Pediatric emergency medicine trisk 3371 3371

unfavorable appearance to the healed wound. Injuries that occurred in a field,
farm, or a wet, swampy area may have high bacterial loads.
The patient’s health status and past medical history should be addressed to
determine if there are additional risk factors for poor healing. If the patient has
diabetes, immunosuppression, malnutrition, or other chronic conditions, such as
cyanotic heart disease, chronic respiratory problems, or renal insufficiency, higher
infection rates may be anticipated. Bleeding disorders and current medications
should be determined because some drugs, such as corticosteroids, may also have
an impact on wound healing. A history of allergies to latex, antibiotics, and local
anesthetics, as well as the child’s tetanus status should be determined.
Physical Examination. A careful physical examination is essential before giving
local anesthesia. First, determine whether there is an associated injury distant
from the obvious wound. It is important to assess the wound for vascular damage
and to control bleeding if present. Brisk flow of blood may indicate injury to a
major vessel. This vessel can usually be safely tamponaded and later ligated or
sutured. The source must be identified, although it is often obscured by profuse
bleeding. Pressure applied to the site or temporary use of a tourniquet or inflated
blood pressure cuff (less than 2 hours) can help control hemorrhage and allow for
identification of the bleeding vessel. Blind clamping of an artery should be
avoided except in the scalp. Palpation of pulses and capillary refill distal to the
site of injury must be checked.
Next, potential nerve damage must be assessed. For example, in a cooperative
child, the provider should always test the median and ulnar nerves of an injured
upper extremity. If a young child does not permit this, sensation may be tested
with use of pinprick. Fortunately, when sensation is intact, motor function of the
nerve is usually also intact.
Next, the wound must be evaluated for possible tendon injury. The superficial
location of extensor tendons of the dorsum of the hand predisposes them to injury.
Tendon injuries are sometimes visible if the wound is wide and deep. For
example, a torn tendon on the flexor surface of the forearm may be seen when the
patient with a laceration to the wrist is asked to flex the hand and wrist. Unless

the tendon injury is obvious, wounds over joints and tendons should be put
through a full range of motion. A young patient may not be cooperative enough to
flex and extend the fingers on command. Therefore, it is important to inspect the
resting position of the injured hand in a young child to note a flexor tendon injury
to the finger. One digit may be found extended at rest, while the other uninjured