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or long-term cosmesis or complications such as infection or wound dehiscence Additionally, caregivers had a significantly higher future preference for the absorbable sutures Tissue adhesives such as 2-octylcyanoacrylate have also demonstrated similar cosmesis, less pain, and shorter procedure times when compared to sutures for simple lacerations, but may have a slightly increased risk of wound dehiscence Regional Nerve Blocks CLINICAL PEARLS AND PITFALLS Important areas for regional nerve blocks on the face include the medial third of the eyebrow (supraorbital nerve), the infraorbital foramen (infraorbital nerve), and to cm above the inferior border of mandible (mental nerve) Clinical Considerations Local or regional anesthesia may be used to aid in the suturing of facial lacerations in children Regional anesthesia has the distinct advantage of allowing the physician to perform a painless procedure, without distorting the anatomic structures under repair In addition, regional blocks, in general, require fewer anesthetics (see Chapter 130 Procedures ) The supraorbital nerve exits the supraorbital rim in the medial third of the eyebrow approximately to cm from the facial midline Local infiltration in this region can effectively provide anesthesia to the ipsilateral hemiforehead The infraorbital nerve exits through the infraorbital foramen, approximately mm inferior to the infraorbital rim Effective block of this nerve can provide anesthesia to the ipsilateral medial cheek and upper lip Anesthesia of the lower lip and chin may be achieved by infiltration of the ipsilateral mental (infraoral) nerve This nerve exists approximately to cm superior to the inferior border of the mandible The supraorbital and infraorbital nerves, as well as the mental nerve, exit the facial skeleton from foramen, which are in-line with the first premolar tooth Guidelines for Subspecialty Consultation CLINICAL PEARLS AND PITFALLS Lacerations that require subspecialty consultation include those with injury to deep structures such as nerves or ducts, are associated with tissue loss, or that involve the cartilage of the ear or nose Clinical Considerations Most facial lacerations can be repaired by the pediatric emergency medicine physician Injuries that require subspecialist consultation include (i) lacerations with evidence of injury to deep structures (a major motor nerve or a glandular duct), (ii) cases in which a substantial amount of devitalized tissue exists or actual tissue loss has occurred, (iii) wounds in which the amount of bleeding cannot be easily controlled, (iv) full-thickness defects of the ear and nose that involve cartilage, and (v) cases in which it is unclear exactly which tissue to approximate to restore preinjury anatomy and aesthetics (e.g., lips, eyelids, nostrils, ears) Suggested Readings and Key References Goals of Emergency Therapy Druelinger L, Guenther M, Marchand EG, et al Radiographic evaluation of the facial complex Emerg Med Clin North Am 2000;18:393–410 Eggensperger Wymann NM, Holzle A, Zachariou Z, et al Pediatric craniofacial trauma J Oral Maxillofac Surg 2008;66:58–64 Imahara SD, Hopper RA, Wang J, et al Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank J Am Coll Surg 2008;207:710–716 Ryan ML, Thorson CM, Otero CA, et al Pediatric facial trauma: a review of guidelines for assessment, evaluation, and management in the emergency department J Craniofac Surg 2011;22:1183–1189 Vyas RM, Dickinson BP, Wasson KL, et al Pediatric facial fractures: current national incidence, distribution, and health care resource use J Craniofac Surg 2008;19:339–349 Facial Fractures Dogan S, Kalafat UM, Yüksel B, et al Use of radiography and ultrasonography for nasal fracture identification in children under 18 years of age presenting to the ED Am J Emerg Med 2017;35:465–468 Foulds JS, Laverick S, MacEwen CJ “White-eyed” blowout fracture: a case series of five children Arch Dis Child 2013;98:445–446 Gerbino G, Roccia F, Bianchi FA, et al Surgical management of orbital trapdoor fracture in a pediatric population J Oral Maxillofac Surg 2010;68:1310–1316 Lee DH, Jang YJ Pediatric nasal bone fractures: does delayed treatment really lead to adverse outcomes? Int J Pediatr Otorhinolaryngol 2013;77:726–731 Lee MH, Cha JG, Hong HS, et al Comparison of high-resolution ultrasonography and computed tomography in the diagnosis of nasal fractures J Ultrasound Med 2009;28:717–723 Miller AF, Elman DM, Aronson PL, et al Epidemiology and predictors of orbital fractures in children Pediatr Emerg Care 2018;34:21–24 Paek SH, Jung JH, Kwak YH, et al Clinical decision rule to identify orbital wall facture among children: retrospective derivation and validation study Pediatr Emerg Care 2017 [Epub ahead of print] Yilmaz MS, Guven M, Kayabasoglu G, et al Efficacy of closed reduction for nasal fractures in children Br J Oral Maxillofac Surg 2013;51:e256–e258 Soft Tissue Injuries Al-Abdullah T, Plint AC, Fergusson D Absorbable versus nonabsorbable sutures in the management of traumatic lacerations and surgical wounds: a metaanalysis Pediatr Emerg Care 2007;23:339–344 Farion KJ, Osmond MH, Hartling L, et al Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials Acad Emerg Med 2003;10:110–118 Karounis H, Gouin S, Esiman H, et al A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures Acad Emerg Med 2004;11:730–735 Khan AN, Dayan PS, Miller S, et al Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial Pediatr Emerg Care 2002;18:171–173 Luck RP, Flood R, Eyal D, et al Cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations Pediatr Emerg Care 2008;24:137–142 Luck R, Tredway T, Gerard J, et al Comparison of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations Pediatr Emerg Care 2013;29:691–695 CHAPTER 108 ■ GENITOURINARY TRAUMA R CALEB KOVELL, GREGORY E TASIAN, ROBERT A BELFER INTRODUCTION Genitourinary trauma in children is common with approximately 28,000 children presenting to emergency departments (EDs) in the United States annually with genitourinary injuries Approximately 10% of patients with serious multisystem trauma have genitourinary injuries and 3% of pediatric patients admitted with trauma will have a genitourinary injury Most injuries (90%) are the result of blunt trauma that involves crush injury and acceleration/deceleration forces related to motor vehicle collisions, and falls of high-velocity injuries such as sledding, skateboarding, or skiing The clinical approach to the injured child follows advanced trauma life support guidelines Figure 108.1 provides an algorithm for diagnostic evaluation of pediatric patients with genitourinary trauma Management of genitourinary injuries in the emergency setting generally involves fully identifying the location and extent of the injury, prevention of ongoing injury by establishing urinary drainage and planning for operative procedures, when necessary KEY POINTS The goal of emergency therapy for genitourinary injury is to maximize organ preservation and minimize future morbidity Assessment of the genitourinary system can be undertaken once lifethreatening conditions have been identified and the child has been resuscitated Management of hemodynamically stable children with renal injuries should proceed on the basis of radiographic staging of the traumatic injury RELATED CHAPTERS ... the ear or nose Clinical Considerations Most facial lacerations can be repaired by the pediatric emergency medicine physician Injuries that require subspecialist consultation include (i) lacerations... NM, Holzle A, Zachariou Z, et al Pediatric craniofacial trauma J Oral Maxillofac Surg 2008;66:58–64 Imahara SD, Hopper RA, Wang J, et al Patterns and outcomes of pediatric facial fractures in the... 2008;207:710–716 Ryan ML, Thorson CM, Otero CA, et al Pediatric facial trauma: a review of guidelines for assessment, evaluation, and management in the emergency department J Craniofac Surg 2011;22:1183–1189