Pediatric emergency medicine trisk 3375 3375

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.