Wound & Laceration Conveyance Checklist

Immediate Red Flags

Convey regardless

Uncontrolled or recurrent bleeding despite direct pressure
Pulsatile bleeding or suspected arterial involvement
Visible bone, joint capsule, tendon, or muscle in the wound bed
Suspected underlying fracture — especially open fracture (compound)
Degloving injurySkin and subcutaneous tissue sheared away from underlying fascia — often looks deceptively minor at the skin edge but the deep tissue plane is disrupted
Amputation or near-amputation — partial or complete
Neurovascular compromise distal to wound — pulse, capillary refill, sensation, motor function
Wound over a joint with suspected capsule breach — risk of septic arthritis if missed
High-pressure injection injury (grease gun, paint sprayer) — looks tiny, can devastate the tissue plane beneath
Bite wound — human or animal; high infection risk and often needs surgical review/exploration

Timing — The Golden Period

Affects closure option

Time since injury >6 hours — primary closure less appropriate; rising infection risk, may need delayed closure or healing by secondary intention
Time since injury >12–24 hours on a contaminated or high-risk wound (hand, foot, bite) — primary closure usually no longer appropriate
Unknown time of injury — e.g. found patient, dementia, intoxication — treat as outside the golden period

Why timing matters The golden period isn't a hard cutoff — it's the window where bacterial load is low enough that closing the wound doesn't trap infection inside. Face and scalp wounds (good blood supply) tolerate a longer window than hands, feet, or heavily contaminated wounds (poor blood supply, more bacterial inoculum).

Structures at Risk by Location

Anatomy-dependent

Face — near eyebrow, eyelid, lip margin, or ear — cosmetic and functional outcome depends on precise alignment; lower threshold for plastics/specialist closure
Hand or finger — tendon, nerve, or digital artery injury easily missed on visual inspection alone; test flexor/extensor function and two-point sensation
Near a major vessel or nerve course (e.g. wrist, antecubital fossa, popliteal fossa, neck)
Scalp wound with palpable step or depression — possible underlying skull fracture, not just a laceration
Wound over a tendon with reduced range of movement — even partial tendon injury can present with only mild weakness
Penetrating wound to torso/abdomen — depth cannot be reliably assessed externally; treat as potential cavity breach

Contamination & Infection Risk

Raises threshold

Visible foreign material — soil, glass, gravel, vegetation, clothing fibres
Wound contaminated by soil or organic matter — tetanus risk, may need irrigation/exploration beyond on-scene capability
Crush mechanism — devitalised tissue at wound edges, higher infection rate even with clean-looking skin
Bite wound (repeated from red flags — also a contamination concern in its own right)
Wound in a heavily soiled environment — farmyard, sewage, stagnant water
Tetanus status unknown or incomplete — particularly relevant for tetanus-prone wounds (contaminated, puncture, devitalised tissue, delayed presentation)

Patient Factors

Lowers threshold to convey

Anticoagulant or antiplatelet therapy — harder to achieve haemostasis; even a "simple" laceration can ooze for longer and re-bleed
Diabetes — impaired wound healing, higher infection risk, especially lower limb
Peripheral vascular disease — poor perfusion at wound edges, healing concern
Immunosuppression — steroids, chemotherapy, biologics, known immunodeficiency
Fragile/atrophic skin — long-term steroid use, elderly skin, venous insufficiency — wound edges may not hold sutures or staples well; skin tears in this group often need specialist dressing technique rather than closure
Lives alone / limited social support — affects safety of leaving wound for self-management, independent of the wound itself
Cognitive impairment — affects ability to self-monitor for infection or dressing failure at home

Wound Type

Descriptive

LacerationTearing of skin/tissue from blunt or sharp trauma — edges may be clean (sharp object) or irregular (blunt/shear force)
IncisionClean, sharp-edged cut — typically lower infection risk, often suitable for primary closure if within golden period
Skin tearSeparation of skin layers, common in fragile/aged skin — classified by flap viability rather than treated like a standard laceration
AbrasionSuperficial graze — rarely needs closure, main concern is contamination and pain management
Puncture woundSmall entry, potentially deep tract — depth and structures involved cannot be assessed from the surface; higher tetanus-prone classification
AvulsionTissue partially or fully torn away from its attachment — distinct from degloving in that it may involve a discrete flap rather than a sheet of tissue

STAR Skin Tear Classification

1aEdges realigned, skin/flap colour not pale, dusky or darkened 1bEdges realigned, skin/flap colour pale, dusky or darkened 2aPartial flap loss, edges cannot be realigned, flap colour not pale, dusky or darkened 2bPartial flap loss, edges cannot be realigned, flap colour pale, dusky or darkened 3Total flap loss, entire wound bed exposed

On-Scene Management Considerations

If non-conveyance considered

Haemostasis achieved and confirmed stable on direct pressure release
Wound can be adequately cleaned on scene — visible contamination removed, irrigation if available
Closure achievable with on-scene resources — steri-strips/skin closure strips appropriate for the wound, or it genuinely doesn't need formal closure
Distal neurovascular status confirmed normal and documented
Safety-netting given — infection signs (spreading redness, increasing pain, discharge, fever), when to seek review, who to contact
Follow-up route identified — GP, practice nurse, walk-in, or community service for tetanus/review/suture removal if applicable
Patient/carer able to monitor wound and act on safety-netting advice

Conveyance Decision Summary

Pulls it together

Any one of these present	Suggests
Any Red Flag item	Convey — needs ED/surgical assessment
Outside golden period + contaminated/high-risk site	Convey — delayed closure decision needed
Structures at risk uncertain after exam	Convey — can't safely exclude deep injury on scene
Patient factor present (anticoagulation, fragile skin, immunosuppression) + wound needs closure	Lower threshold to convey, even if wound itself looks straightforward
None of the above, haemostasis secure, closure achievable on scene	Non-conveyance with safety-netting and follow-up route may be appropriate

The trap to avoid A wound that "looks simple" can still need conveyance because of what's underneath it (tendon, joint, fracture), what's on it (contamination, devitalised tissue), or who it's on (anticoagulated, fragile skin, lives alone). Treat the wound, the mechanism, and the patient as three separate questions — a clean answer on one doesn't clear the others.

Glossary

Reference

Golden period: The time window after injury in which primary closure carries acceptably low infection risk — commonly cited as ~6 hours, longer for well-vascularised areas (face, scalp), shorter for poorly vascularised or contaminated wounds (hands, feet, bites).
Primary closure: Closing the wound directly (sutures, staples, glue, steri-strips) at first presentation.
Delayed primary closure: Wound is cleaned and dressed but deliberately left open for several days before closure, used when infection risk is too high to close immediately.
Healing by secondary intention: Wound is left open and allowed to heal from the base up — used for heavily contaminated wounds, significant tissue loss, or where primary closure isn't appropriate.
Tetanus-prone wound: Any wound with significant contamination, puncture mechanism, devitalised tissue, or delayed presentation (>6 hrs) — raises the threshold for tetanus prophylaxis review regardless of vaccination history.
Degloving injury: Forceful separation of skin and subcutaneous tissue from the underlying fascia — the skin surface can look intact or only mildly disrupted while the tissue plane beneath is completely separated.
Devitalised tissue: Tissue with compromised blood supply at the wound edge or bed — appears dusky, pale, or non-bleeding on pinprick — raises infection risk and may need debridement before closure.
STAR Skin Tear Classification: A staging system (1a–3) for skin tears based on whether the skin flap can be realigned and whether the flap/wound bed tissue is viable (colour) — see Wound Type section above for the full grading.