Pediatric emergency medicine trisk 849

previous tetanus immunizations but the wound is not a clean, minor laceration,
tetanus toxoid is indicated if the last dose was more than 5 years prior.
In many cases, the tetanus immunization record is unknown. If tetanus status is
unknown or the patient has received less than three doses of tetanus and the
wound is not clean or minor, tetanus toxoid and tetanus immunoglobulin (TIG)
are indicated. Wounds involving massive tissue destruction and contamination
may also require TIG (see Table 110.1 ). Patients with such wounds should be
admitted to the hospital.

Wound Aftercare
Careful discharge instructions regarding wound care, covering the wound, when it
is ok to get the wound wet, and how to dry it are extremely important. A
summary of discharge instructions is provided in Table 110.4 . The family should
be informed about signs of infection. Specifically, they should be told to return
for medical care if the wound develops increasing pain, redness, edema, and/or
wound discharge, or if the child develops a fever. Analgesics such as ibuprofen
and acetaminophen may be given for minor pain, but worsening pain should
always prompt a wound check. The family should also be informed that the
wound was carefully inspected, and there is still a possibility of a retained foreign
body or an undetected injury that may require further treatment.
Parents should be told that no matter how skillful the repair, every laceration
leaves some scar. The appearance of the scar will change during the next several
months, and the scar’s appearance will not be complete for about 6 to 12 months.
Studies have not shown any specific ointments or creams to be helpful in scar
reduction. What has been shown is that less sun exposure will help reduce scar
formation and hyperpigmentation. Therefore, generous application of sunscreen
for at least 6 months is crucial for optimal results during wound healing.


TABLE 110.4
DISCHARGE INSTRUCTIONS FOR WOUND CARE

1. Keep the wound clean and as dry as possible for the first 24 hrs. The skin
around the wound may be cleaned gently.
2. After 24 hrs, the child may shower and dry the wound gently and completely.
3. Avoid any activities that will keep the wound soaked in water (e.g.,
swimming and a bath) until sutures are removed.
4. Consider oral pain medications.
5. Provide instructions for topical or oral antibiotics if they are recommended
for the patient.
6. If a splint is applied, it should be kept on, clean and dry.
7. Sunscreen may be applied after the wound heals, to minimize pigment
changes.
8. Watch for signs of wound infection and dehiscence.
9. Arrange follow-up for recheck as needed.
Most wounds can be followed up at the time of suture removal. Those wounds
requiring close follow-up (at 24 to 48 hours) include those that are contaminated,
those with tenuous vascular supply, and those showing any signs of infection.
Wounds closed with tape strips do not require removal of the tape because these
will fall off spontaneously. The family should be instructed to trim any edge of
adhesive tape as it lifts off the skin, but not pull the strips off. Tissue adhesive
also sloughs spontaneously. However, nonabsorbable sutures should be removed
at the appropriate time, depending on the location of the injury. The importance
of timely removal should be stressed to the patient and family. Removing sutures
too early may lead to dehiscence and widening of the scar. Sutures left in too long
may create an unnecessary tissue reaction and result in visible cross-hatching
(“railroad ties”).
Wounds on the scalp or face are nourished by a better blood supply and
generally exhibit more rapid healing. Sutures in these areas are removed more
quickly than other locations to avoid unsightly tracts.
When sutures are subject to considerable tension (over joints and on the
hands), they should be left in place longer ( Table 110.5 ). After removal of

sutures, it may be necessary to reinforce the healing wound with tape strips to
prevent dehiscence.


TABLE 110.5
SUTURE REMOVAL TIMING
Wound location

Time of removal (days)

Neck
Face
Scalp
Upper extremities,
trunk
Lower extremities
Joint surface

3–4
4–5
7–10
7–10
8–10
10–14

As discussed previously, in the first 12 to 24 hours, wound dressings should be
changed only if wet or soiled. After that, gentle washing can be permitted as long
as the wound is then patted rather than rubbed dry and covered again. There is no
proven harm to exposing the sutures to soap and water for short periods of time.

MANAGEMENT OF SPECIFIC WOUNDS
The principles of wound care discussed earlier should be applied in repairing any
of the wounds discussed in the following section. These principles include
evaluation of the wound by history, physical examination, and when indicated,
radiographic or ultrasound imaging. After the wound is evaluated, the feasibility
of closure and the possible need for consultation with a surgical specialist should
be considered. The following section discusses some of the commonly
encountered wounds in children.

Facial and Oral Wounds
CLINICAL PEARLS AND PITFALLS


Appearing unhurried and confident, giving the child, when age
appropriate, some control of the situation, and explaining the upcoming
procedure can help reduce anxiety.
Use of distraction techniques and anxiolytics can avoid the need for
procedural sedation.
Tap water can be used instead of saline and is equally effective in
reducing the risk of infection.
Using 6-0 absorbable material is recommended for skin closure
whenever possible and obviates the need for suture removal at followup.
No specific ointments or creams have been found to be helpful in scar
reduction. However, application of sunscreen after the wound heals
may decrease hyperpigmentation of the forming scar.
The use of epinephrine with local anesthesia during lip laceration repair
could obscure the vermilion border landmark.
The eyebrow should not be shaved during wound preparation as
regrowth is unpredictable.
If the frontalis muscle is involved and is not properly approximated, its

function (eyebrow elevation) could be disrupted.
In repairing the earlobe or auricular rim, if the skin edges are not
everted at the time of closure, “notching” may occur.

Forehead Lacerations
Forehead lacerations are common in early childhood. These injuries commonly
occur after falls on objects or furniture such as coffee tables. Most of these
lacerations are simple and not associated with any other significant injuries.
However, careful evaluation of the head and neck for other injuries is warranted.
Superficial transverse lacerations of the forehead usually have a favorable
cosmetic outcome. Closure with simple or continuous cuticular sutures using 6-0
absorbable material is recommended. Deeper transverse lacerations involving the
deep fascia, frontalis muscle, or periosteum should be repaired in layers.
Absorbable 5-0 material such as Monocryl, coated Vicryl, or gut can be used. If
the deeper tissue plains are not closed, the function of the frontalis muscle, that is,
eyebrow elevation, may be hampered. Other facial expressions can also be
affected because the skin may tether to the scar tissue, bridging the unrepaired
gaping tissues.