That night I reflected on how things would have been subtly but significantly different at Patan Hospital. A sterilized suture set, autoclaved, packed and ready to use along with a ready to use surgical suture would be available. The procedure would have taken place in a more private space and not where visitors had the opportunity to peak in through our foldable privacy screen. Maybe the patient would have had to wait longer to get attention but the difference would not have been much, considering the time it takes to prepare every instrument here.

Each minor aspect of this difference deserves to be heard, talked about and their solution sought for. I plan to write about each of these as a series of article that follows. Proper resource allocation is a time and economy intensive goal; nevertheless the ultimate one. Maybe small workarounds are what we need during the period of transition, especially for places like Beltar.

Laceration repair is a common procedure in every emergency department. Setting differs and with it the availability of resources. Nevertheless, the core principles that govern patient care and the science behind it remains the same. While we wait for more convenient and sophisticated solutions, which all patients deserve, here are some points to remember regarding laceration repair that can help provide an acceptable standard of care even in resource-limited settings.

• While working in rural, one should be well aware of its limitations. Some lacerations that require surgical consultation and need to be referred include (1):
  • Deep wounds of the hand or foot
  • Full-thickness lacerations of the eyelid, lip, or ear
  • Lacerations involving nerves, arteries, bones, or joints
  • Penetrating wounds of unknown depth
  • Severe crush injuries
  • Severely contaminated wounds requiring drainage

• Non-contaminated wounds can be successfully closed up to 18 hours post-injury while clean head wounds can be repaired up to 24 hours after injury (2).

• Drinkable tap water can be used for wound irrigation instead of sterile saline. At least 50 to 100 ml of irrigation solution per 1 cm of wound length is needed at a pressure of 5 to 8 psi for optimal dilution of wound’s bacterial load. The wound can be put under running water or can be irrigated using a 19-gauge needle with a 35 ml syringe (3).

• Local hair should be clipped, not shaved, to prevent wound contamination(4).

• Strict sterile techniques are unnecessary to be followed during laceration repairs. The instruments touching wound (sutures, needles, etc.) should be sterile, but everything else only needs to be clean(1). Clean non-sterile examination gloves can be used instead of sterile gloves during wound repair(5).
• Local anesthesia with lidocaine 1% or bupivacaine 0.25% is appropriate for small wounds while large wounds occurring on limbs may require a regional block (1). Epinephrine should not be used in anatomic areas with end arterioles, such as fingers, toes, nose, penis, and earlobes.
• Maximum doses of local anesthetic are as follow (6):
  • Lidocaine (without epinephrine): 3 – 5 mg/kg
  • Lidocaine (with epinephrine): 7 mg/kg
  • Bupivacaine (without epinephrine): 1 – 2 mg/kg
  • Bupivacaine (with epinephrine): 3 mg/kg
• The suture used for skin repair include non-absorbable sutures (nylon and polypropylene) while absorbable sutures (polyglactin, polyglycolic) is used to close deep lacerations. For skin closure, silk sutures are no longer used because of skin abscess formation, their poor tensile strength and high tissue reactivity. In general, a 3–0 or 4–0 suture is appropriate on the trunk, 4–0 or 5–0 on the extremities and scalp, and 5–0 or 6–0 on the face (6).
  • Sterilization of sutures can be done by complete immersion in povidone-iodine 10% solution for 10 minutes followed by rinsing in sterile saline/water. Sutures that can be sterilized or re-sterilized include monofilament sutures (Prolene or Nylon) and coated sutures (Vicryl, Ethibond) (7).