All traumatic lacerations are contaminated to some degree; however, the level of contamination differs based on etiology, wound location, and time of injury. Wound preparation includes all of the steps required prior to wound closure (either by primary or secondary intention) aimed at reducing the risk of infection, optimizing cosmetic outcome, and minimizing patient pain and discomfort. For most wounds, adequate preparation requires some form of anesthesia, be it topical, local, or regional. For other patients (especially young children or the mentally disabled), anxiolysis using oral or intranasal midazolam or ketamine may be required. When patient cooperation is problematic and absolute immobilization is required (e.g., when repairing a laceration near the eye or in the mouth), procedural sedation or even general anesthesia should be considered.
Although the order of procedures may vary, in general, wound preparation starts with decontamination of the skin surrounding the laceration, followed by local anesthesia through the wound edges. After achieving adequate wound anesthesia, the wound is reexamined. When necessary, sharp debridement of obviously devitalized or heavily contaminated tissue should be performed. Finally, wound cleansing (e.g., scrubbing or irrigation) should be used to remove any remaining debris and bacteria. After excluding the presence of embedded foreign bodies and underlying tissue damage (e.g., tendon injuries), the wound is repaired. With heavily contaminated wounds, irrigation with soap and water under running tap water may precede local anesthesia when tolerated by patients. Early application of a topical anesthetic may make this procedure less uncomfortable.
Although routinely practiced in other settings (e.g., the operating room), full sterile technique (mask, cap, gown, and gloves) apparently does not reduce wound infection rates after laceration repair in the ED setting.1 Use of sterile gloves for laceration repair or outpatient surgical procedures does not reduce infection rates compared to clean, nonsterile gloves.2 Hand washing prior to patient contact is a tenet of infection control, but there is no firm evidence that one form of hand antisepsis is better than another for reducing postprocedure wound infections.3 Nonetheless, gloves protect the provider and should routinely be used, even if not sterile. Common sense suggests that masks should be used during wound preparation and closure when the practitioner has a respiratory infection or is otherwise potentially contagious.
Due to the presence of abundant normal microbial flora, skin disinfection is generally the first step in wound preparation. There is no evidence to support the historic practice of skin disinfection prior to ED laceration closure using povidone-iodine.4 Chlorhexidine is likely a better agent, as noted in a meta-analysis of 13 randomized controlled trials involving 6997 patients undergoing clean or clean-contaminated surgeries; preoperative chlorhexidine antisepsis was associated with a lower incidence of surgical site infections (relative risk, 0.70; 95% confidence interval, 0.60 to 0.83).5 Regardless of which agent is used, avoid contact of the antiseptic agent ...