Pediatric emergency medicine trisk 842

Children with minor trauma should be assessed for any associated
serious injuries and wound management should not preempt care of
more life-threatening injuries.
A thorough evaluation includes learning the mechanism of injury, the
age of the wound, determining if there is a retained foreign body, and a
careful physical examination that includes assessing for any associated
injuries.
All wounds should be examined before and after cleansing to
determine the best plan for repair.
All wounds heal by scarring but the goal is to minimize their
appearance.
The use of absorbable sutures in pediatrics is favored in certain
situations, as it avoids an additional procedure of suture removal.
The use of topical anesthetics, anxiolysis, child life specialists, and
distraction techniques can all be helpful and effective to facilitate wound
repair.
Maximize patient and parent satisfaction by setting expectations on
length of stay, providing timely care, optimizing cosmetic results,
minimizing pain, and avoiding infection.
RELATED CHAPTERS
Resuscitation and Stabilization
A General Approach to the Ill or Injured Child: Chapter 7
Medical, Surgical, and Trauma
Infectious Disease Emergencies: Chapter 94
ENT Trauma: Chapter 106
Genitourinary Trauma: Chapter 108
Hand Trauma: Chapter 109
Ocular Trauma: Chapter 114
Procedures and Appendices
Procedural Sedation: Chapter 129
Procedures: Chapter 130

The Children’s Hospital of Philadelphia Clinical Pathway
Clinical Pathway for Evaluation/Treatment of Child With a
Laceration
URL: />Authors: S. Fesnak, MD; E. Friedlander, MD; E. Lichtman, RN
Posted: February 2019

GENERAL PRINCIPLES OF MINOR WOUND REPAIR
The goals of wound repair are to obtain hemostasis, prevent infection, minimize
pain, and achieve optimal cosmetic outcomes.

Obtaining Hemostasis
Hemostasis is important not only to prevent ongoing bleeding but also for clear
wound visualization prior to any repair. Application of direct pressure with gauze
is the fastest and most commonly used technique to obtain hemostasis. If there is
continued bleeding, applying a blood pressure cuff or tourniquet proximal to the
wound for a short period is acceptable. Injecting a local anesthetic with a
vasoconstrictor such as epinephrine can help with hemostasis and can be safely
used in areas of end-organ blood supply (e.g., digits, ear, nose, penis) despite
traditional warnings of caution.

Prevention of Infection
Bacteria inhabit normal intact skin. This is the usual source of infection when
skin tissue is disrupted. The amount of bacteria on the skin varies by anatomic
location. High counts of bacteria are in moist areas such as the axilla and
perineum, as well as in areas of exposed skin such as the hands, face, and feet.
Low counts of bacteria exist in dry areas such as the back, chest, and abdomen.
Areas colonized with high bacterial contamination are most prone to infection.
Wounds in regions of high vascularity, such as the scalp and face, are less prone

to bacterial infection despite the high bacteria count. The oral cavity is highly
contaminated with bacteria, and this is an important source of infection when a
child sustains a bite wound.
Wounds inflicted by shearing forces with a sharp object such as a knife cause
minimal devitalization of adjacent areas and thus are less likely to lead to
infection. Wounds caused by a blunt object striking the skin at an angle of less
than 90 degrees result in a tension injury such as an avulsion or flap. These
injuries involve a larger force applied to the skin than that of a shearing injury,


and frequently there is more devitalized tissue. Therefore, these wounds are more
likely to become infected and are often more difficult to repair. Finally,
compression injuries from blunt trauma perpendicular to the skin cause the most
tissue disruption and devitalization. These wounds are characterized by ragged
edges, and lead to the highest infection rates and risk of scarring.

Cosmesis and Wound Healing
Normal skin is under constant tension due to high collagen content. Tension is
also produced by underlying structures such as joints and muscles. The amount of
tension varies by anatomic location and position of a body part. Lacerations that
run parallel to joints and follow Langer lines of skin tension usually heal more
quickly and with better cosmetic results. Wounds under a large amount of tension,
crossing joints, or perpendicular to wrinkle lines may heal with wide, or more,
visible scars.
Lacerations regain about 5% of their previous strength 2 weeks after injury,
30% after 1 to 2 months, and full tensile strength 6 to 8 months after the original
injury. Many factors, such as infection, tissue edema, and poor nutrition, may
delay this progression.
All wounds deeper than the dermis have the potential for scar formation. Scar
formation involves the laying down of collagen, which is a complex process

essential in restoring tensile strength of the skin. Collagen synthesis begins within
48 hours of the injury and reaches a peak within the following week. Anything
that interferes with collagen synthesis, such as infection, may lead to wound
dehiscence at this time. Tissue contraction is expected with all healing wounds
through the action of fibroblasts. Therefore, eversion of suture lines is desired at
the time of repair so the skin will contract to become flat after healing.
Remodeling may occur for up to 12 months. The scar may fade and recede over
the first 3 months, and the final appearance of the scar may not be apparent until
6 to 9 months after injury.

Parental Satisfaction
In general, there are many factors that influence parental and patient satisfaction
with ED experience. In the case of lacerations, as in any pain-inducing condition,
parents are concerned that their child’s pain, both at presentation and during any
repair, is addressed properly. Additionally, parents are almost always concerned
about the cosmetic outcome of the wound, particularly in the case of facial
lacerations. Communicating information about the healing process, the nature of
the wound, and the expected cosmetic outcome, as well as the timeline for
complete healing can help prevent dissatisfaction.


Rate of Wound Infection After Repair
The rate of wound infection is reported between 2% and 10%. Decreasing the
likelihood of infection can help prevent additional morbidity and optimize
cosmesis, as wounds that are infected during the healing process are more likely
to scar. Efforts to reduce the risk of infection can be achieved by proper
techniques discussed throughout the chapter.

Current Evidence
Lacerations account for 30% to 40% of all injuries in a pediatric ED. Blunt

trauma with sufficient force or contact with sharp objects causes the majority of
lacerations. Animal bites account for the remainder. More than 40% of the
wounds involve a fall. Boys are injured twice as often as girls. The mechanism of
injury varies with the patient’s age. In younger children, falls and accidents are
classic mechanisms; violent encounters are more likely in older children.
Two-thirds of the injuries occur during warm weather months, although half of
injuries in urban environments occur indoors. Serious morbidity or mortality from
minor lacerations is rare; however, complications occur in nearly 10%. Children
are less likely to get wound infections compared with adults. In children, the
infection rate is about 2% for all sutured wounds. The risk of infection increases
if there is a delay in primary closure.
Absorbable sutures for the repair of facial lacerations in children can be used to
avoid the need for suture removal. Data support that these sutures have equally
acceptable cosmetic outcomes in facial lacerations.
In pediatrics, it is important to consider painless alternatives to sutures in some
cases. These include tape strips and tissue adhesives (i.e., skin glue). Tape strips
have the advantage of not leading to marks in the skin, minimal tissue reaction,
and fewer wound infections than sutures. Skin glue has been demonstrated in
multiple studies to have cosmetic results that are comparable to those of sutures
for low-tension wounds.
There are no proven benefits to the use of routine oral antibiotics to prevent
wound infection and their use is controversial. The risk of antibiotic use from
allergic reaction to growth of resistant organisms may outweigh the benefits.
Antibiotics should be routinely considered for wounds with high risk of infection
such as bites, devitalized tissue, and heavily contaminated wounds.
The immunization and tetanus status of a patient with a wound should always
be obtained and guidelines for tetanus prophylaxis followed, which is discussed
later in the chapter ( Table 110.1 ).

Clinical Considerations