
_ Given proxmity of laceration to potential tendon, every effort made to evaluate for possible neuro-vascular-tendon injury. 
Motor-neuro-vascular exam intact prior to procedure
No evidence of tendon injury on exploration of wound.
Motor-neuro-vascular exam intact after procedure

_ not UTD and administered

_Radiographs not indicated given no hx c/f retained foreign body and wound exploration performed for FB.
_Radiographs (interpreted in ED, formal read and call back mechanism for over-reads:
 obtained and no radio-opaque foreign body seen
no fracture seen

_ given no underlying fracture, routine abx not indicated
_if underlying fracture, presumed to be open fracture and as such abx administered based upon Gustillo-Anderson grading:
Grade I: Wound <1cm, Little soft tissue injury or crush injury, Moderately clean puncture site, Infection risk 0-12%
Grade II: Laceration >1cm, No extensive soft tissue damage, but slight or moderate crush injury, Moderate contamination, Infection risk 2-12%
Grade III: Extensive damage to soft tissue, including neurovascular structures and muscle, High degree of contamination, Infection risk 5-50%
Further subcategorized:
III A: Fracture covered by soft tissue (Infection risk 5-10%)
III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%)
III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%)
Additional Considerations: Fracture with non-communicating overlying wound, Additional sites of injury found in 40-80% of cases, Nerve, vascular, muscular, and/or ligamentous injury

Grade I Fracture:
Cefazolin (Ancef) 2g IV three times daily
Ciprofloxacin 400mg IV BID (avoid in pediatrics)
Grade II/III Fracture Options[edit]
Add Gentamicin 300 mg (1-1.7mg/kg) IV to any of the Grade I regemins
If concern for Clostridium then consider single drug regimen of Pipericillin/Tazobactam 4.5g (80mg/kg) IV three times daily

Advised on follow up timing for suture removal.

I discussed the possibility of residual foreign body with patient and that no matter how thorough the search it is still a possibility. I explained to return if patient notices signs of retained FB.

I also explained what to look for with regard to infection. The patient agreed to return with any increasing discharge, extending erythema, fever, nausea/vomiting or any other changes.

I also discussed the inevitability of scarring with the patient. They understand that all lacerations will leave a varying degree of scarring and optimal outcome/cosmetic appearance can never be guaranteed. They also understand the possibility of prompt revision by plastic surgery if desired.

*This information is intended for educational purposes only and not intended for use in patient care (which requires a trained credentialed attending physician and individualization of the medical care plan to the specific patient).

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