Pediatric emergency medicine trisk 845

the splash guard just above the skin surface, the clinician should apply firm
pressure to the plunger. This technique is usually capable of generating 5 to 8
lb/psi which is considered ideal pressure for wound irrigation. Some institutions
may have splash guards that attach directly to the bottle of saline. Consider
warming the saline before irrigation because this may be more comfortable. Tap
water is equally effective at irrigating wounds without increasing risk for
infection. Soaking the injured body part should be avoided because this may lead
to maceration of the wound and edema.
Scrubbing the wound should be reserved for particularly “dirty” wounds in
which contaminants are not effectively removed with irrigation alone. Use topical
or infiltrative anesthetics for pain control before scrubbing. It may be necessary to
extract some foreign material with fine forceps if it remains adherent after
copious irrigation. This will avoid tattooing of the skin and reduce the risk of
infection.
In rare cases, the wound must be extended with a scalpel to allow proper
exploration and cleaning. The provider should consider trimming small amounts
of tissue in irregular lacerations and excising necrotic skin but should not make
dramatic changes in the wound. Devitalized tissue should be removed only if it
looks ischemic or is otherwise clearly indicated. If more extensive debridement is
deemed necessary, consultation with a surgical specialist is recommended.
Subcutaneous fat can be safely and easily removed if it interferes with wound
closure. It is wise to remove such fat carefully, in small quantities, to avoid
disruption of small vessels and cutaneous nerve branches. Avoid removal of facial
fat because this may leave an unsightly depression. Debridement is advantageous
because it creates well-defined wound edges that can be more easily opposed.
However, excessive removal of tissue can create a defect that is difficult to close
or may increase tension at the wound margin such that scarring is more likely.
Examine the wound further after cleansing and debridement. After exploration,
it is wise to reevaluate the decision to close the wound primarily. When
proceeding further, emergency providers should wash their hands before donning
gloves. Sterile gloves are still commonly utilized, although some studies report no

increased risk of infection with nonsterile gloves. Sterile masks do not reduce the
risk of wound infections, but a facial splash shield is useful to protect the
clinician. The area surrounding the wound should be appropriately draped before
wound repair. However, if a young child is particularly upset by facial drapes,
they can be omitted. Proper cleaning of the wound is more important to
uncomplicated healing than meticulous attempts to avoid introduction of small
numbers of bacteria by preserving a sterile field.


Type of Suture/Equipment. Suture material must have adequate strength while
producing minimal inflammatory reaction. Nonabsorbable sutures such as
monofilament nylon (Ethilon) or polypropylene (Prolene) retain most of their
tensile strength for more than 60 days and are relatively nonreactive. Thus, they
are appropriate for closing the outermost layer of a laceration. With nylon, it is
important to secure the knot adequately with at least four to five throws per knot.
Polypropylene is useful for lacerations in the scalp or eyebrows because it has a
blue color that is more visible and thus easier to remove, although it has memory
and therefore is somewhat more difficult to control while suturing. Silk is rarely
used because of increased tissue reactions and infection.
Absorbable sutures are also used in some wounds. Absorbable synthetic
sutures such as Dexon, Monocryl, or Vicryl should be used in deeper,
subcuticular layers. These materials may elicit an inflammatory response and may
extrude from the skin before they are absorbed, if they are placed too close to the
skin. When subcuticular sutures are used, they should be placed on the deeper
surface of the dermis, and epithelial margins may be approximated with either
tape strips or cuticular sutures. Synthetic absorbable sutures are less reactive than
chromic gut and retain their tensile strength for long periods, making them useful
in areas with high dynamic and static tensions. Absorbable sutures are also
advantageous for intraoral lacerations. Some recommend using rapidly
absorbable sutures (e.g., fast-absorbing gut or Vircyl rapide ) for skin closure of

facial wounds in children to avoid the need for subsequent suture removal.
Equally acceptable cosmetic results are found with absorbable sutures compared
with nonabsorbable sutures in pediatric facial laceration repair. Some hand
specialists also advocate for absorbable sutures for hand lacerations in young
children since removing them can be quite difficult in uncooperative young
patients.
A 3-0 suture is recommended for tissues with strong tension, such as fascia,
and 4-0 is recommended for deep tissues with light tension, such as subcutaneous
tissue. Skin is best closed with 4-0 to 7-0 and oral mucosa with 3-0 to 4-0 sutures.
The emergency provider should use the finest sutures (6-0) for wounds of the
face; heavier sutures for scalp, trunk, and extremities (4-0 or 5-0); and 3-0 or 4-0
for thick skin, such as the sole of the foot, or over large joints, such as the knee.
Needles are available in various forms, including cuticular, plastics, and
“reverse cutting.” The reverse cutting needle is used most for laceration repair. Its
outer edge is sharp to allow for atraumatic passage of the needle through the
relatively tough dermal and epidermal layers; this minimizes cutting of the skin
where suture tension is the greatest. A higher-grade plastic needle (designated P


or PS) is often used for repairs on the face. A small needle (e.g., P3) should be
used for wounds that require fine cosmesis. Needles come in various sizes such as
3/8 and 1/2 circle. Clinicians may develop a preference for a specific needle.
However, in general, a 3/8 reverse cutting needle satisfies most needs.
Closure Techniques. Two of the most important goals of suturing are to match
the layers of the injured tissues and to create eversion of the wound margins so
they will flatten as the wound heals. Layers on one side of a wound should be
sutured to the corresponding, matching layers on the other side. First, all layers of
skin that have been injured should be identified. Then, an attempt to oppose each
layer (muscles, fascia, subcutaneous tissue, and skin) as nearly as possible back to
its original location should be made. This is achieved by carefully matching the

depth of the bite taken on each side of the wound when suturing.
Proper suture placement should result in slight eversion of the wound so there
is not a depressed scar when remodeling takes place. Eversion may be achieved
by slight thumb pressure on the wound edge as the needle is entering the opposite
side. Sutures should take equal bites from both wound edges so one margin does
not overlap the opposite margin when the knot is tied. Wound edge eversion is
best achieved by taking proper bites while suturing, not by pulling the knot tightly
( Fig. 110.2 ).
Suture placement may be deep or superficial. Deep sutures reapproximate the
dermal layers of skin and do not penetrate the epidermis. They help relieve skin
tension and improve the cosmetic appearance by reducing the width of the scar.
They should be avoided in wounds prone to infection because they will further
increase this risk. To place a deep suture, the needle is placed at the depth of the
wound and removed at a more superficial level. The needle is then inserted
superficially into the opposite side of the wound and exits deeply so the knot is
buried within the wound. The needle end and free end of the suture should be on
the same side of the loop before the knot is tied ( Fig. 110.3 ). The simple
interrupted technique (described next) with absorbable suture material should be
used.


FIGURE 110.2 Suturing technique for wound edge eversion.

Superficial or percutaneous sutures are passed through the dermis and
epidermis and leave the knot visible at the skin surface. Skin should be closed
with a minimal amount of tension. Sutures should be pulled tightly enough to
approximate the wound edges, but not so tightly that they cause tissue necrosis.
Sutures that seem well placed initially may begin to cut into the tissue in the next
few days because of swelling and inflammation. There is no need to tightly close
the skin if other layers have been well sutured. Scalp wounds are an exception.

They are under considerable tension, and the knots in this location should be
pulled firmly to keep the skin together. The wound will be hidden by hair, so the