The Procedural Pause
Picture this: It's Dec. 31 at 11:59 p.m. You're spending your designated holiday working the overnight. You're eating some leftover fruitcake in the nurse's lounge, and you see the following complaint sign into triage: “Drunk/face pain.”
You decide to take a chance, and hope this guy has something easy to fix. It's your lucky day. There is no need to consult plastics or transfer this patient to another facility. You are actually pretty lucky because the laceration goes right though the eyebrow and spares the orbit and globe space.
This patient also denies any other injury, and the bleeding is controlled. He is awake, alert, and — surprisingly — not rude! It is important to take caution with inebriated patients because ethanol can mask pain and other complications. These patients need a full evaluation and often repeat questioning. You can be the judge on how far you want to work up this type of injury, but we can make a few suggestions.
- Local infiltration analgesia 1% lidocaine with epinephrine is best. There is no need for 2% lidocaine, and it is OK to use with epinephrine if you find bleeding is complicating things.
- Image studies if indicated (CT head, orbits, face, cervical spine, etc.).
- Wound care, copious irrigation (update tetanus).
- Suture and repair (6.0 adorable Vicryl + 6.0 Prolene).
- Proper questioning and full examination. Localize the acute injury and survey other possible injuries.
- Order appropriate imaging based on exam and history.
- Clean the area around the eyebrow laceration with 10% povidone-iodine or chlorhexidine gluconate. Do not allow this to enter the wound itself. (Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine, 6th edition, Philadelphia: Saunders/Elsevier, 2014.)
- Anesthetize the area. A local infiltration of 1%, not 2% lidocaine, is sufficient.
- Allow just a few minutes for anesthesia to take effect, and test the area with a clean new needle to see if the patient experiences any pain.
- Inspect the area with magnification to check for any foreign body. Gently rinsing the interior of the wound is required. Copious irrigation may cause more damage to the delicate facial tissues.
- Use as little debridement as possible, but whatever is necessary.
- Use a 6.0 or 5.0 prolene suture to close the wound. Note: Subcutaneous sutures may be used. Prolene is the least secure when dealing with knot security, but it has the best tensile strength. It also has the least tissue reactivity (compared with nylon and silk) and handles well. (Roberts JR, Hedges JR, 2014.)
- Prolene is the best choice for eyebrow laceration because it can be easily identified during suture removal from the eyebrow because of its bluish hue.
- Your best choice here is simple interrupted. The first suture re-approximates the edges of the eyebrow. Deep lacerations may be best closed by also using subcutaneous sutures. The case above is borderline.
- You may consider using skin glue if the laceration is superficial. The case above is too large and not appropriate for skin glue.
- You can reinforce skin glue or sutures with Steri-Strips.
- Have the patient keep the area uncovered!
- Topical bacitracin has not been proven effective. It often keeps the area too moist and prevents proper wound healing, causing scarring.
- Have the patient follow up in four or five days for suture removal.
- Refer to plastics if needed.
- Does the patient also have a scalp laceration? Note that these can bleed freely without a pressure dressing and should be repaired rapidly. Using lidocaine with epinephrine decreases bleeding during repair of scalp and facial lacerations.
- Keep good form when handling the forceps using the thenar grip technique and lift the skin gently, allowing for the best cosmetic results. The less insult to the skin after the initial trauma, the better.
- Consider undermining to help relieve tension.
- Consider the layered closure technique. This also creates less tension and better cosmetic results. (Roberts JR, Hedges JR, 2014.)
- Do not tie the sutures too tightly. Instead, loosely apply the first throw and then reinforce the second, third, and fourth throws.
- DO NOT grab too much tissue while suturing, crowd your sutures, space out your sutures, or stick the same area more than once.
- Definitely consider ophthalmology or plastic surgery consult for this repair if the wound extends past the browline onto the eyelid. Most ED clinicians can repair these injuries, but a canaliculus injury should also be considered and discussed with appropriate consults if possible. (Roberts JR, Hedges JR, 2014.)
A patient shows up in your emergency department with a facial and an eyebrow laceration. The original injury occurred “sometime yesterday.” Can you repair both or none? Do these wounds need antibiotics? The answer is: You can repair both, and you do not need antibiotics. For simple lacerations, anesthetize the area and simply trim away the edges of the old wound opening. Use a no. 15 blade, a 1 mm-deep incision with an undermining technique. (Roberts JR, Hedges JR, 2014.) As noted above, 5.0 and 6.0 (not 7.0) prolene is appropriate for the eyebrow, 6.0 nylon for the face.
Most lacerations heal without complications regardless of management. “Mismanagement may result in wound infections, prolonged convalescence, unsightly and dysfunctional scars, and, rarely, mortality,” according to a study in the Annals of Emergency Medicine. (1999;34:356.) Simply put, avoid infection and anything that may cause an unpleasant scar.
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