UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
● Procedure 15·Wound care·Moderate tier
15.
Laceration
Repair.
Assess · irrigate · anesthetize · choose closure · close · dress.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
Source-of-truth: 01_Procedures/15_Laceration_Repair/
Source-of-truth: 01_Procedures/15_Laceration_Repair/
Laceration Repair · UCI Neurology APP Class II
01 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
High-volume bedside · cosmetic outcomes visible · litigation-exposed
1–5%
wound-infection rate for primary closure of simple lacerations —
a rate that doubles when irrigation volume is inadequate
or the golden-period window is ignored.
- Highest-volume bedside procedure across the APP service — every shift, every site.
- The technique is simple; the decision architecture around it is not — wound assessment drives every downstream choice.
- Two preventable failure modes dominate malpractice exposure: missed deeper injury (tendon, nerve, foreign body) and local anesthetic systemic toxicity.
- UCI OPPE target: documented infection < 3%, dehiscence < 2%, cosmetic revision < 2%.
Forsch RT, Little SH, Williams C. Am Fam Physician. 2017;95(10):628–636
StatPearls — Wound Closure Techniques · NCBI Bookshelf NBK470598
StatPearls — Wound Closure Techniques · NCBI Bookshelf NBK470598
Laceration Repair · Why this matters
02 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
01 · Affective
Position the patient.
Ergonomic operator access and adequate lighting — the UCI canonical step says "make it comfortable for you the provider."
02 · Cognitive
Indication, contra, complication.
State indications for primary closure; recite the verbatim UCI contraindication list; recognize the four canonical complications.
03 · Cognitive
Anesthesia ceilings.
Calculate lidocaine max — 4.5 mg/kg plain, 7 mg/kg with epi — and identify the five epi-forbidden distal-appendage sites.
04 · Psychomotor
Irrigation & sterile field.
1–2 L normal saline, moderate pressure, 50–100 mL per cm of wound. CHG prep, sterile drape, sterile gloves.
05 · Psychomotor
Closure-method choice.
Sutures vs staples vs tissue adhesive — matched to location, length, tension, contamination. Simple interrupted is the workhorse.
06 · Affective
LAST recognition.
Verbalize epi-forbidden sites pre-injection; recognize LAST prodrome (perioral numbness, tinnitus, metallic taste) and activate ASRA protocol.
Laceration Repair · Course objectives
03 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
01 · Mechanism
Sharp · crush · bite · glass.
Drives contamination risk and the question of whether to close at all. Bite mechanism is typically not closed primarily.
02 · Time since injury
Golden-period window.
Simple < 5 cm, no gross contamination, non-LE — closable up to 12–18 h per Forsch 2017. Face shorter; LE shorter.
03 · Contamination
Clean · contaminated · gross.
If you can't irrigate it clean, you can't close it primarily. Heavily contaminated → delayed primary or secondary intention.
04 · Location
Face · scalp · trunk · limb.
Determines closure window, suture size, removal timing, cosmetic stakes, and which closure method is appropriate.
05 · Depth
Epidermis · dermis · fat · fascia.
Deeper than mid-dermis needs layered closure (absorbable dermal + non-absorbable skin). Through fascia escalates.
06 · Under the hood
Tendon · nerve · vessel · foreign body.
Always do a distal neurovascular exam — sensation, motor, capillary refill, pulse. Exposed deep structure → do not close, escalate.
Forsch RT et al. Am Fam Physician. 2017;95(10):628–636 · StatPearls Wound Closure NBK470598
Laceration Repair · Wound assessment
05 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
| Closure type | Indication | Window | Why |
|---|---|---|---|
| Primary intention | Clean simple laceration · edges approximate · no gross contamination | Face ≤ 6 h · trunk ≤ 12 h · scalp ≤ 24 h · simple < 5 cm non-LE ≤ 12–18 h | Best cosmetic result, fastest healing, lowest re-visit rate. |
| Delayed primary | Grossly contaminated · cannot irrigate clean today | Pack open · re-evaluate at 72–96 h | Allow inflammatory phase to declare, then close if bed is clean. |
| Secondary intention | High bacterial load · tissue loss · edges will not approximate | — | Let it close on its own — scar is worse, infection risk is lower. |
| Tissue adhesive | Low-tension · short · clean · off the face if cosmetic stakes high | Within standard golden period | Painless, fast, no removal — but not for high-tension or hair-bearing scalp. |
| Staples | Scalp · trunk · extremity (not face, not hand) | Within standard golden period | Fast, hemostatic, low infection rate; cosmetic match for scalp. |
Forsch RT et al. Am Fam Physician. 2017;95(10):628–636 · StatPearls NBK470598 · Nicks BA et al. Int J Emerg Med. 2010;3(4):399–407 · PMC3047833
Laceration Repair · Indication by closure type
06 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
Verbatim UCI list — relative contraindications
- Bite wounds — animal & human
- Grossly contaminated wounds
- Tissue loss — edges will not approximate
- Involvement of underlying structures
- Complex facial or hand wounds
- Chronic wounds
UCI canonical — Laceration Repair Learning Objectives, Section 3 · C-2
Practical escalation triggers
- Cat bite to the hand → infection risk dominates; do not close · cover with augmentin · escalate
- Human bite to the hand (clenched-fist injury) → emergent hand surgery, not a bedside closure
- Exposed tendon, nerve, vessel, joint capsule, bone → escalate to hand surgery, plastics, or ED attending
- Heavily contaminated wound past the golden period → delayed primary or secondary intention
- Devitalized tissue requiring formal debridement → operating-room debridement, not bedside
- Wound under arterial tension that will not approximate → flap repair, not simple closure
StatPearls Wound Closure Techniques · NBK470598 · Nicks BA et al. Int J Emerg Med. 2010;3(4):399–407
Laceration Repair · Contraindications
07 / 21
UUCI · APP Class II
Key fact · anesthesia safety
Lidocaine maximum dose · ASRA LAST 2020 Checklist
4.5mg/kg
plain 1% lidocaine — adult maximum
7mg/kg
1% lidocaine with epinephrine — adult maximum
Epi-forbidden sites — verbalize before drawing up
Fingers · Toes · Ears · Nose · Penis.
UCI canonical: "never use epinephrine for fingers or penis lacerations."
Forsch 2017 extends the list to the full five distal-appendage end-arterial beds.
LAST prodrome
- Perioral numbness · metallic taste
- Tinnitus · diplopia · agitation
- Late: seizure · cardiac arrest
Neal JM et al. ASRA LAST Checklist 2020. Reg Anesth Pain Med. 2021;46(1):81–82
08 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
Kit checklist
- 1% lidocaine (± epi 1:100,000)
- 25g needle for infiltration · 27g for face
- 10–20 mL syringe for anesthetic
- 30–60 mL syringe + 18g angiocath / splash shield
- 1–2 L normal saline (irrigation)
- CHG-alcohol prep
- Sterile gloves · sterile drape · gauze
- Needle driver · Adson forceps · iris scissors
- Suture by location (size + material)
- Stapler (scalp) · tissue adhesive (low-tension small)
- Xeroform + sterile gauze for dressing
- Tetanus (Td or TdAP) per ACIP if indicated
- Hemostat · vessel ligature (if bleeding)
Anesthesia sequence
- Calculate lidocaine max by weight — verbalize during time-out
- Choose plain vs epi — verbalize epi-forbidden sites aloud
- Inject through wound edges (less painful than through skin)
- Slow injection · aspirate before each bolus
- Wait 5–10 min for full onset (UCI canonical timing)
- Test for adequate anesthesia before any cutting
- Cumulative-dose discipline — track every mL given
Forsch RT et al. Am Fam Physician. 2017;95(10):628–636 · Neal JM ASRA LAST 2020
Laceration Repair · Kit & anesthesia
09 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
- 01Consent documented. Indication, risks (infection, pain, neurovascular injury, scar, LAST), alternatives (delayed primary, referral, secondary intention), right to decline. Cosmetic-outcome discussion mandatory for face/scalp.
- 02Allergies & tetanus reconciled. Lidocaine / amide allergy? Latex? Adhesive? Tetanus status per CDC ACIP — Td or TdAP indicated?
- 03Lidocaine dose calculated. Weight-based max — verbalize the calculation aloud. Decide plain vs epinephrine.
- 04Epi-forbidden sites verbalized. Fingers · Toes · Ears · Nose · Penis — audible safety pause if epi is on the tray.
- 05Time-out called. Per TJC UP.01.03.01 — correct patient, procedure, site / side, equipment, consent confirmed aloud.
TJC standard
UP.01.03.01
Pre-procedure verification, site marking, formal time-out — the three-part protocol that exists because lidocaine is given to the wrong patient, on the wrong site, at the wrong dose, more often than the system tolerates.
The Joint Commission. Universal Protocol UP.01.03.01.
TJC Hospital Accreditation Standards · 2024.
TJC Hospital Accreditation Standards · 2024.
Laceration Repair · Pre-procedure time-out
10 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
01
Position ·
provider comfort.
- Patient supine or seated, wound visible
- Adjust bed / chair height to your hands
- Adequate lighting · headlamp if needed
- "Make it comfortable for you the provider"
02
Irrigate ·
1–2 L saline.
- 50–100 mL per cm of wound length
- Moderate pressure (5–8 PSI)
- 30–60 mL syringe + 18g angiocath / splash shield
- Tap water = saline for simple wounds (Cochrane)
03
Prep ·
sterile field.
- CHG-alcohol skin prep · allow to dry
- Sterile gloves · sterile drape
- Open suture tray on sterile field
- Drape head-to-toe-of-wound, not just the cut
04
Anesthetize ·
wait 5–10 min.
- Inject through wound edges, slow
- Aspirate before each bolus
- Track cumulative mL against weight-based max
- Wait 5–10 min then test before cutting
Forsch RT et al. Am Fam Physician. 2017;95(10):628–636 · StatPearls NBK470598
Laceration Repair · Steps 1–4
12 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
Step 05 — explore · debride · hemostasis
- Inspect the base under anesthesia — tendon, nerve, vessel, foreign body
- Foreign body found → remove if shallow, image if retained
- Devitalized tissue → judicious debridement, sharp, conservative
- Hemostasis — direct pressure, hemostat, vessel ligation if needed
- Exposed deep structure → STOP, escalate, do not close
Step 06 — close · cross-reference Procedure 08
- Simple interrupted — workhorse for most acute lacerations
- Eversion · equal bites · depth equal to width · knot off to the side
- Tension-free apposition — if it pulls, change the plan
- Layered closure if deep — absorbable dermal + non-absorbable skin
- Technique geometry taught in Procedure 08 — Suturing
Suturing technique deep-dive: see Procedure 08 — Suturing — for full coverage of knot variants, needle/needle-driver mechanics, simple interrupted vs vertical/horizontal mattress vs subcuticular, and removal-timing-by-location.
Gerullis H, Heuck CJ, Schneider P. Layered wound closure following resection of radionecrosis. Wikimedia Commons · CC BY 2.0
Choice rule
| Method | Best for |
|---|---|
| Sutures | Most lacerations · cosmetic stakes · high-tension areas |
| Staples | Scalp · trunk · extremity (fast · hemostatic) |
| Adhesive | Short · low-tension · clean · cooperative patient |
Laceration Repair · Closure method & execution
13 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
01 · Scalp
Staples first.
Fast, hemostatic, cosmetically acceptable under hair. Alternative: 3-0 or 4-0 nylon. Remove at 7–10 days.
02 · Lip · vermillion
Align the border.
First stitch goes through the vermillion border — exact alignment matters more than anything else on the face. 1 mm off is visible at 6 months.
03 · Ear
Cover the cartilage.
Close perichondrium first, then skin. Never leave cartilage exposed under skin — chondritis risk.
04 · Digit / nailbed
No epi · refer if nailbed.
Plain lidocaine only (epi-forbidden). Nailbed laceration → repair with absorbable 6-0; consider hand-surgery consult.
05 · Bite — esp. hand
Do not close.
Cat & human bites to the hand → infection risk dominates. Augmentin, escalation, often no primary closure.
06 · Complex flap
Escalate.
Stellate, flap, avulsion — geometric closure outside bedside-APP scope. Plastics or ED attending.
07 · Deep extremity
Check NV exam.
Sensation, motor, capillary refill, pulse — every laceration with extremity depth gets a documented exam before closure.
08 · Pediatric
Sedation question.
If cooperation insufficient and wound is non-trivial → escalate for ED procedural sedation, not bedside force.
Laceration Repair · Special situations
14 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair · Critical checkpoint
Critical safety · two events that mandate stop & escalate
Stop injecting.
Stop closing.
Event 01 · LAST
Perioral numbness, tinnitus, metallic taste, diplopia — any one means stop the injection, ABCs, call for help. Severe: 20% lipid emulsion 1.5 mL/kg lean body mass bolus, then infusion. Per ASRA LAST 2020.
Event 02 · deep structure
Exposed tendon, nerve, vessel, joint capsule, bone — or any positive neurovascular finding distal to the wound — do not close. Pack moist gauze, dressing, escalate to hand surgery or plastics.
Rule
Closing over an unrecognized
injury is the malpractice case.
injury is the malpractice case.
Neal JM et al. ASRA LAST Checklist 2020.
Reg Anesth Pain Med. 2021;46(1):81–82
Reg Anesth Pain Med. 2021;46(1):81–82
Laceration Repair · Critical · LAST & deep-structure stop
15 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
Complications — incidence & mitigation
| Event | Rate | Mitigation |
|---|---|---|
| Wound infection | 1–5% | Irrigation volume · stewardship · close past golden period only when safe |
| Dehiscence | < 2% | Tension-free closure · appropriate suture size/material · accurate removal timing |
| Hypertrophic / keloid scar | variable | Patient counseling · sun protection · silicone gel · dermatology referral |
| Missed deeper injury | — | Mandatory NV exam · base inspection under anesthesia · escalate if uncertain |
| Foreign body retention | — | Direct inspection · imaging if suspected radiopaque material |
| Allergic reaction | rare | True amide allergy uncommon · preservative more often culprit · preservative-free vial |
| LAST | rare · catastrophic | Weight-based dose calc · cumulative tracking · ASRA 2020 protocol |
Five pitfalls we see in real cases
- Skipping tetanus reconciliation. Every traumatic laceration gets a tetanus status check; Td or TdAP per CDC ACIP if non-current.
- Inadequate irrigation. Tablespoons, not liters. 50–100 mL per cm of wound or you are guaranteeing infection.
- Closing past the golden period on a contaminated wound — delayed primary or secondary intention.
- Cumulative lidocaine error. "Just a little more" stacks. Track every mL, calculate the ceiling before you start.
- Missing the deep injury. No NV exam, no base inspection — closure over a transected tendon ends in court.
Forsch RT et al. Am Fam Physician. 2017;95(10):628–636
StatPearls Wound Closure · NBK470598 · CDC ACIP · tetanus prophylaxis
StatPearls Wound Closure · NBK470598 · CDC ACIP · tetanus prophylaxis
Laceration Repair · Complications & pitfalls
17 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
Discharge instructions
- Keep dressing dry for 24 hours; then gentle washing OK
- Watch for infection: spreading redness, increasing pain, fever, drainage
- Return precautions: opened wound, numbness/weakness distal, fever, drainage
- Scar care: sun protection · silicone gel once closed · expect 6–12 mo to mature
- Tetanus: Td or TdAP per CDC ACIP if non-current — administered or scheduled
- Antibiotic stewardship: not for clean wounds; indicated for bites, puncture, immunocompromised
- Document every instruction given
Suture-removal timing by location
| Location | Days |
|---|---|
| Face | 4–5 |
| Scalp | 7–10 |
| Trunk | 7–10 |
| Upper extremity | 7–10 |
| Lower extremity | 10–14 |
| Joint-crossing | 10–14 · immobilize |
Forsch RT et al. Am Fam Physician. 2017;95(10):628–636 · StatPearls NBK470598
Laceration Repair · Aftercare · removal timing
18 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
| Stage | Trigger | Scope |
|---|---|---|
| FPPE | Board approval of laceration-repair privilege | First 5 independent cases · per-case review < 14 days · aggregate at 5 |
| Case mix | FPPE pass criterion | ≥ 1 face/scalp · ≥ 1 extremity · ≥ 1 with debridement |
| OPPE | Every 6 months (TJC MS.08.01.03) | 10% sample (min 2, max 10) · 100% review on complication / return / revision |
| Reinstatement | < 5 cases over 24 mo | Bench validation + 2 proctored cases · case mix preserved |
OPPE indicators · targets
- Wound infection rate < 3%
- Dehiscence rate < 2%
- Return-visit for complication < 5%
- Cosmetic-revision request rate < 2%
- Documentation completeness 100%
- Tetanus reconciliation (indicated cases) 100%
- Antibiotic stewardship appropriate 100%
- Successful primary closure first attempt ≥ 95%
LOW-MED tier · sim not gated
Bench practice recommended.
Laceration Repair · FPPE / OPPE pathway
19 / 21
UUCI · APP Class II
Procedure 15 · Laceration Repair
- 01Forsch RT, Little SH, Williams C. Laceration repair: a practical approach. Am Fam Physician. 2017;95(10):628–636.
- 02StatPearls — Wound Closure Techniques. National Center for Biotechnology Information, NCBI Bookshelf NBK470598.
- 03Neal JM, Neal EJ, Weinberg GL. ASRA Local Anesthetic Systemic Toxicity Checklist: 2020 version. Reg Anesth Pain Med. 2021;46(1):81–82.
- 04Nicks BA, Ayello EA, Woo K, Nitzki-George D, Sibbald RG. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med. 2010;3(4):399–407. PMC3047833.
- 05Fernandez R, Green HL, Griffiths R, Atkinson RA, Ellwood LJ. Water for wound cleansing. Cochrane Database Syst Rev. 2022;9(9):CD003861. doi:10.1002/14651858.CD003861.pub4.
- 06Centers for Disease Control and Prevention (CDC). ACIP Recommendations · Tetanus prophylaxis in wound management. CDC; current edition.
- 07The Joint Commission. Universal Protocol UP.01.03.01. TJC Hospital Accreditation Standards; 2024.
- 08The Joint Commission. HR.01.06.01 · MS.08.01.01 · MS.08.01.03 — competency & FPPE/OPPE. 2024.
- 09Mayeaux EJ. The Essential Guide to Primary Care Procedures. 2nd ed. Wolters Kluwer; 2015.
- 10Gerullis H, Heuck CJ, Schneider P. Layered wound closure following resection of radionecrosis (image). Wikimedia Commons · CC BY 2.0.
- 11UCI APP Class 2 Training Plan Process. Department of Neurology, University of California, Irvine. April 2026.
- 12UCI Neurology Laceration Repair Training Plan & Competence Assessment (canonical source documents). UCI Department of Neurology APP Education; 2026-05-05.
Laceration Repair · References
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