Pediatric emergency medicine trisk 844

FIGURE 110.1 A seemingly superficial laceration at the wrist might be treated simply by
closure of the subcutaneous tissue and skin, unless one appreciates the abnormal posture of a
finger when the hand is at rest. The loss of normal flexor tone as a result of a divided superficial
tendon results in the involved finger lying in a position of relative extension.

Patients found to have vascular, nerve, or tendon injury or deep, extensive
wounds to the face warrant consultation with a surgical specialist for possible
repair in the operating room.
Management
Decision to Close the Wound. Most wounds may be closed primarily, meaning
the wound edges are approximated as soon as possible after the injury to speed
healing and improve the cosmetic result. If primary closure is delayed, the risk of
subsequent infection increases. Some authors suggest that the “golden period” for
wound closure is 6 hours. However, wounds at low risk for infection (e.g., a clean
kitchen knife injury) can be closed even 12 to 24 hours after the injury.
Most wounds of the face are best closed primarily, even up to 24 hours after
injury to achieve an optimal cosmetic effect. If the wound is extensive or has a
high potential for infection (e.g., a dog bite), thorough irrigation is essential, and
in cases of extensive or complex wounds, the operating room may be the best site
for this repair. Conversely, wounds at high risk for infection such as those in


anatomic locations with poor blood supply, contaminated or crush wounds, and
those involving immunocompromised hosts should be closed promptly, within 6
hours of injury. Some contaminated wounds (e.g., animal or human bites or those
occurring on a farm) in an immunocompromised host should not be sutured, even
if the patient presents immediately for care. Some wounds should be allowed to
heal by secondary intention (secondary closure), although scar formation may be
more unsatisfactory. Infected wounds, ulcers, and many animal bites are best left
to heal by granulation and reepithelialization. Human bites over the
metacarpophalangeal joints (clenched-fist bites) are especially prone to infection

and risk infection with primary closure. Puncture wounds to the foot, with only a
small laceration and a low concern for cosmetic results, may also be left open. A
small sterile wick of iodoform gauze may be placed inside the wound to keep the
edges open. This gauze can be removed after 2 to 3 days, and the subsequent
granulation tissue will aid healing.
TABLE 110.2
WOUND ASSESSMENT—GENERAL PRINCIPLES
Primary survey—control bleeding
Secondary survey—other injury?
History
Mechanism
Age of wound—time of injury
Possible foreign body
Environment
Health status—tetanus immunization
Physical examination
Location
Muscle function
Tendon involvement
Vascular injury
Nerve injury
Foreign material
Laboratory
Consider radiographs or ultrasound if a foreign body or fracture is suspected


If a wound is not closed initially, delayed primary closure (tertiary closure) can
be considered after the risk of infection decreases, about 3 to 5 days later. This is
recommended for selected heavily contaminated wounds and those associated
with extensive damage. These uncommon wounds in pediatrics might include

high-velocity missile injuries, crush injuries, explosion injuries of the hand,
industrial wounds, those occurring on a farm, and some extensive bite wounds.
The wound should be cleaned and debrided and covered at the time of initial
presentation, then reassessed in a few days for infection. A contaminated but
healing wound may gradually gain sufficient resistance to infection to permit
uncomplicated closure at a later time. This approach may reduce discomfort and
lead to a better cosmetic result than no repair. Tertiary closure is used rarely in
pediatrics because children have few severely contaminated wounds.
Preparing the Child and Family. It is important to reassure the child and the
family that everything will be done to care for the wound appropriately and to
relieve the patient’s pain and anxiety. In many cases, early removal of blood and
foreign material from the surface of the wound is reassuring. Also, carefully
chosen words will reduce fear for the procedure. The provider must honestly
warn the patient of an impending painful stimulus but may leave open the
possibility that it may not hurt as much as the child thinks. Appearing unhurried
and confident, giving the child some control of the situation, and explaining the
upcoming procedure seem to help reduce anxiety and pain for many patients. The
parent(s) and child should be informed that steps will be taken to make the
procedure as quick and painless as possible, such as with the use of topical
anesthetics. The clinician should provide an age-appropriate empathic
explanation, to reduce anxiety. Prepare instruments that may be frightening, such
as needles and scalpels, away from the child. Distraction techniques, such as
allowing the child to listen to music or view age-appropriate, entertaining videos
during the procedure can be quite effective (see Chapter 7 A General Approach to
the Ill or Injured Child ). Child life specialists, if available, are also a good
resource.
Inviting the parent to be in the room increases their level of confidence in the
provider and can improve their overall satisfaction with the visit. Most parents
want to be present during wound repair in the ED, and most can be a stabilizing
force if properly oriented. The parent can reassure or distract the child with a

story while maintaining physical contact under necessary drapes and restraints. It
is usually best if the parent is sitting down and focusing on the child, rather than
directly observing the procedure.


Appropriate use of sedation and local anesthetics is essential for successful
repair of lacerations in some children. Some younger children can undergo repair
after being placed in a restraining device, such as a papoose board, or wrapping
the child securely but comfortably in a bedsheet for better immobilization.
Restraint is needed to ensure the child’s safety and allow for more rapid
completion of the procedure. Because the child may get excessively warm while
being restrained, it is important to ensure proper ventilation and assess the child’s
comfort during the restraint process. A caring, but firm assistant is often needed
to further immobilize the injured body part and complete the procedure
successfully. It is better to use such hospital personnel instead of parents to
immobilize a child. A school-age child can usually cooperate without restraint.
Some children may require procedural sedation and/or anesthesia depending on
the type, extent and location of the wound, and the child’s age and level of
development (see Chapter 129 Procedural Sedation ). Some extensive wounds
may warrant more significant repair that is best accomplished with surgical
consultation and possible intraoperative repair.
Minimizing Risk of Infection. Hair near the wound usually creates minimal
difficulty during repair. Shaving the hair in the area of the wound may damage
hair follicles and increase risk of infection. If necessary to facilitate repair, the
hair should be clipped with scissors. Alternatively, petroleum jelly can be used to
keep unwanted scalp hair away from the wound while suturing. Hair over the
eyebrows should never be removed because this may lead to abnormal or slow
regrowth.
It is essential to clean the wound periphery at the time of wound evaluation.
Povidone-iodine solution (a 10% standard solution) is often used because it is a

safe and effective antimicrobial with little tissue toxicity. This solution may be
diluted with saline 1:10 to create a 1% solution. Use of chlorhexidine or
povidone-iodine surgical scrub preparations, hydrogen peroxide, or alcohol in the
wound itself is not recommended. These may be irritating to tissues and may
injure white cells, increasing the risk of infection.
Wound irrigation is extremely important to reduce bacterial contamination,
remove any particular matter, and prevent subsequent infection. It is often
necessary to anesthetize the wound before thoroughly cleansing. Using universal
precautions, the wound should be irrigated with normal saline, approximately 100
mL/cm of laceration. More may be needed if the wound is unusually large or
contaminated. Use a large syringe (20 to 60 mL) with a splash guard (commonly
20-gauge bore) attached to the end to reduce splatter during the irrigation. With