Wound care, suturing and local anaesthetic safety

Start with danger and haemostasis. Apply direct pressure and elevate when appropriate; use haemostatic measures within competence. Spurting bleeding, shock, expanding haematoma or bleeding uncontrolled by pressure needs urgent surgical or emergency support. Record initial contamination and avoid clamping unseen vessels blindly. Analgesia and calm positioning improve examination quality.

History identifies mechanism, object, time, environment, crush, injection injury, glass, soil, water, animal or human bite, anticoagulation, diabetes, immunosuppression, allergy, tetanus status and dominant hand. Ask about numbness and loss of movement. Wounds caused by assault, self-harm or occupational exposure also need safeguarding and psychosocial or employer pathways.

Before anaesthetic, examine and document distal circulation, capillary refill, sensation in named nerve territories, active tendon movement against resistance when safe, joint stability and possible compartment tension. Test before infiltrating because anaesthetic can erase deficits. Suspected tendon, nerve, vessel, joint, open fracture, retained deep foreign body or high-pressure injection needs specialist assessment.

Equipment includes PPE and eye protection, sterile field, irrigation fluid and splash control, syringe or approved irrigation device, forceps, needle holder, scissors, appropriate monofilament or other suture, dressing, sharps bin and resuscitation equipment. Local anaesthetic requires the exact ampoule, clearly labelled syringe, suitable needle and a written maximum-dose calculation.

Clean surrounding skin without driving antiseptic into tissues. Small superficial cuts can be rinsed with drinking-quality tap water under NHS advice. Clinical irrigation of deeper or contaminated traumatic wounds follows the wound-specific local protocol, using its recommended solution, adequate volume and splash protection. Remove accessible loose debris under direct vision; embedded foreign bodies, devitalised tissue or threatened structures require appropriate procedural expertise rather than blind probing or forceful removal.

Explore under adequate light and anaesthesia through the wound’s range of movement, using blunt visual techniques rather than blind probing. Imaging may help for radiopaque glass or fracture but does not replace exploration, and some materials are radiolucent. Punctures, deep palmar wounds, facial wounds, bites, nail-bed injuries and wounds over joints have structure-specific pathways.

Decide closure after irrigation and assessment. Primary closure suits selected clean, viable wounds that can be apposed without harmful tension. Heavily contaminated, infected, devitalised, late-presenting or high-risk wounds may need delayed primary closure or healing by secondary intention. Facial, eyelid, lip-border, tendon, nerve or complex hand wounds need a clinician with the relevant repair skill.

Antibiotics are not routine for every sutured laceration. Use wound-specific current guidance for bites, open fractures, gross contamination, deep infection or high-risk host factors. Tetanus prevention depends on wound category and documented immunisation, using current UKHSA guidance. Irrigation and debridement cannot be replaced by antibiotics.

Local anaesthetic dose safety is product-specific. Confirm drug, concentration in mg/mL, whether adrenaline is present, patient weight, age, frailty, pregnancy, cardiac, hepatic and renal disease and other local anaesthetic exposure. Convert percentage correctly: 1% lidocaine contains 10 mg/mL. Maximum dose varies by product; use the current SmPC rather than a memorised universal limit.

As a worked calculation, if the selected current SmPC states usual infiltration 3–5 mg/kg and a general maximum 200 mg for plain 1% lidocaine, a 60-kg adult’s weight-derived range reaches 180–300 mg, but the product cap limits total to 200 mg: 20 mL of 10 mg/mL. Patient and site factors may require less. Another licensed product may state different limits, so never transfer this result.

Prepare resuscitation capability where the administered dose or block risk warrants. Clean skin, use a fine needle and consider field block through intact skin rather than repeatedly injecting wound edges. Aspirate before incremental deposition where appropriate, inject slowly and pause for severe pain or resistance. Do not inject adrenaline-containing preparations into an end-artery area without specific current product and specialist justification.

Local anaesthetic systemic toxicity can begin with circumoral tingling, metallic taste, tinnitus, dizziness, agitation or drowsiness and progress to seizure, hypotension, conduction disturbance and cardiac arrest. Stop injecting, call resuscitation help, manage airway, oxygenation and seizures and follow the 2025 Resuscitation Council UK LAST algorithm, including 20% lipid emulsion by the exact algorithm.

For a simple interrupted suture, mount the curved needle about two-thirds from its tip, handle only with instruments and stabilise the edge gently. Enter at 90 degrees an appropriate distance from the edge, rotate through dermis following needle curvature and exit at equal depth and distance. Repeat on the opposite edge if needed to create a symmetric bite and slight eversion.

Tie a flat square knot using the instrument tie, alternating throws, with sufficient throws for the suture material. Approximate rather than blanch or strangulate. Place sequential sutures to distribute tension and align landmarks, reassessing edges and perfusion. Deep tension, dead space or layered closure may require absorbable sutures and additional competency. Count and discard sharps directly.

Choose dressing for bleeding, exudate, location and patient ability. Provide written care: keep appropriately clean/dry initially, then follow local wound advice; elevation and analgesia; return for spreading redness, pus, fever, increasing pain, bleeding, numbness, colour change, wound separation or reduced movement. Give a site-specific suture-review/removal plan rather than one universal day count.

At follow-up, reassess infection, perfusion, function, dehiscence and scar. Remove alternate sutures first when uncertain about support. Steri-strips may reinforce. Refer if infection crosses a joint, function changes, pain is disproportionate or a retained foreign body is suspected. Direct supervision is required until competent; complex closure, procedural sedation, regional blocks and children require extra training.