Start with function and perfusion
A wound can look tidy and still conceal a tendon injury, retained foreign body or poorly perfused flap. The goal is safe healing with preserved function. Closure comes after those threats have been assessed. RCH laceration guidance.
Control bleeding with direct pressure; assess other injuries. Record mechanism, contamination, timing, comorbidities, medicines, allergies and vaccinations. Before anesthesia, document distal sensation, movement and perfusion. Use adequate light, exposure and analgesia; if deep structures cannot be assessed safely, seek the relevant surgical team before closure. RCH laceration guidance. SAEM wound-care guidance.
For hand wounds, test individual tendons and movement against resistance. Preserved movement does not exclude a partial tendon injury. Pain or weakness with testing warrants protection, splinting and timely hand-specialist assessment. A normal radiograph does not exclude tendon damage. AHRQ hand-examination review.
Choose imaging to answer a specific question: radiographs for fracture or radiopaque material, including most glass and metal; ultrasound for suspected radiolucent material such as wood or for localization. Small fragments and limited scans can be missed. Persistent suspicion needs further assessment, not blind probing. ACEP foreign-body guidance. RCH laceration guidance.
Suspected open fracture, joint penetration, high-pressure injection or neurovascular injury needs an urgent specialist pathway. For an open fracture, give IV prophylaxis promptly under the local protocol. NICE specifically advises against ED irrigation of open long-bone, hindfoot or midfoot fractures before wound excision. NICE open-fracture guidance. SAEM wound-care guidance.
Prepare the wound without adding injury
Anesthetize enough to permit examination and cleaning. Lidocaine 1% contains 10 mg/mL. Healthy-adult label ceilings are 4.5 mg/kg, maximum 300 mg, without epinephrine; 7 mg/kg, maximum 500 mg, with it. Count all administered local anesthetic, use the lowest effective dose and individualize for comorbidity. These ceilings are not pediatric doses or protection against accidental intravascular injection. Check perfusion and product precautions before using epinephrine. Lidocaine product label.
Irrigate suitable soft-tissue wounds with saline and remove visible debris. Potable tap water is an option for uncomplicated lacerations: a randomized trial found no significant infection difference from saline in its selected population. This does not establish safety for every water source, immunocompromised patient or complex injury. Weiss et al., randomized irrigation trial.
Use controlled flow and splash protection. The endpoint is adequate decontamination without tissue damage, rather than a fixed pressure or volume per centimetre. Remove accessible foreign material and nonviable tissue while conserving viable edges; difficult deep removal belongs with an experienced operator. SAEM wound-care guidance.
Keep alcohol-based skin preparations out of the wound and sensitive structures. Follow the exact product’s application, drying and electrocautery restrictions; prevent pooling and allow complete drying before draping. Skin antisepsis and wound irrigation serve different purposes. ChloraPrep labeling.
Decide whether, and how, to close
Use the whole risk profile rather than a rigid clock cutoff. Contamination, diabetes, lower-limb location and larger wounds were associated with infection in a prospective cohort. Its timing findings do not mean that every late wound is safe to close. Quinn et al., prospective laceration cohort.
Primary closure suits adequately assessed, cleaned, viable wounds without infection and with acceptable tension. For selected contaminated or uncertain wounds, clean and dress first, arrange review, and consider delayed closure after about 3–5 days only if suitable and uninfected. Punctures, infected wounds and some tissue-loss wounds are better left open. Laceration closure guidance.
Sutures allow precise approximation; staples suit selected scalp or trunk wounds. Strips or tissue adhesive suit clean, superficial, easily approximated low-tension wounds. Keep glue on the surface, out of the wound, and away from the eye. Deep repair or tension relief cannot be replaced by a stronger surface seal. SAEM wound-care guidance. RCH laceration guidance.
Tight sutures compress the wound edge and impair perfusion. Approximate without strangulation; use deeper tension-relieving repair only when needed. A dusky edge or persistent gaping should trigger reassessment of viability and the closure plan. Mattress sutures are not a solution to tissue that cannot tolerate tension. Laceration closure guidance.
Arrange aftercare before discharge
Provide written, closure-specific instructions: keep the initial dressing clean and dry, explain when gentle washing may start, and avoid soaking until adequately healed. Glue and strips need their own product instructions. Plan suture or staple removal by site, tension and healing; assess the wound before removing support. Laceration closure guidance.
Give a definite review plan for high-risk wounds, commonly within 24–48 hours as a practical local workflow. Return sooner for spreading redness, pus, fever, worsening pain or wound separation. Uncontrolled bleeding, new numbness, weakness or a cold/pale digit needs urgent reassessment. A review appointment does not replace these instructions. NHS wound safety-netting.
Use antibiotics for a defined indication
Antibiotics do not remove debris or restore viable tissue. Routine systemic prophylaxis is unnecessary for simple non-bite lacerations. AAST allows a short course, generally no more than 24 hours, for selected high-risk isolated soft-tissue injuries; this is consensus guidance, not a universal prescription. Established infection requires a treatment assessment. AAST antibiotic consensus, 2024.
Check tetanus separately
For a completed primary series, give a tetanus booster if the last dose was at least 10 years ago for a clean minor wound, or at least 5 years ago for a dirty or major wound. Unknown, absent or incomplete vaccination calls for vaccination with any wound and a plan to complete the series. CDC tetanus guidance.
For dirty or major wounds, give TIG 250 IU IM when vaccination is unknown or incomplete, or when the patient has HIV or severe immunodeficiency regardless of vaccination history. TIG is not indicated for clean minor wounds. Antibiotics do not prevent tetanus. CDC tetanus guidance.
Use the age-appropriate vaccine. Tdap is preferred for eligible patients without documented prior Tdap and when tetanus vaccination is indicated during pregnancy. When vaccine and TIG are both needed, use separate syringes and different anatomical sites. Check vaccine contraindications and the local immunization schedule. ACIP vaccine guidance. ACIP administration guidance.
Recognize wounds needing a different plan
Scalp: control bleeding and assess depth before choosing staples, sutures or hair apposition. The HAT trial studied selected linear wounds under 10 cm with hair at least 3 cm long; active bleeding and severe contamination were excluded. Do not omit cleaning because a scalp wound is short. HAT randomized trial.
Nail bed: assess fracture, tissue loss and nail-fold injury; agree repair and protection with the hand team. NINJA, a 451-child multicentre trial, found no infection or cosmetic advantage from nail replacement. A 60-patient 2026 trial favored replacement, but its abstract does not establish pediatric applicability; it should not outweigh NINJA for children. NINJA pediatric trial. 2026 nail-bed trial.
Bites, punctures and complex injuries
For cat or human bites that break skin and draw blood, NICE recommends prophylaxis; consider it for selected nonbleeding skin-breaking bites according to depth, site and host risk. Dog-bite prophylaxis is selective. Co-amoxiclav is a usual first choice when suitable; choose dose and alternatives for age, allergy, pregnancy and organ function. NICE distinguishes 3-day prophylaxis from a usual 5-day treatment course, with review. NICE bite guidance.
A clenched-fist wound over a knuckle can communicate with tendon or joint: obtain urgent hand assessment. AAST recommends prophylaxis for through-and-through skin-to-mouth wounds; simple intraoral wounds usually do not need it. Soil/water contamination, gunshot injury and open fracture require injury-specific decisions rather than the same oral antibiotic course. AAST antibiotic consensus, 2024. NICE bite guidance.
For plantar punctures, look for retained material and deep infection, especially with delayed symptoms or diabetes. In a retrospective series of infected puncture wounds in adults with diabetes, tennis-shoe injuries were associated with Pseudomonas; this does not establish an automatic prophylactic fluoroquinolone regimen. Arrange early reassessment and specialist input for suspected bone or joint infection. Diabetic puncture-infection cohort.
After a potential rabies exposure, wash promptly and thoroughly and contact public health for exposure-specific prophylaxis. Also assess relevant human-bite or blood exposure for bloodborne-virus risk. Antibiotics do not replace exposure prophylaxis. CDC rabies guidance. NICE bite guidance.
Before the patient leaves
Document what was examined, any uncertainty, treatment and follow-up. Recheck distal perfusion after repair or splinting and confirm removal of any procedural tourniquet. The final question is whether the wound is safely assessed and supported, not simply whether the skin edges are closed. AHRQ hand-examination review.
