IV fluids, caffeine (IV or oral), antiemetics, analgesics,

barbiturates, diphenhydramine, and ergots. Headaches

lasting >24 hours may be alleviated by an epidural blood

patch performed by an anesthesiologist. If the headache

does not have a postural component, lasts more than 1

week, or recurs after initially resolving, consider the

LUMBAR PUNCTURE

possibility of a subdural hematoma. Subdural hemato ­

mas are due to tearing of bridging veins from decreased

CSF volume.

Patients may also complain of mild backache after an

LP. This is common from trauma of the spinal needle and

is usually self-limited, resolving in a few days. Other potential complications include iatrogenic infection caused by

improper sterile technique, a contaminated field, or contaminated needle. Infectious complications include cellulitis, skin abscess, epidural or spinal abscess, discitis, or

osteomyelitis.

SUGGESTED READING

Fong B, VanBendegom J. Lumbar puncture. In: Reichman EF,

Simon RR. Emergency Medicine Procedures. 1st ed. New York,

NY: McGraw-Hill, 2004.

Ladde JG. Central nervous system procedures and devices. In:

Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK,

Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive

Study Guide. 7th ed. New York, NY: McGraw-Hill, 2011:1178-1180.

Miles S. Ellenby, et al. Lumbar puncture. N Engl J Med. 2006;335:12.

Wright BL, Lai JT, Sinclair AJ. Cerebrospinal fluid and lumbar

puncture: a practical review. ] Neural. 2012;259:1 530-1545.

Laceration Repair

Jeffrey N. Siegelman, MD

Key Points

• The timing of wound closure is determined by balancing

the risk of infection with the likelihood of scarring.

• Identify and remove foreign bodies before wound closure.

INDICATIONS

Any wound deeper than a superficial abrasion should be

considered for closure to improve the cosmetic result, preserve viable tissue, and restore tensile strength. This can be

accomplished with sutures, tissue adhesive, or staples.

Tissue adhesive may be indicated for hemostatic wounds in

low tension areas that are at low risk for infection. Staples

are appropriate for relatively linear lacerations located on

the extremities, trunk, or scalp.

CONTRAINDICATIONS

The decision about whether and when to repair a laceration is based on many factors, which can be divided

broadly into host and wound factors. Host factors include

age (elderly patients have 3-4 times higher rate of infection

and slower wound healing), malnutrition, and immunocomprornise ( eg, diabetes mellitus). Wound factors include

timing, location, mechanism, and contamination. Bacterial

counts begin to increase 3-6 hours post-injury, and every

attempt is made to achieve primary wound closure as

expeditiously as possible. However, there is no evidencedbased definitive time by which wounds must be closed.

Wounds of the face and scalp rarely become infected

( 1-2%) because the face and scalp have an excellent blood

supply; such wounds may be closed safely 24 hours or

more after injury. Infection rates of upper ( 4o/o) and lower

(7%) extremity wounds are higher, and many practitioners

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