previous tetanus immunizations but the wound is not a clean, minor laceration, tetanus toxoid is indicated if the last dose was more than years prior In many cases, the tetanus immunization record is unknown If tetanus status is unknown or the patient has received less than three doses of tetanus and the wound is not clean or minor, tetanus toxoid and tetanus immunoglobulin (TIG) are indicated Wounds involving massive tissue destruction and contamination may also require TIG (see Table 110.1 ) Patients with such wounds should be admitted to the hospital Wound Aftercare Careful discharge instructions regarding wound care, covering the wound, when it is ok to get the wound wet, and how to dry it are extremely important A summary of discharge instructions is provided in Table 110.4 The family should be informed about signs of infection Specifically, they should be told to return for medical care if the wound develops increasing pain, redness, edema, and/or wound discharge, or if the child develops a fever Analgesics such as ibuprofen and acetaminophen may be given for minor pain, but worsening pain should always prompt a wound check The family should also be informed that the wound was carefully inspected, and there is still a possibility of a retained foreign body or an undetected injury that may require further treatment Parents should be told that no matter how skillful the repair, every laceration leaves some scar The appearance of the scar will change during the next several months, and the scar’s appearance will not be complete for about to 12 months Studies have not shown any specific ointments or creams to be helpful in scar reduction What has been shown is that less sun exposure will help reduce scar formation and hyperpigmentation Therefore, generous application of sunscreen for at least months is crucial for optimal results during wound healing TABLE 110.4 DISCHARGE INSTRUCTIONS FOR WOUND CARE Keep the wound clean and as dry as possible for the first 24 hrs The skin around the wound may be cleaned gently After 24 hrs, the child may shower and dry the wound gently and completely Avoid any activities that will keep the wound soaked in water (e.g., swimming and a bath) until sutures are removed Consider oral pain medications Provide instructions for topical or oral antibiotics if they are recommended for the patient If a splint is applied, it should be kept on, clean and dry Sunscreen may be applied after the wound heals, to minimize pigment changes Watch for signs of wound infection and dehiscence Arrange follow-up for recheck as needed Most wounds can be followed up at the time of suture removal Those wounds requiring close follow-up (at 24 to 48 hours) include those that are contaminated, those with tenuous vascular supply, and those showing any signs of infection Wounds closed with tape strips not require removal of the tape because these will fall off spontaneously The family should be instructed to trim any edge of adhesive tape as it lifts off the skin, but not pull the strips off Tissue adhesive also sloughs spontaneously However, nonabsorbable sutures should be removed at the appropriate time, depending on the location of the injury The importance of timely removal should be stressed to the patient and family Removing sutures too early may lead to dehiscence and widening of the scar Sutures left in too long may create an unnecessary tissue reaction and result in visible cross-hatching (“railroad ties”) Wounds on the scalp or face are nourished by a better blood supply and generally exhibit more rapid healing Sutures in these areas are removed more quickly than other locations to avoid unsightly tracts When sutures are subject to considerable tension (over joints and on the hands), they should be left in place longer ( Table 110.5 ) After removal of sutures, it may be necessary to reinforce the healing wound with tape strips to prevent dehiscence TABLE 110.5 SUTURE REMOVAL TIMING Wound location Time of removal (days) Neck Face Scalp Upper extremities, trunk Lower extremities Joint surface 3–4 4–5 7–10 7–10 8–10 10–14 As discussed previously, in the first 12 to 24 hours, wound dressings should be changed only if wet or soiled After that, gentle washing can be permitted as long as the wound is then patted rather than rubbed dry and covered again There is no proven harm to exposing the sutures to soap and water for short periods of time MANAGEMENT OF SPECIFIC WOUNDS The principles of wound care discussed earlier should be applied in repairing any of the wounds discussed in the following section These principles include evaluation of the wound by history, physical examination, and when indicated, radiographic or ultrasound imaging After the wound is evaluated, the feasibility of closure and the possible need for consultation with a surgical specialist should be considered The following section discusses some of the commonly encountered wounds in children Facial and Oral Wounds CLINICAL PEARLS AND PITFALLS Appearing unhurried and confident, giving the child, when age appropriate, some control of the situation, and explaining the upcoming procedure can help reduce anxiety Use of distraction techniques and anxiolytics can avoid the need for procedural sedation Tap water can be used instead of saline and is equally effective in reducing the risk of infection Using 6-0 absorbable material is recommended for skin closure whenever possible and obviates the need for suture removal at followup No specific ointments or creams have been found to be helpful in scar reduction However, application of sunscreen after the wound heals may decrease hyperpigmentation of the forming scar The use of epinephrine with local anesthesia during lip laceration repair could obscure the vermilion border landmark The eyebrow should not be shaved during wound preparation as regrowth is unpredictable If the frontalis muscle is involved and is not properly approximated, its function (eyebrow elevation) could be disrupted In repairing the earlobe or auricular rim, if the skin edges are not everted at the time of closure, “notching” may occur Forehead Lacerations Forehead lacerations are common in early childhood These injuries commonly occur after falls on objects or furniture such as coffee tables Most of these lacerations are simple and not associated with any other significant injuries However, careful evaluation of the head and neck for other injuries is warranted Superficial transverse lacerations of the forehead usually have a favorable cosmetic outcome Closure with simple or continuous cuticular sutures using 6-0 absorbable material is recommended Deeper transverse lacerations involving the deep fascia, frontalis muscle, or periosteum should be repaired in layers Absorbable 5-0 material such as Monocryl, coated Vicryl, or gut can be used If the deeper tissue plains are not closed, the function of the frontalis muscle, that is, eyebrow elevation, may be hampered Other facial expressions can also be affected because the skin may tether to the scar tissue, bridging the unrepaired gaping tissues