Wound assessment
- Mechanism — sharp vs blunt/crush, contamination (soil, saliva, water), time since injury, tetanus-prone features (see below).
- Structures at risk — examine and document tendon function, distal sensation and perfusion before any local anaesthetic is given. Test tendons through full range of movement against resistance — a partial laceration can still move normally.
- Foreign body — glass, gravel and metal are generally radiopaque; request an X-ray if a foreign body is suspected or the mechanism makes one likely (most glass fragments ≥2 mm are visible on plain film).
- Depth and extent — explore under adequate anaesthesia and good light; do not probe blindly near named vessels or nerves.
- Document a hand/limb diagram where relevant, photograph if local policy allows, and note allergies and tetanus/vaccination status.
Irrigation
- Volume and pressure matter more than sterility of the fluid. Randomised trials and meta-analyses show potable tap water gives infection rates no different from sterile saline for uncomplicated lacerations, and is an acceptable, economical alternative in the ED.
- Irrigate generously — high-pressure, large-volume irrigation (a syringe with a splash guard or a running tap) is what reduces infection risk, regardless of which fluid is used.
- Remove visible debris and devitalised tissue; consider gentle debridement of ragged or heavily contaminated edges.
Contaminated or high-risk wounds (bites, heavy soiling, delayed presentation) may still warrant saline and a lower threshold for surgical washout.
Choosing a closure method
Favours sutures
- Wounds under tension, over joints, or needing precise edge apposition.
- Deep dermal layer needed to reduce tension before skin closure.
Favours staples / adhesive / strips
- Staples — linear scalp wounds; fast, good hair-bearing cosmesis.
- Tissue adhesive — clean, low-tension wounds with easily apposed edges; avoid near the eyes and mucosa.
- Steri-Strips — superficial, low-tension wounds, or as adjunct after suturing.
Equipment & typical suture sizes
Lidocaine 1% ± adrenaline, syringe, needles
Suture pack: needle holder, toothed forceps, scissors
Irrigation fluid + syringe/splash guard
Sterile gloves, drape, skin prep
Face/eyelid: 6-0 to 5-0 monofilament nylon
Scalp: 3-0 to 4-0, or staples
Limbs/trunk: 4-0 to 3-0
Deep dermal: absorbable (e.g. polyglactin)
Tissue adhesive / Steri-Strips as alternatives
Sizes are typical ranges — always match to wound tension, skin thickness and local formulary.
Simple interrupted suture technique
Anaesthetise and prepare
Infiltrate lidocaine, re-explore the wound, irrigate, and drape.
LAST rescue — AAGBI algorithm ↗Enter perpendicular to the skin
Needle enters and exits at 90° to the skin surface on both sides, taking equal "bites" of tissue at equal depth from the wound edge, to evert the edges.
Instrument tie
Tie using the needle holder: wrap the long end around the holder 2–3 times for the first throw, then single throws in alternating directions (square knot), placing the knot to one side of the wound line, not directly over it.
Space evenly
Repeat at regular intervals so wound edges appose without gaps or excess tension on any single suture.
Deep dermal layer if needed
Use buried absorbable sutures to close dead space and take tension off the skin layer before placing skin sutures.
Suture/staple removal timing
Approximate ranges — extend for wounds under tension or in patients with impaired healing (e.g. diabetes, steroids):
Face — around 5 days
Scalp — around 7–10 days
Limbs — 10–14 days
Joints / high-tension areas — up to 14 days
Tetanus prophylaxis
Assess every wound against the UKHSA Green Book (chapter 30) categories:
Clean wound
- Low likelihood of harbouring tetanus spores.
- Manage vaccination status alone — booster only if the primary/booster schedule is incomplete or overdue.
Tetanus-prone / high-risk
- Puncture wounds, contamination with soil/manure, devitalised tissue, delayed presentation, or surgical treatment delayed >6 hours.
- High-risk (heavy contamination, extensive devitalised tissue): human tetanus immunoglobulin regardless of vaccination history, plus vaccine if not up to date.
Follow the current Green Book chapter 30 algorithm for immunoglobulin and vaccine decisions — thresholds are reviewed periodically.
Antibiotics
- Antibiotics are not routine for simple, clean lacerations closed promptly in immunocompetent patients.
- Consider antibiotics for bites (human/animal), heavily contaminated wounds, wounds involving joints/tendons/bone, immunocompromise, or significantly delayed presentation — this differs from the simple-laceration default.
Safety-netting & documentation
- Advise on signs of infection (increasing pain, redness, discharge, fever) and when to return.
- Keep the wound clean and dry per local advice; arrange removal timing and follow-up if needed.
- Document mechanism, examination of structures, irrigation, closure method and material, tetanus/antibiotic decisions, and safety-netting advice given.
Supervision pointers
Generic ED skills entrustment levels — not a named curriculum DOPS:
| 1 | Observed only — describes assessment steps, irrigation principles and closure options. |
| 2a | Performs simple closure with supervisor scrubbed alongside; correctly assesses tendon/nerve/vessel function first. |
| 2b | Performs with supervisor in department; selects closure method appropriately and manages tetanus decisions. |
| 3 | Indirect supervision; manages complex/contaminated wounds and recognises when referral is needed. |
| 4 | Independent; teaches technique and troubleshoots difficult closures. |
References
- UK Health Security Agency. Tetanus: the green book, chapter 30 (updated June 2025).
- Comparison of wounds' infection rate between tap water and normal saline cleansing: a meta-analysis of RCTs. PMC 2021.
- Irrigation of traumatic lacerations in the ED: evidence on tap water as an alternative to sterile saline — a scoping review, 2025.
- Forsch RT, et al. Essentials of Skin Laceration Repair. Am Fam Physician 2008;78(8):945-951.