Pediatric emergency medicine trisk 847

to cm away from the wound edge deeply into the wound It is then passed through the opposite side and reenters the wound parallel to the initial suture To avoid “buckling” and to provide some eversion of the wound edges, the skin must be entered perpendicularly, and the wound must be entered and exited at the same depth ( Fig 110.8 ) FIGURE 110.8 The horizontal mattress stitch is useful for closing the deep layer in shallow lacerations and in body areas with little subcutaneous tissue Certain dyed suture materials may cause a tattooing of the skin if placed in such a shallow position (From Grisham J Wound care In: Dieckmann RA, Fiser DH, Selbst SM, eds Illustrated Textbook of Pediatric Emergency & Critical Care Procedures St Louis, MO: Mosby; 1997:678, reprinted with permission.) The modified horizontal mattress stitch (half-buried) is often used to close a flap It is also called the corner stitch It relieves intrinsic tension and avoids vascular compromise when approximating the tip of the flap Using 5-0 or 6-0 sutures, the provider should enter intact skin across from the apex of the flap and exit the wound just below the subcuticular plane The needle should be brought to the tip of the flap, entering and exiting at the subcuticular plane Then, the needle is brought across the edge of the flap in the subcuticular plane and the skin is exited A knot should be tied in the usual manner and the tip of the flap brought to the apex of the wound ( Fig 110.9 ) Placing the needle in the flap edge first can be done to repair wounds in which there is ample perfusion to the flap The edge of the flap can then be moved back and forth until proper alignment with the opposite fixed side is obtained After the tip of the flap is sutured, the sides of the flap are brought together Care must be taken to ensure there is no tension on sutures at the tip of the flap For wounds with several stellate flaps, subcuticular sutures should be used to hold the tips of the flap together Then, a single suture at the tip will provide good apposition without further damage Other interrupted sutures can be placed on the lateral margins of the wound to provide further support If the wound has many narrowbased stellate flaps or necrotic flap tips, the wound may be better managed with excision and simpler repair ( Fig 110.10 ) Surgical specialty consultation should be considered in these complex wound repairs FIGURE 110.9 The corner stitch Also called the half-buried horizontal mattress stitch, this technique allows repair of flap-type lacerations without further compromising blood flow Place additional simple interrupted sutures along the sides of the flap if necessary (From Grisham J Wound care In: Dieckmann RA, Fiser DH, Selbst SM, eds Illustrated Textbook of Pediatric Emergency & Critical Care Procedures St Louis, MO: Mosby; 1997:676, reprinted with permission.) FIGURE 110.10 Variation in laceration injuries and suggestions for management: Simple laceration (A ), elliptical excision of damaged wound margins (B ), excision and closure of stellate laceration (C ,D ), and flap-type laceration (E ) Staples can be applied more rapidly than sutures and have a lower rate of infection, with less of a foreign-body reaction They are best for wounds of the scalp, trunk, and extremities when saving time is important and cosmesis is less of a concern Therefore, they are particularly helpful when treating mass casualties, or when restraining a patient with a suitable wound is challenging Staples are left in place for the same length of time as sutures They are somewhat more painful to remove and should be removed with a specially designed instrument to avoid tissue damage Staples not allow for meticulous cosmetic repair as with sutures Thus, they should not be used for lacerations of the face, neck, hands, or feet They should also not be used if the patient requires magnetic resonance imaging (MRI) or computed tomography (CT) Painless Alternatives to Sutures Skin tape causes no suture marks, minimal tissue reaction, and fewer wound infections than sutures Tape strips, cut to size, can be used to take up tension at the wound margins and can be placed between sutures, or can be placed over absorbable sutures for additional protection These strips are also useful as the only means to close simple lacerations that extend just through the dermis They may be as useful as tissue adhesives for facial lacerations in children Multiple tangential, triangular skin flaps (e.g., those created when an unrestrained passenger hits the windshield of a car) are closed well with tape strips Likewise, old or contaminated wounds, such as dog bites on the extremities, can be loosely approximated with skin tape When tape is used, the wound should be cleansed as any other wound Care must be taken to properly realign the dermis and epithelium If the tape is pulled too tightly, the margins of the wound may overlap, causing the wound to heal with a raised ridgelike area where the overlap occurred The tape is applied perpendicularly across the wound with some space between to allow the wound to drain An adhesive such as benzoin can keep the strips more secure if it is applied to the adjacent skin (not the wound) and allowed to dry before applying the tape strips Importantly, benzoin can cause intense burning sensation if it comes into contact with the wound and should be applied at least to mm away from the wound edge but within a reaching distance of the tape Some recommend leaving the taped wound uncovered because a bandage may increase moisture and cause the tape to fall off prematurely Tape strips should not be used on wounds subject to tension, such as those over flexor surfaces of joints They should not be applied in areas of the body that are moist, such as the palms or axillae, because they will not adhere They may be ... (From Grisham J Wound care In: Dieckmann RA, Fiser DH, Selbst SM, eds Illustrated Textbook of Pediatric Emergency & Critical Care Procedures St Louis, MO: Mosby; 1997:676, reprinted with permission.)