Pediatric emergency medicine trisk 845

the splash guard just above the skin surface, the clinician should apply firm pressure to the plunger This technique is usually capable of generating to lb/psi which is considered ideal pressure for wound irrigation Some institutions may have splash guards that attach directly to the bottle of saline Consider warming the saline before irrigation because this may be more comfortable Tap water is equally effective at irrigating wounds without increasing risk for infection Soaking the injured body part should be avoided because this may lead to maceration of the wound and edema Scrubbing the wound should be reserved for particularly “dirty” wounds in which contaminants are not effectively removed with irrigation alone Use topical or infiltrative anesthetics for pain control before scrubbing It may be necessary to extract some foreign material with fine forceps if it remains adherent after copious irrigation This will avoid tattooing of the skin and reduce the risk of infection In rare cases, the wound must be extended with a scalpel to allow proper exploration and cleaning The provider should consider trimming small amounts of tissue in irregular lacerations and excising necrotic skin but should not make dramatic changes in the wound Devitalized tissue should be removed only if it looks ischemic or is otherwise clearly indicated If more extensive debridement is deemed necessary, consultation with a surgical specialist is recommended Subcutaneous fat can be safely and easily removed if it interferes with wound closure It is wise to remove such fat carefully, in small quantities, to avoid disruption of small vessels and cutaneous nerve branches Avoid removal of facial fat because this may leave an unsightly depression Debridement is advantageous because it creates well-defined wound edges that can be more easily opposed However, excessive removal of tissue can create a defect that is difficult to close or may increase tension at the wound margin such that scarring is more likely Examine the wound further after cleansing and debridement After exploration, it is wise to reevaluate the decision to close the wound primarily When proceeding further, emergency providers should wash their hands before donning gloves Sterile gloves are still commonly utilized, although some studies report no increased risk of infection with nonsterile gloves Sterile masks not reduce the risk of wound infections, but a facial splash shield is useful to protect the clinician The area surrounding the wound should be appropriately draped before wound repair However, if a young child is particularly upset by facial drapes, they can be omitted Proper cleaning of the wound is more important to uncomplicated healing than meticulous attempts to avoid introduction of small numbers of bacteria by preserving a sterile field Type of Suture/Equipment Suture material must have adequate strength while producing minimal inflammatory reaction Nonabsorbable sutures such as monofilament nylon (Ethilon) or polypropylene (Prolene) retain most of their tensile strength for more than 60 days and are relatively nonreactive Thus, they are appropriate for closing the outermost layer of a laceration With nylon, it is important to secure the knot adequately with at least four to five throws per knot Polypropylene is useful for lacerations in the scalp or eyebrows because it has a blue color that is more visible and thus easier to remove, although it has memory and therefore is somewhat more difficult to control while suturing Silk is rarely used because of increased tissue reactions and infection Absorbable sutures are also used in some wounds Absorbable synthetic sutures such as Dexon, Monocryl, or Vicryl should be used in deeper, subcuticular layers These materials may elicit an inflammatory response and may extrude from the skin before they are absorbed, if they are placed too close to the skin When subcuticular sutures are used, they should be placed on the deeper surface of the dermis, and epithelial margins may be approximated with either tape strips or cuticular sutures Synthetic absorbable sutures are less reactive than chromic gut and retain their tensile strength for long periods, making them useful in areas with high dynamic and static tensions Absorbable sutures are also advantageous for intraoral lacerations Some recommend using rapidly absorbable sutures (e.g., fast-absorbing gut or Vircyl rapide ) for skin closure of facial wounds in children to avoid the need for subsequent suture removal Equally acceptable cosmetic results are found with absorbable sutures compared with nonabsorbable sutures in pediatric facial laceration repair Some hand specialists also advocate for absorbable sutures for hand lacerations in young children since removing them can be quite difficult in uncooperative young patients A 3-0 suture is recommended for tissues with strong tension, such as fascia, and 4-0 is recommended for deep tissues with light tension, such as subcutaneous tissue Skin is best closed with 4-0 to 7-0 and oral mucosa with 3-0 to 4-0 sutures The emergency provider should use the finest sutures (6-0) for wounds of the face; heavier sutures for scalp, trunk, and extremities (4-0 or 5-0); and 3-0 or 4-0 for thick skin, such as the sole of the foot, or over large joints, such as the knee Needles are available in various forms, including cuticular, plastics, and “reverse cutting.” The reverse cutting needle is used most for laceration repair Its outer edge is sharp to allow for atraumatic passage of the needle through the relatively tough dermal and epidermal layers; this minimizes cutting of the skin where suture tension is the greatest A higher-grade plastic needle (designated P or PS) is often used for repairs on the face A small needle (e.g., P3) should be used for wounds that require fine cosmesis Needles come in various sizes such as 3/8 and 1/2 circle Clinicians may develop a preference for a specific needle However, in general, a 3/8 reverse cutting needle satisfies most needs Closure Techniques Two of the most important goals of suturing are to match the layers of the injured tissues and to create eversion of the wound margins so they will flatten as the wound heals Layers on one side of a wound should be sutured to the corresponding, matching layers on the other side First, all layers of skin that have been injured should be identified Then, an attempt to oppose each layer (muscles, fascia, subcutaneous tissue, and skin) as nearly as possible back to its original location should be made This is achieved by carefully matching the depth of the bite taken on each side of the wound when suturing Proper suture placement should result in slight eversion of the wound so there is not a depressed scar when remodeling takes place Eversion may be achieved by slight thumb pressure on the wound edge as the needle is entering the opposite side Sutures should take equal bites from both wound edges so one margin does not overlap the opposite margin when the knot is tied Wound edge eversion is best achieved by taking proper bites while suturing, not by pulling the knot tightly ( Fig 110.2 ) Suture placement may be deep or superficial Deep sutures reapproximate the dermal layers of skin and not penetrate the epidermis They help relieve skin tension and improve the cosmetic appearance by reducing the width of the scar They should be avoided in wounds prone to infection because they will further increase this risk To place a deep suture, the needle is placed at the depth of the wound and removed at a more superficial level The needle is then inserted superficially into the opposite side of the wound and exits deeply so the knot is buried within the wound The needle end and free end of the suture should be on the same side of the loop before the knot is tied ( Fig 110.3 ) The simple interrupted technique (described next) with absorbable suture material should be used FIGURE 110.2 Suturing technique for wound edge eversion Superficial or percutaneous sutures are passed through the dermis and epidermis and leave the knot visible at the skin surface Skin should be closed with a minimal amount of tension Sutures should be pulled tightly enough to approximate the wound edges, but not so tightly that they cause tissue necrosis Sutures that seem well placed initially may begin to cut into the tissue in the next few days because of swelling and inflammation There is no need to tightly close the skin if other layers have been well sutured Scalp wounds are an exception They are under considerable tension, and the knots in this location should be pulled firmly to keep the skin together The wound will be hidden by hair, so the ... acceptable cosmetic results are found with absorbable sutures compared with nonabsorbable sutures in pediatric facial laceration repair Some hand specialists also advocate for absorbable sutures for... subcutaneous tissue Skin is best closed with 4-0 to 7-0 and oral mucosa with 3-0 to 4-0 sutures The emergency provider should use the finest sutures (6-0) for wounds of the face; heavier sutures for