Topical anesthetic for select pediatric facial wounds
LET gel application
Avoid mucosal surfaces when not indicated
Onset time planning before irrigation
Wound cleansing and exploration
Irrigation and preparation
High-volume irrigation for contaminated wounds (ACEP Level C)
Normal saline irrigation
Tap water acceptable for low-risk wounds
Wound exploration under adequate anesthesia
Depth assessment to fascia and muscle
Foreign body and devitalized tissue assessment
Hemostasis techniques
Direct pressure
Epinephrine-containing local anesthetic adjunct
Closure technique and materials
Closure principles
Primary closure favored for most facial lacerations (ACEP Level C)
Excellent vascularity and cosmetic benefit
Low infection rate relative to other sites
Layered closure for deep wounds
Deep dermal absorbable sutures
5-0 or 6-0 absorbable for dermis
Buried knots to reduce track marks
Skin closure technique
6-0 nylon or polypropylene for face
Simple interrupted for precision alignment
Key cosmetic landmarks
Vermilion border alignment first stitch
Use of fine nonabsorbable suture
Marking border before anesthesia and cleansing
Eyebrow edge preservation
No shaving of eyebrow hair
Align brow margin carefully
Special region repair
Lip through-and-through laceration
Mucosal layer absorbable closure
5-0 absorbable for mucosa
Saliva contamination mitigation
Muscle layer approximation
Orbicularis oris alignment
Tension reduction for skin layer
Skin layer precision
Vermilion border stitch first
Early follow-up for edema and infection
Eyelid laceration precautions
If lid margin involvement, specialist repair (ACEP Level C)
Notching risk with misalignment
Tarsal plate alignment complexity
If medial canthus involvement, canalicular injury pathway
Stenting requirement likelihood
Early ophthalmology involvement
Antibiotics, tetanus, and rabies
Antibiotic prophylaxis
No routine antibiotics for clean, uncomplicated facial lacerations (ACEP Level C)
Low baseline infection risk
Stewardship consideration
Bite wounds prophylaxis
Amoxicillin-clavulanate PO
Adult dosing 875 mg every 12 hours
Typical prophylaxis duration 3 days to 5 days
Penicillin allergy alternative
Doxycycline PO option for nonpregnant patients
Add metronidazole for anaerobic coverage if needed
Through-and-through oral lacerations prophylaxis consideration (ACEP Level C)
High bacterial load environment
Early signs of infection monitoring
Tetanus prophylaxis
Tdap or Td based on immunization history
Booster if indicated by wound type and timing
Tetanus immune globulin for high-risk wounds with incomplete immunization
High-risk wound features
Contamination with soil
Devitalized tissue or puncture component
Rabies considerations for animal bites
Rabies risk assessment
Wild animal exposure
Unavailable animal for observation
Public health consultation pathway
Post-exposure prophylaxis initiation when indicated
Local protocol adherence
Scar optimization and aftercare adjuncts
Cosmetic outcome measures
Early suture removal planning to reduce track marks
Face 3 to 5 days typical
Steri-strip support after removal
Sun protection counseling
Sunscreen and physical barriers
Hyperpigmentation risk reduction
Silicone gel or sheeting consideration after epithelialization
Hypertrophic scar risk reduction
Patient adherence planning
Special Populations
Pregnancy
Pregnancy-specific considerations
Imaging selection and shielding when CT considered
Minimize radiation when feasible
Risk-benefit documentation for trauma imaging
Antibiotic selection safety
Avoid doxycycline
Beta-lactams preferred when appropriate
Tetanus immunization considerations
Tdap timing context
Maternal and neonatal protection benefits
Geriatric
Geriatric considerations
Anticoagulation prevalence and bleeding risk
Lower threshold for CT head after falls
Prolonged oozing and hematoma risk
Fragile skin and tissue handling
Higher risk of skin tearing with sutures
Use of fine sutures and gentle eversion
Delayed presentation and infection risk
Social factors affecting timing
Early follow-up planning
Pediatrics
Pediatric considerations
Anxiety and cooperation planning
Child life support when available
Procedural sedation pathway when needed
Topical anesthesia and needle-sparing approaches
LET gel use
Intranasal analgesia options per local protocol
Nonaccidental trauma screening in concerning patterns
Inconsistent history
Multiple injuries at different healing stages
Background
Epidemiology
Epidemiology summary
Facial lacerations common in falls, sports, assaults, and motor vehicle collisions
Pediatric predominance in play-related injuries
Adult predominance in occupational and assault-related injuries
Low infection rates in clean facial lacerations compared with extremity wounds
Rich facial blood supply benefit
Early closure typically favored
Pathophysiology
Tissue and healing concepts
Facial vascularity and rapid epithelialization
Lower risk of infection in clean wounds
Strong cosmetic incentive for precise approximation
Scar formation timeline
Tensile strength increases over weeks to months
Scar remodeling over months
Crush injury and devitalization increase complication risk
Infection risk higher in stellate wounds
Need for conservative debridement on face
Therapeutic Considerations
Repair strategy rationale
Primary closure improves cosmetic outcomes when contamination controlled (ACEP Level C)
Facial subunit alignment importance
Vermilion border and eyelid margin precision
Layered repair reduces tension and widens scars less
Deep dermal support
Fine epidermal sutures
Antibiotic stewardship
Avoid routine antibiotics in clean lacerations
Target prophylaxis to bites and high-risk wounds
Patient Discharge Instructions
copy discharge instructions
Home care instructions
Keep wound clean and dry for first 24 hours
After 24 hours, gentle washing with soap and water
Pat dry, avoid scrubbing
Dressing plan
Thin layer of petrolatum
Clean bandage if rubbing or contamination risk
Suture care and removal
Face sutures removal in 3 to 5 days
If absorbable sutures, expect gradual dissolution and avoid picking
Return to ED now
Increasing redness spreading beyond wound edges
Warmth and worsening swelling
Pus or foul drainage
Fever or systemic illness
Chills
Rapid heart rate with weakness
Worsening pain not controlled with usual medications
Expanding hematoma
New numbness or weakness of face
Vision changes
Blurry vision, double vision
New eye pain or inability to move the eye normally
Scar care after healing
Sun protection for 6 to 12 months
Sunscreen daily on healed skin
Hat or physical sun barrier
Silicone gel or sheets after skin closed
Use as directed for weeks to months
Stop if rash or irritation
References
Clinical guidelines and core sources
Key guidance sources
ACEP clinical resources on wound management and procedural care (ACEP Level C references)
Laceration evaluation and repair principles
Procedural sedation and analgesia guidance
CDC tetanus prophylaxis guidance
Tdap or Td booster recommendations by wound type
Tetanus immune globulin indications
IDSA guidance for animal and human bite infection management
Antibiotic prophylaxis recommendations for high-risk bites
Polymicrobial coverage principles
Evidence-based procedural references
Repair technique references
Emergency medicine and family medicine laceration repair reviews
Irrigation and closure technique summaries
Suture selection by anatomic site
Ophthalmology and facial plastics references for eyelid, canalicular, and facial nerve injuries
Indications for specialist repair
Timing considerations for optimal outcomes
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.