Pediatric emergency medicine trisk 844

FIGURE 110.1 A seemingly superficial laceration at the wrist might be treated simply by closure of the subcutaneous tissue and skin, unless one appreciates the abnormal posture of a finger when the hand is at rest The loss of normal flexor tone as a result of a divided superficial tendon results in the involved finger lying in a position of relative extension Patients found to have vascular, nerve, or tendon injury or deep, extensive wounds to the face warrant consultation with a surgical specialist for possible repair in the operating room Management Decision to Close the Wound Most wounds may be closed primarily, meaning the wound edges are approximated as soon as possible after the injury to speed healing and improve the cosmetic result If primary closure is delayed, the risk of subsequent infection increases Some authors suggest that the “golden period” for wound closure is hours However, wounds at low risk for infection (e.g., a clean kitchen knife injury) can be closed even 12 to 24 hours after the injury Most wounds of the face are best closed primarily, even up to 24 hours after injury to achieve an optimal cosmetic effect If the wound is extensive or has a high potential for infection (e.g., a dog bite), thorough irrigation is essential, and in cases of extensive or complex wounds, the operating room may be the best site for this repair Conversely, wounds at high risk for infection such as those in anatomic locations with poor blood supply, contaminated or crush wounds, and those involving immunocompromised hosts should be closed promptly, within hours of injury Some contaminated wounds (e.g., animal or human bites or those occurring on a farm) in an immunocompromised host should not be sutured, even if the patient presents immediately for care Some wounds should be allowed to heal by secondary intention (secondary closure), although scar formation may be more unsatisfactory Infected wounds, ulcers, and many animal bites are best left to heal by granulation and reepithelialization Human bites over the metacarpophalangeal joints (clenched-fist bites) are especially prone to infection and risk infection with primary closure Puncture wounds to the foot, with only a small laceration and a low concern for cosmetic results, may also be left open A small sterile wick of iodoform gauze may be placed inside the wound to keep the edges open This gauze can be removed after to days, and the subsequent granulation tissue will aid healing TABLE 110.2 WOUND ASSESSMENT—GENERAL PRINCIPLES Primary survey—control bleeding Secondary survey—other injury? History Mechanism Age of wound—time of injury Possible foreign body Environment Health status—tetanus immunization Physical examination Location Muscle function Tendon involvement Vascular injury Nerve injury Foreign material Laboratory Consider radiographs or ultrasound if a foreign body or fracture is suspected If a wound is not closed initially, delayed primary closure (tertiary closure) can be considered after the risk of infection decreases, about to 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 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 Appropriate use of sedation and local anesthetics is essential for successful repair of lacerations in some children Some younger children can undergo repair after being placed in a restraining device, such as a papoose board, or wrapping the child securely but comfortably in a bedsheet for better immobilization Restraint is needed to ensure the child’s safety and allow for more rapid completion of the procedure Because the child may get excessively warm while being restrained, it is important to ensure proper ventilation and assess the child’s comfort during the restraint process A caring, but firm assistant is often needed to further immobilize the injured body part and complete the procedure successfully It is better to use such hospital personnel instead of parents to immobilize a child A school-age child can usually cooperate without restraint Some children may require procedural sedation and/or anesthesia depending on the type, extent and location of the wound, and the child’s age and level of development (see Chapter 129 Procedural Sedation ) Some extensive wounds may warrant more significant repair that is best accomplished with surgical consultation and possible intraoperative repair Minimizing Risk of Infection Hair near the wound usually creates minimal difficulty during repair Shaving the hair in the area of the wound may damage hair follicles and increase risk of infection If necessary to facilitate repair, the hair should be clipped with scissors Alternatively, petroleum jelly can be used to keep unwanted scalp hair away from the wound while suturing Hair over the eyebrows should never be removed because this may lead to abnormal or slow regrowth It is essential to clean the wound periphery at the time of wound evaluation Povidone-iodine solution (a 10% standard solution) is often used because it is a safe and effective antimicrobial with little tissue toxicity This solution may be diluted with saline 1:10 to create a 1% solution Use of chlorhexidine or povidone-iodine surgical scrub preparations, hydrogen peroxide, or alcohol in the wound itself is not recommended These may be irritating to tissues and may injure white cells, increasing the risk of infection Wound irrigation is extremely important to reduce bacterial contamination, remove any particular matter, and prevent subsequent infection It is often necessary to anesthetize the wound before thoroughly cleansing Using universal precautions, the wound should be irrigated with normal saline, approximately 100 mL/cm of laceration More may be needed if the wound is unusually large or contaminated Use a large syringe (20 to 60 mL) with a splash guard (commonly 20-gauge bore) attached to the end to reduce splatter during the irrigation With ... 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... 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