Hmm...we can fix that, we have the technology

I love simple interrupted, it gets the job done. Quick and simple, and if there's any concern for infection, they are easy to remove. You need to break down the situation to 3 sections: pain control, style, and infection control.

1) Ouch! Pain control.
We have the basics: lidocaine with or without epinephrine. There's also bupivacaine, a longer acting albiet more expensive version. Don't forget to avoid the fingers, nose, toes, hose, and even the pinna of the ear.



Now, I remember getting pimped on the max dosage of lidocaine: 300mg OR 7 mg/kg. What does that mean? If we have a 130lb. adolescent with 1% lidocaine in a 10mg/ml vial, that gives us a max dose of
130 lb/2.2= 59 kg x 7mg/kg= 413 mg x 10mg/ml= 41.3 ml. BUT, remember the max dosage of 300mg? That means you can only give 30ml.

 
What about sodium bicarb?
Most anesthetics are acidic in nature, and we warn patients of the burning sensation when injecting. This can be worse for the little youngsters. You can add 1mL of sodium bicarbonate to 9mL of lidocaine (or 1mL bicar to 19 mL bupivacaine) to help lessen the burn. BUT! Adding bicarb will limit the shelf-life to 7 days and can reduce the effectiveness of the anesthetic.

The decision to use local technique vs. nerve blocks is subject to the location:
http://practicalplasticsurgery.org/docs/Practical_03.pdf

2) Style points!

 I could provide all these diagrams, but I'll be honest. These sources from UCI Emergency Medicine Interest Group and UW Department of Family Medicine do a better job:

http://www.uciemig.com/sutureWorkshop_handout.pdf

http://www.fammed.washington.edu/network/sfm/workshops/sutureworkshop.htm

Splashcap®

3) Infection control.
 Irrigate, irrigate, irrigate!! Get saline bottle, poke 5-6 holes with a 18g needle and squeeze away up to 2 liters. Some places are fancy and have screw on tops to provide a consistent pressure of saline to irrigate.

There is the classic "golden period" in emergency medicine that after a certain period of time, the wound should be allowed to granulate and close by secondary intention. However, this period is highly variable with different institutions ranging from 4-12 hours. So long story short, you need to rely on your clinical impression and institutional guidelines. However, there are some situations you should avoid suturing:

- animal bites (remember, humans are animals too!)

- contaminated wounds in which irrigation may not be sufficient.

What about foreign bodies? X-ray is great for metallic or plastic pieces, but for wood pieces U/S is a fantastic tool.

Antiobiotics should be given if there is any concern for infection, and make sure they get follow-up for wound check (24-48h):

Cephalexin (Keflex®) 250mg q4h x 10 days.

Cephazolin (Ancef®) 1gm IV is a good 1st line choice, especially with suspect for bone/joint infection.

Animal bite?

Amoxicillin-Clavulante (Augmentin™) 875mg q12h x 5d

Piperacillin and Tazobactem (Zosyn®) 4.5mg IV
 

Watch out for Pseudomonas (esp. diabetics, foot punctures) !!! 
Ciprofloxacin (Cipro®) 500mg BID x 14 days.
Piperacillin and Tazobactem (Zosyn®) 3.375g IV q 8 h x 7-10 days. If severe, 4.5g

community MRSA? 
Trimethoprim-sulfamethoxazole (Bactrim® DS) 1-2 tabs BID 5-10 days.



Don't forget Tetanus!!!! Anyone that can't confirm last immunization, incomplete immunization (< 3 doses or in kids (refer to AAP Red Book®, also on UpToDate®),  < 10 years for a clean wound, < 5 years "dirty" wound.

Last but not least, pain medication!

References:

Dehn, R.W., and Asprey, D.P. (2007). Essential Clinical Procedures (2nd ed.). Philadelphia, PA:Saunders Elsevier.

Sanford Guide® Antimicrobial Therapy 2011-12 v1.4

UpToDate®