Facial lacerationMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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469 items

☷ Legend

01Approach to the Critical Patient/attcp34

Immediate priorities

›Immediate stabilization

›If airway compromise from facial trauma, initiate airway management

›Blood and vomitus suction readiness

›Early difficult airway team activation for massive facial bleeding

›If uncontrolled hemorrhage, direct pressure and hemostatic measures

›Scalp and face pressure dressing

›If arterial spurting, clamp avoidance and urgent specialist consult

›If altered mental status or high-energy mechanism, trauma protocol activation

›Cervical spine precautions until cleared

›Concussion and intracranial hemorrhage screening pathway

›Early red flags

›If periorbital laceration with vision change, emergent ophthalmology pathway

›Globe rupture exclusion before eyelid manipulation

›Orbital compartment syndrome screening

›If through-and-through cheek laceration, parotid duct and buccal branch injury concern

›ENT or plastics consultation trigger

›Intraoral exam escalation

›If lip laceration crossing vermilion border, cosmetic alignment critical

›Specialist repair consideration for complex wounds

›Time-sensitive meticulous closure

Hemodynamic and pain targets

›Physiologic targets

›Adequate perfusion and mental status baseline

›If syncope or pallor, evaluate occult blood loss and head injury

›If on anticoagulants, lower threshold for imaging and observation

›Pain control sufficient to permit irrigation and layered repair

›Regional anesthesia preference for large facial wounds

›Procedural sedation pathway if required for cooperation

Contamination control and timing

›Wound timing and contamination framework

›Primary closure favored for most facial lacerations due to high vascularity (ACEP Level C)

›Delayed primary closure consideration for heavily contaminated wounds

›Bite wounds individualized by location and infection risk (ACEP Level C)

›Early irrigation and foreign body removal priority

›If glass or gravel suspected, imaging pathway for retained foreign body

›Tattooing risk from asphalt and dirt, early debridement consideration

02History/hx47

Injury and wound context

›Mechanism and timeline

›Time since injury

›Delayed presentation risk factors

›Prior attempted closure or adhesives

›Mechanism of injury

›Blunt impact with possible fracture

›Sharp object with deep structure injury risk

›Location context

›Road rash and contamination exposure

›Water exposure and atypical pathogens

›Contamination and foreign body risk

›Glass, metal, wood, teeth, gravel exposure

›Retained foreign body symptoms

›Prior foreign body removal attempts

›Bite history

›Human bite

›Dog or cat bite

Patient factors and bleeding risk

›Bleeding and comorbidity profile

›Anticoagulant or antiplatelet use

›Warfarin, DOACs, clopidogrel, aspirin

›Last dose timing for DOACs

›Bleeding disorder history

›Hemophilia, von Willebrand disease

›Liver disease

›Diabetes mellitus (E11.9) and wound healing concerns

›Poor glycemic control markers

›Peripheral vascular disease history

›Immunization and infection prevention

›Tetanus immunization status

›Unknown or incomplete series

›Last booster timing

›Rabies exposure context for animal bites

›Unavailable animal for observation

›Unvaccinated wild animal exposure

Symptoms suggesting associated injuries

›Associated symptom screen

›Headache, vomiting, amnesia, seizure

›Mild traumatic brain injury pathway trigger

›Anticoagulated head injury pathway trigger

›Vision changes, diplopia, eye pain, photophobia

›Globe injury concern

›Orbital fracture concern

›Malocclusion, trismus, dental injury

›Mandible fracture concern

›Tooth fragment foreign body concern

›Facial numbness or weakness

›Infraorbital nerve injury concern

›Facial nerve injury concern

03Physical Exam/exam52

Wound assessment and hemostasis

›Wound characterization

›Location and cosmetic subunits

›Eyelid and canthal regions

›Nasolabial fold and lip vermilion border

›Length, depth, and configuration

›Linear, stellate, avulsion, flap

›Tissue devitalization and crush features

›Active bleeding pattern

›Venous oozing

›Pulsatile bleeding and arterial injury concern

›Local tissue considerations

›Wound edge viability

›Dusky flap tips

›Need for conservative debridement on face

›Contamination

›Embedded grit and tattooing risk

›Organic debris

Neurovascular and deep structure exam

›Cranial nerve and sensory exam

›Facial nerve function by branch distribution

›Brow elevation and eye closure

›Smile, puff cheeks, lip depression

›Trigeminal nerve sensory map

›V1 forehead and cornea risk context

›V2 infraorbital region sensation

›V3 jaw and chin sensation

›Salivary and lacrimal structures

›Parotid duct injury screening

›Laceration along line from tragus to upper lip

›Saliva pooling or clear fluid from wound

›Lacrimal system and eyelid injury screening

›Medial canthus laceration and canalicular injury concern

›Lid margin involvement and tarsal plate concern

›Ocular and orbital screening

›Visual acuity baseline

›Decreased acuity trigger for urgent ophthalmology

›Contact lens use infection risk context

›Pupillary symmetry and afferent pupillary defect

›Orbital compartment syndrome concern

›Intracranial injury concern

›Extraocular movements and diplopia

›Entrapment concern

›Blowout fracture concern

PITFALLS

›Common misses

›Inadequate exploration under anesthesia leading to retained foreign body

›Glass fragments in cheek and forehead wounds

›Tooth fragments in lip lacerations

›Missed canalicular injury in medial eyelid lacerations

›Excess tearing after closure

›Poor outcomes without early repair

›Vermilion border misalignment

›Visible step-off after healing

›Repair precision threshold within 1 mm

04Differential Diagnosis/ddx37

Traumatic mimics and associated injuries

›Associated injuries to exclude

›Orbital fracture (S02.3)

›Diplopia and infraorbital numbness

›Step-off deformity

›Nasal fracture (S02.2)

›Epistaxis and deformity

›Septal hematoma risk

›Mandible fracture (S02.6)

›Malocclusion

›Trismus

›Traumatic brain injury (S06.-)

›Loss of consciousness

›Vomiting or severe headache

›Deep structure injuries

›Facial nerve injury (S04.5)

›Weakness in branch distribution

›Temporal and zygomatic branch risk with temple wounds

›Parotid duct injury (S01.4 with duct involvement, SNOMED: parotid duct injury)

›Cheek laceration over masseter

›Salivary leakage

›Canalicular injury (SNOMED: lacrimal canaliculus laceration)

›Medial eyelid laceration

›Excess tearing

Infection and wound complication differential

›Early complications

›Retained foreign body

›Persistent pain

›Nonhealing wound

›Hematoma formation

›Expanding swelling

›Continued oozing after closure

›Infectious concerns

›Animal bite infection

›Pasteurella species risk for cat bites

›Polymicrobial risk for dog bites

›Human bite infection

›Eikenella corrodens risk

›Deep space infection risk

05Laboratory Tests/lt24

Hemorrhage and comorbidity evaluation

›Bleeding and systemic evaluation

›Complete blood count for significant bleeding concern

›Hemoglobin trend if ongoing hemorrhage

›Platelet count if abnormal bleeding history

›Coagulation studies for anticoagulant context (ACEP Level C)

›INR for warfarin use

›aPTT for heparin exposure context

›Type and screen for major facial trauma with persistent bleeding

›Transfusion planning for unstable patients

›Massive transfusion protocol trigger if shock

Infection-related testing

›Selective infection workup

›No routine labs for uncomplicated facial laceration (ACEP Level C)

›Clinical diagnosis of wound infection preferred

›Avoid unnecessary testing

›Wound culture for established infection or abscess

›Purulence after delayed presentation

›Failed initial antibiotic therapy

Procedural safety adjuncts

›Targeted bedside testing

›Point-of-care glucose for altered mental status

›Hypoglycemia mimic of concussion symptoms

›Hyperglycemia and dehydration context

›Pregnancy test when imaging or medication choices affected

›CT radiation planning

›Medication safety planning

06Diagnostic Tests/dt41

Scoring Systems

›Decision tools for associated injuries

›Canadian CT Head Rule framework when head injury suspected

›High-risk features guiding CT head

›Medium-risk features guiding CT head

›NEXUS Cervical Spine criteria framework when neck injury suspected

›Low-risk clearance pathway

›Imaging pathway when criteria not met

MRI

›MRI role

›Limited acute role for isolated facial laceration

›Time and availability constraints

›Foreign body safety concerns for metallic fragments

›Consideration for suspected soft tissue complication when CT nondiagnostic

›Deep space infection concern

›Facial nerve course evaluation in select cases

›CT indications

›CT head for concerning head injury features or anticoagulated patients (ACEP Level B)

›Persistent vomiting

›Worsening headache or neurologic deficit

›CT maxillofacial for suspected fracture (ACEP Level C)

›Bony tenderness and step-off

›Malocclusion or trismus

›CT orbit for suspected orbital fracture or retrobulbar hemorrhage

›Diplopia or limited extraocular movement

›Proptosis and decreased vision

›CT interpretation pearls

›Facial fractures and sinus involvement

›Air-fluid levels and occult fracture clue

›Orbital floor defect and muscle entrapment

›Intracranial hemorrhage screening

›Subdural hematoma

›Subarachnoid hemorrhage

Ultrasound (or US)

›Ultrasound applications

›Point-of-care ultrasound for retained foreign body in soft tissue (ACEP Level B)

›Wood and radiolucent foreign bodies

›Guidance for targeted removal

›Ocular ultrasound avoidance if globe rupture not excluded

›Contraindicated pressure on eye concern

›Ophthalmology-directed imaging preference

›Vascular evaluation adjunct for expanding hematoma

›Pseudoaneurysm concern in select cases

›Hematoma characterization

07Disposition/dispo27

Discharge versus admission framework

›Disposition criteria

›Discharge appropriate for uncomplicated facial laceration after repair

›Hemostasis achieved

›Neurovascular exam intact

›Observation or admission triggers

›Significant head injury symptoms

›Uncontrolled bleeding or expanding hematoma

›Transfer triggers

›Need for specialty repair not available

›Complex facial trauma requiring maxillofacial surgery

Consultation triggers

›Specialty consultation

›Ophthalmology triggers

›Eyelid margin involvement

›Medial canthus laceration and canalicular injury concern

›ENT or plastics triggers

›Parotid duct injury concern

›Facial nerve weakness

›Oral and maxillofacial surgery triggers

›Through-and-through lip with complex tissue loss

›Suspected mandible fracture

Follow-up timing

›Follow-up plan

›Early wound check for high-risk wounds

›Contaminated wounds

›Bite wounds

›Suture removal planning

›Face sutures typically 3 to 5 days

›Eyelid sutures typically 3 to 5 days

08Treatment/t103

Analgesia and anesthesia

›Pain and anesthesia strategy

›Local anesthesia options

›Lidocaine 1% with epinephrine 1

›Max dose 7 mg/kg (ACEP Level C)

›Epinephrine avoidance consideration for end-arterial compromise concern

›Lidocaine 1% without epinephrine

›Max dose 4.5 mg/kg

›Shorter duration planning

›Regional nerve blocks for face

›Infraorbital nerve block for upper lip and cheek

›Landmark at infraorbital foramen region

›Avoid intravascular injection aspiration technique

›Mental nerve block for lower lip and chin

›Landmark near mental foramen

›Bilateral block consideration for midline wounds

›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

09Special Populations/sp30

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

10Background/b27

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

11Patient Discharge Instructions/pdi30

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

12References/r17

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

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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