1. Trang chủ
  2. » Kinh Tế - Quản Lý

Pediatric emergency medicine trisk 850

4 2 0

Đang tải... (xem toàn văn)

THÔNG TIN TÀI LIỆU

Thông tin cơ bản

Định dạng
Số trang 4
Dung lượng 86,44 KB

Nội dung

Vertical forehead lacerations tend to have a more visible scar because they traverse the skin tension lines Complex forehead wounds, such as stellate lacerations from windshield impact and those with tissue loss, particularly secondary to animal bites, may require consultation with a plastic surgeon Forehead lacerations are rarely associated with skull fractures, but facial or intracranial injuries should be ruled out Eyebrow Lacerations Eyebrow lacerations are common Repairing an eyebrow laceration is complicated by the presence of hair It is advisable not to shave the eyebrow for wound preparation because it serves as a landmark during repair Also, eyebrow regrowth is unpredictable; it may be either slow or incomplete, potentially leading to poor cosmetic outcome Debridement, if required, should be minimal and along the same axis of the hair shafts to avoid damage to hair follicles; otherwise, alopecia of the brow will result Closure with simple interrupted stitches using nonabsorbable material is usually sufficient Attention must be paid to avoid inverting the hair-bearing edges into the wound It is also important to pay attention to proper alignment of both ends of a wound along an eyebrow Eyelid Lacerations Most eyelid lacerations are simple transverse wounds of the upper eyelid just inferior to the eyebrow Repairing these wounds does not require any special skills Well-approximated lacerations in the transverse crease of the eyelid will heal well if left alone However, recognizing complicated eyelid lacerations is crucial for proper repair and optimal outcome (see Chapter 114 Ocular Trauma ) Vertical lacerations involving the lid margin require precision in approximation to avoid deformity and malfunction of the eyelid Injuries potentially involving the levator palpebrae muscle, medial canthal ligament, or lacrimal duct should be considered for ophthalmology referral A high index of suspicion for lacrimal duct injury is particularly important when evaluating a medially positioned lower eyelid laceration If not repaired, inferior duct injury may lead to chronic tearing as the lower lacrimal duct is the main drain of tears from the conjunctival sac Evaluation for an associated injury of the globe is a must, particularly if periorbital fat is exposed or tarsal plate penetration is present (see Chapter 114 Ocular Trauma ) External Ear Blunt Trauma and Lacerations Although the ears are subject to trauma because of their exposed position, lacerations involving the ears are rather rare The auricle contains a cartilaginous structure that provides the framework for the complex shape of the ear The perichondrium covering the cartilage provides it with nutrients and oxygen Traumatic separation of the cartilage from the perichondrium may lead to necrosis, leaving the auricle deformed The overlying skin is thin but well vascularized Skin flaps with small pedicles often survive and should not be hastily debrided Simple auricular lacerations can be repaired without consultation To avoid chondritis, approximation of the skin is important so no cartilage is exposed It is imperative to avoid catching the auricular cartilage with the needle tip because the skin and perichondrium are in close proximity to each other Occasionally, debridement of the cartilage is needed to obtain complete coaptation of the wound; however, cartilage debridement should be kept to a minimum and only performed by providers comfortable with this type of repair Complex auricular lacerations with significant skin damage and involvement of the auricular cartilage can be difficult to repair and may require consultation with a surgical specialist In general, when repairing auricular cartilage, 5-0 absorbable sutures should be used to approximate the edges Landmarks of the auricle should be used for proper alignment The perichondrium should be included in the sutures so the suture material does not tear through the friable cartilage and also to ensure restoration of nutrient and oxygen supply For the same reason, excessive tension should be avoided Closure of the skin should follow as described previously If the laceration involves the anterior and posterior aspects of the ear, closure of the posterior aspect first is recommended To avoid a deep scar line (notching) in repairing the earlobe or the auricular rim, the skin edges should be everted at the time of closure because fibrotic tissue will eventually pull the scar line down, leading to notching For partial avulsion or total amputation of the ear, make every effort to reattach the amputated part because tissue survival and cosmetic outcome are often favorable Furthermore, blunt ear trauma can lead to a simple contusion or a significant subperichondrial hematoma that can comprise the auricular cartilage Classically, a significant perichondrial hematoma is tense and appears as smooth ecchymotic swelling that disrupts the normal contour of the auricle This injury is particularly common among wrestlers Auricular hematoma should be promptly drained to avoid necrosis of the cartilage and deformed auricle or cauliflower ear (see Chapter 106 ENT Trauma ) After repair of ear lacerations or evacuation of an auricular hematoma, a pressure dressing should be applied Follow-up in 24 hours to evaluate vascular integrity to the area is recommended Nasal Lacerations Blunt injuries to the nose are much more common than lacerations When a nasal laceration results from blunt trauma, careful evaluation of underlying nasal bones and examination for a nasal septal hematoma are essential Other associated injuries, such as facial bone fractures or injuries to the orbit, should also be ruled out The skin overlying the nose is taut and stiff Approximating the edges of simple, nongaping nasal wounds, mostly along the upper half of the nose, is usually straightforward Wounds with any gaping, commonly in the lower part of the nose, can be difficult to coapt because of the nature of the skin in this location The suture material can tear through the skin easily Absorbable subcutaneous stitches are recommended before skin closure to relieve tension and prevent tearing through the wound edges Skin closure should be with simple interrupted 6-0 absorbable material Early removal of the sutures is advised for the same reason Full-thickness nasal lacerations involving the alae nasi or entering the vestibule require layered closure The procedure should start with the nasal mucosa, using absorbable material and finish with the skin, preferably using continuous subcuticular suture technique The nasal cartilage, when involved, rarely requires sutures When alignment is difficult, a few fine sutures (Vicryl or plain catgut) will help hold it in place When the free rim of the nare is involved, precise alignment is imperative for good cosmetic outcome For complex nasal lacerations, lacerations associated with fractures, or when there is tissue loss, consultation with a surgical specialist is recommended Lip Lacerations Lip lacerations are a particular concern because of the importance of the lip as a facial landmark The lip is a vascular structure with multiple layers The vermilion border, the junction of the dry oral mucosa and facial skin, serves as an important landmark for proper repair when involved The vermilion border is easily identified by its relative pallor compared to the neighboring lip and skin Therefore, the use of epinephrine with local anesthesia should be avoided so the landmark is not obscured When parted, the vermilion border should be precisely reapposed using a 6-0 suture The buccal mucosal surface is then closed with 5-0 absorbable material, followed by the skin, using 6-0 nonabsorbable sutures Fastabsorbing gut is also an alternative when suture removal is likely to be challenging The parents should be warned that, while the lip is still anesthetized, there is a chance that the child will bite the sutures off and that they should distract the child from doing so In general, lip lacerations should be closed in layers, depending on the depth of the wound In full-thickness lip lacerations, a three-layer repair is required The emergency provider should begin with the oral mucosa, using 5-0 absorbable material, followed by the orbicularis oris muscle layer to include the inner and outer fibrofatty layers, and finish with the skin, using 6-0 nonabsorbable or fastabsorbing gut, interrupted sutures Small wounds, less than cm, on the inner aspect of the lip without communication to the skin surface need not be repaired External lip wounds not communicating with the mucosal surface can be closed by either single- or double-layer closure, depending on the depth and degree of gaping of the wound Absorbable sutures (5-0) for the subcutaneous layer and either absorbable or nonabsorbable (6-0) sutures for closure of the skin can be used, depending on the ease with which they can be removed Extensive lip injuries with tissue loss or those caused by electric burns, especially those that involve the angle of the mouth, should be referred to a plastic surgeon Associated injuries such as dental trauma, mandibular fractures, and closed head injuries should be ruled out Cheek Lacerations When managing lacerations involving the cheeks, the provider must evaluate the integrity of the underlying structures The parotid gland and duct, the facial nerve, and the labial artery are in close proximity to the surface of the skin and can be injured, often as a result of an animal bite If parotid gland or duct injury is identified, consultation with a surgical specialist is advised Puncture wounds resulting from animal bites should be debrided and irrigated thoroughly Some of these puncture wounds are better off left without closure to reduce infection rate, especially if the cosmetic outcome is unlikely to be compromised Otherwise, simple interrupted 6-0 absorbable sutures can be used to close uncomplicated lacerations of the cheeks Tongue Lacerations The tongue is a vascular and muscular organ Tongue lacerations often hemorrhage excessively in the beginning, but the bleeding usually ceases quickly as the lingual muscle contracts Controversy exists surrounding the indications for closure, which is in part related to the challenge of repair given the inaccessibility of these wounds Most tongue lacerations can be left alone with good results However, large lacerations involving the free edge may heal with a notch causing dysfunction of the tongue Generally, this type of laceration should be repaired Large flaps and lacerations that continue to bleed or are likely to become contaminated with food ... the depth of the wound In full-thickness lip lacerations, a three-layer repair is required The emergency provider should begin with the oral mucosa, using 5-0 absorbable material, followed by

Ngày đăng: 22/10/2022, 11:08

TÀI LIỆU CÙNG NGƯỜI DÙNG

  • Đang cập nhật ...

TÀI LIỆU LIÊN QUAN