Pediatric emergency medicine trisk 842

Children with minor trauma should be assessed for any associated serious injuries and wound management should not preempt care of more life-threatening injuries A thorough evaluation includes learning the mechanism of injury, the age of the wound, determining if there is a retained foreign body, and a careful physical examination that includes assessing for any associated injuries All wounds should be examined before and after cleansing to determine the best plan for repair All wounds heal by scarring but the goal is to minimize their appearance The use of absorbable sutures in pediatrics is favored in certain situations, as it avoids an additional procedure of suture removal The use of topical anesthetics, anxiolysis, child life specialists, and distraction techniques can all be helpful and effective to facilitate wound repair Maximize patient and parent satisfaction by setting expectations on length of stay, providing timely care, optimizing cosmetic results, minimizing pain, and avoiding infection RELATED CHAPTERS Resuscitation and Stabilization A General Approach to the Ill or Injured Child: Chapter Medical, Surgical, and Trauma Infectious Disease Emergencies: Chapter 94 ENT Trauma: Chapter 106 Genitourinary Trauma: Chapter 108 Hand Trauma: Chapter 109 Ocular Trauma: Chapter 114 Procedures and Appendices Procedural Sedation: Chapter 129 Procedures: Chapter 130 The Children’s Hospital of Philadelphia Clinical Pathway Clinical Pathway for Evaluation/Treatment of Child With a Laceration URL: https://www.chop.edu/clinical-pathway/laceration-clinical-pathway Authors: S Fesnak, MD; E Friedlander, MD; E Lichtman, RN Posted: February 2019 GENERAL PRINCIPLES OF MINOR WOUND REPAIR The goals of wound repair are to obtain hemostasis, prevent infection, minimize pain, and achieve optimal cosmetic outcomes Obtaining Hemostasis Hemostasis is important not only to prevent ongoing bleeding but also for clear wound visualization prior to any repair Application of direct pressure with gauze is the fastest and most commonly used technique to obtain hemostasis If there is continued bleeding, applying a blood pressure cuff or tourniquet proximal to the wound for a short period is acceptable Injecting a local anesthetic with a vasoconstrictor such as epinephrine can help with hemostasis and can be safely used in areas of end-organ blood supply (e.g., digits, ear, nose, penis) despite traditional warnings of caution Prevention of Infection Bacteria inhabit normal intact skin This is the usual source of infection when skin tissue is disrupted The amount of bacteria on the skin varies by anatomic location High counts of bacteria are in moist areas such as the axilla and perineum, as well as in areas of exposed skin such as the hands, face, and feet Low counts of bacteria exist in dry areas such as the back, chest, and abdomen Areas colonized with high bacterial contamination are most prone to infection Wounds in regions of high vascularity, such as the scalp and face, are less prone to bacterial infection despite the high bacteria count The oral cavity is highly contaminated with bacteria, and this is an important source of infection when a child sustains a bite wound Wounds inflicted by shearing forces with a sharp object such as a knife cause minimal devitalization of adjacent areas and thus are less likely to lead to infection Wounds caused by a blunt object striking the skin at an angle of less than 90 degrees result in a tension injury such as an avulsion or flap These injuries involve a larger force applied to the skin than that of a shearing injury, and frequently there is more devitalized tissue Therefore, these wounds are more likely to become infected and are often more difficult to repair Finally, compression injuries from blunt trauma perpendicular to the skin cause the most tissue disruption and devitalization These wounds are characterized by ragged edges, and lead to the highest infection rates and risk of scarring Cosmesis and Wound Healing Normal skin is under constant tension due to high collagen content Tension is also produced by underlying structures such as joints and muscles The amount of tension varies by anatomic location and position of a body part Lacerations that run parallel to joints and follow Langer lines of skin tension usually heal more quickly and with better cosmetic results Wounds under a large amount of tension, crossing joints, or perpendicular to wrinkle lines may heal with wide, or more, visible scars Lacerations regain about 5% of their previous strength weeks after injury, 30% after to months, and full tensile strength to months after the original injury Many factors, such as infection, tissue edema, and poor nutrition, may delay this progression All wounds deeper than the dermis have the potential for scar formation Scar formation involves the laying down of collagen, which is a complex process essential in restoring tensile strength of the skin Collagen synthesis begins within 48 hours of the injury and reaches a peak within the following week Anything that interferes with collagen synthesis, such as infection, may lead to wound dehiscence at this time Tissue contraction is expected with all healing wounds through the action of fibroblasts Therefore, eversion of suture lines is desired at the time of repair so the skin will contract to become flat after healing Remodeling may occur for up to 12 months The scar may fade and recede over the first months, and the final appearance of the scar may not be apparent until to months after injury Parental Satisfaction In general, there are many factors that influence parental and patient satisfaction with ED experience In the case of lacerations, as in any pain-inducing condition, parents are concerned that their child’s pain, both at presentation and during any repair, is addressed properly Additionally, parents are almost always concerned about the cosmetic outcome of the wound, particularly in the case of facial lacerations Communicating information about the healing process, the nature of the wound, and the expected cosmetic outcome, as well as the timeline for complete healing can help prevent dissatisfaction Rate of Wound Infection After Repair The rate of wound infection is reported between 2% and 10% Decreasing the likelihood of infection can help prevent additional morbidity and optimize cosmesis, as wounds that are infected during the healing process are more likely to scar Efforts to reduce the risk of infection can be achieved by proper techniques discussed throughout the chapter Current Evidence Lacerations account for 30% to 40% of all injuries in a pediatric ED Blunt trauma with sufficient force or contact with sharp objects causes the majority of lacerations Animal bites account for the remainder More than 40% of the wounds involve a fall Boys are injured twice as often as girls The mechanism of injury varies with the patient’s age In younger children, falls and accidents are classic mechanisms; violent encounters are more likely in older children Two-thirds of the injuries occur during warm weather months, although half of injuries in urban environments occur indoors Serious morbidity or mortality from minor lacerations is rare; however, complications occur in nearly 10% Children are less likely to get wound infections compared with adults In children, the infection rate is about 2% for all sutured wounds The risk of infection increases if there is a delay in primary closure Absorbable sutures for the repair of facial lacerations in children can be used to avoid the need for suture removal Data support that these sutures have equally acceptable cosmetic outcomes in facial lacerations In pediatrics, it is important to consider painless alternatives to sutures in some cases These include tape strips and tissue adhesives (i.e., skin glue) Tape strips have the advantage of not leading to marks in the skin, minimal tissue reaction, and fewer wound infections than sutures Skin glue has been demonstrated in multiple studies to have cosmetic results that are comparable to those of sutures for low-tension wounds There are no proven benefits to the use of routine oral antibiotics to prevent wound infection and their use is controversial The risk of antibiotic use from allergic reaction to growth of resistant organisms may outweigh the benefits Antibiotics should be routinely considered for wounds with high risk of infection such as bites, devitalized tissue, and heavily contaminated wounds The immunization and tetanus status of a patient with a wound should always be obtained and guidelines for tetanus prophylaxis followed, which is discussed later in the chapter ( Table 110.1 ) Clinical Considerations ... throughout the chapter Current Evidence Lacerations account for 30% to 40% of all injuries in a pediatric ED Blunt trauma with sufficient force or contact with sharp objects causes the majority... Data support that these sutures have equally acceptable cosmetic outcomes in facial lacerations In pediatrics, it is important to consider painless alternatives to sutures in some cases These include