Assess, clean, anaesthetise, close, dress — simple laceration repair

Structured clinical encounter — minor trauma and procedural skill

This station tests whether the candidate leads a calm, child-centred laceration repair from assessment to aftercare, performs the procedure safely, and adapts judgement when the scenario turns to a contaminated bite. Marks reward the structured assessment, the topical-first analgesia, the closure-method choice, the safe local anaesthetic dosing, and the family-centred communication. [1] [8]

Stem

A previously well four-year-old is brought to the emergency department after falling against a table edge and splitting the skin over her chin. The laceration is clean, three centimetres long, superficial, and the edges oppose easily. She is frightened but cooperative with distraction. Her immunisations are up to date and she last ate two hours ago. The parent asks what will happen. [1]

Candidate tasks

1. Lead the structured assessment (3 minutes). Take a targeted history and examine the wound in good light, assessing depth, edges, contamination, foreign body, and — for a face wound — the lip vermillion border, facial nerve function, and distal sensation and function. Run the MADNESS check including safeguarding and tetanus status. [1]
2. Provide painless analgesia (2 minutes). Apply topical LET gel into the wound under an occlusive dressing for twenty to thirty minutes, with distraction and comfort positioning. Explain to the parent that this makes the repair painless and protects the child's future experience of healthcare. [4] [2]
3. Irrigate and close (3 minutes). Irrigate with tap water (as effective as saline). Close with tissue adhesive, because the wound is clean, low-tension, simple, under five centimetres, and the edges oppose easily. State the contraindications to tissue adhesive (mucosa, high-tension, bites, infected). [8] [9]
4. Counsel the family and plan follow-up (2 minutes). Give written advice: keep clean and dry for forty-eight hours, do not pick at the glue (it peels off at five to ten days), protect the scar from sun, and return with spreading redness, increasing pain, swelling, discharge, or fever. State that the scar fades over twelve to eighteen months. No removal appointment is needed for tissue adhesive. [1]
5. Defend the local anaesthetic safety (2 minutes). State the maximum doses — lidocaine three milligrams per kilogram plain, seven with adrenaline, bupivacaine two — and the early signs and treatment of local anaesthetic systemic toxicity. [10]

Examiners' discussion points

• Why tissue adhesive here and not sutures? The wound is clean, low-tension, simple, under five centimetres, and the edges oppose easily. Tissue adhesive is fast, painless, needs no removal, and gives equivalent cosmetic outcome. [8]
• The child becomes very distressed despite LET. Layer in comfort positioning, distraction (including virtual reality), a child-life worker, and consider minimal or moderate procedural sedation in a monitored setting, because combined strategies reduce procedural distress and its behavioural aftermath. [2]
• The stem pivots: now it is a dog bite to the hand. Irrigate copiously, do not close primarily, assess tendon, nerve, joint, and bone, give amoxicillin-clavulanate prophylaxis, check tetanus status, and review at forty-eight hours. Primary closure of a hand bite traps infection. [12]

Marking grid (out of 20)