wound management
DESCRIPTION
Wound managementTRANSCRIPT
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Wound ManagementKelly D. Black, MD, MSc,* Stephen John Cico, MD, MEd, Derya Caglar, MD
*Department of Pediatrics, University of South Dakota Sanford School of Medicine, and Department of Emergency
Medicine, Sanford USD Medical Center and Sanford Childrens Hospital, Sioux Falls, SD.Departments of Pediatrics and Family Medicine, University of South Dakota Sanford School of Medicine, and
Department of Emergency Medicine, Sanford USD Medical Center and Sanford Childrens Hospital, Sioux Falls, SD.Department of Pediatrics, University of Washington School of Medicine, and Department of Emergency Medicine,
Seattle Childrens Hospital, Seattle, WA.
Practice Gap:
Clinicians should be familiar with the principles of wound management,
including repair methods, risks for infection, tetanus prophylaxis, and
appropriate use of antibiotics and diagnostic studies.
Objectives After completing this article, the reader should be able to:
1. Identify important history and physical examination ndings
pertaining to wounds.
2. Know the indications for diagnostic studies in the management of
wounds.
3. Dene primary and secondary wound closure and know the
indications for each type of closure.
4. Understand the different anesthesia options for woundmanagement.
5. Know the different closure options and indications for the use of each
method of closure.
6. Recognize the importance of special care when treating wounds of
the lips, tongue and intraoral cavity, ears, and nailbeds.
7. Recognize the risk of infection related to bite wounds and the
indications for repair.
8. Understand the management of puncture wounds.
9. Know the indications for tetanus prophylaxis after sustaining
a wound.
10. Know the indications for antibiotics after sustaining a wound.
Abstract
The care of wounds is common in pediatric practice. Most simple wounds
can be handled by clinicians in the ofce or by trained emergency
AUTHOR DISCLOSURE Drs Black, Cico, andCaglar have disclosed no nancialrelationships relevant to this article. Thiscommentary does not contain a discussion ofan unapproved/investigative use ofa commercial product/device.
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medicine clinicians. Knowledge of appropriate wound care, wound repair
techniques, and judicious use of antibiotics for prophylaxis ensures the
best possible long-term outcomes. The following review describes
appropriate recommendations for acute and long-term wound care,
management, and special circumstances common to pediatric practice.
CASE
The parents of a 3-year-old boy bring their son to the pediatric
emergency department after he fell and hit his mouth on their
glass coffee table approximately 30 minutes ago. The child has
a laceration to his lower lip and tongue. The parents state that the
wounds initially were bleeding profusely but by applying pressure,
they were able to stop the bleeding. You examine the child and
take the history from the parents. The child has a past medical
history of ear infections with tympanostomy tube placement
under general anesthesia 1 year ago. He is otherwise healthy
and up to date on his immunizations. Physical examination
shows the child to be at his neurologic baseline without evidence of
other injuries. The parents ask if emergency department physi-
cians routinely repair these types of injuries or if a plastic surgeon
may be needed for the repair. You consider how to answer the
parents question while also wondering if both lacerations need to
be repaired and if the child will need to be sedated for the repair.
INTRODUCTION AND EPIDEMIOLOGY
Pediatric wounds are common presenting complaints in
primary care ofces, urgent care facilities, and emergency
departments. According to Centers for Disease Control and
Prevention (CDC) National Center for Health Statistics data,
more than 80 million ambulatory visits for injuries occurred
in 2009 through 2010. (1) In this same time period, 41million
visits for injuries occurred across United States emergency
departments. (1) According the CDCs web-based Injury
Statistics Query and Reporting System data for ages 0 to
18 years, more than 140,000 nonfatal dog bite injuries and
more than 528,000 nonfatal cut/pierce injuries occurred in
2012. (2) Rates of injuries to males were higher than injuries to
females in all categories. (2) An estimated 4.5 million dog bites
occur annually, half of which involve children, and one in ve
dog bites requires medical attention. (3) Dog bites occur more
often than cat bites and the two combined account for the
majority of nonhuman bite wounds.
Pediatric wounds tend to be categorized into three etiology-
based categories in the medical literature: injury-related
wounds, bites, and burns. Injury-related wounds include lac-
erations, avulsions, and punctures. This review examines
injury-related wounds and bites; chronic wounds are out-
side the scope of the article.
HISTORY AND PHYSICAL EXAMINATION FINDINGS
As with any diagnosis and evaluation, history and physical
examination ndings are important to the management and
outcome of wound repair. Key historical points are similar to
other conditions and include current medications, allergies,
immunization status, developmental stage, and coexisting
medical conditions. Developmental delays or chronic medical
conditions (eg, autism, collagen-vascular disease) may affect
the clinicians ability to repair the wound or alter wound
healing. Other key history items are the time elapsed since the
wound, mechanism of injury, and environment in which the
injury occurred to identify potential wound contamination.
Vital signs should be reviewed for indications of hem-
orrhage, such as unexplained tachycardia or hypotension.
The physical examination should include assessment for
neurovascular compromise, tendon injury, and underlying
fractures. Wounds should also be carefully inspected for
retained foreign bodies.
DIAGNOSTIC STUDIES
Diagnostic studies are rarely needed for thechildwith a simple
laceration or wound. However, indications do exist for both
radiographic imaging and laboratory studies in the acute
management of wounds. Laboratory studies may be indicated
if concerns arise, such as prolonged bleeding or difculty in
achieving hemostasis that may indicate an underlying disor-
der.However, studies are rarely needed in routinewound care.
Radiographs may be helpful if the clinician has concerns
about retained glass or metal. Ultrasonography can be par-
ticularly helpful to evaluate for a radiolucent foreign body or to
assist in removal of a foreign body during the procedure.
WOUND CLOSURE
PrimaryPrimary closure of a wound involves denitive repair at the
time of presentation. Generally, trainees are taught sterile
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technique for primary wound closure, but Ruthman et al
found that the use of surgical caps and masks did not
decrease the rate of infection for lacerations when compared
to their nonuse. (4) Sterile glove use also did not decrease
infection rates compared to nonsterile gloves, although the
use of powder-covered or dusted gloves, which are becom-
ing increasingly rare in the medical setting, is associated
with higher rates of infection compared to the more com-
monly used powder-free gloves. (5)
Most patients present early with traumatic wounds; only
1% to 2% present to the emergency department seeking care
for a wound that is more than 19 hours old. (6) One study
found no signicant difference in the rate of infection for
wounds that were repaired within 6 hours of occurrence
compared to those that were repaired more than 6 hours
after the injury occurred. (6) This is contrary to common
lore on wound repair passed down in medical training. The
best current recommendation for time to wound closure is
that wounds of the head and face should be closed whenever
they present to a clinician, assuming there is no evidence of
infection. Other wounds may be closed up to 19 hours after
their occurrence, which covers nearly 100% of wounds
encountered by clinicians.
Wound irrigation with tap water has been associated with
equivalent infection rates as irrigation with sterile normal
saline solutions in the pediatric population, (79) and these
two solutions are the standards for wound care in the
medical setting. Tap water remains themost common home
treatment of lacerations and wounds. High-pressure irriga-
tion (>8 psi) can be obtained with either syringe-driven
uids (2535 psi) or use of a standard faucet (45 psi). (7,10)
Standard-concentration povidone-iodine solution (10%) has
been found to be toxic to skin broblasts, and 1% diluted
solutions of povidone-iodine and hydrogen peroxide solu-
tions have not been denitively shown to be advantageous in
decreasing rates of infection compared with saline and tap-
water irrigation. (11)
SecondaryWound closure by secondary intention describes allowing
the laceration to heal naturally without any attempt at
primary wound closure. Allowing a laceration to heal by
secondary intention is a reasonable option for lacerations
that present late to the clinician. The rates of infection at
3 months postinjury, approximately 3% with good wound
care, are similar for small lacerations (
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ANESTHESIA
Anesthesia can be applied topically to open wounds. Lido-
caine, epinephrine, and tetracaine (LET) is commonly used
in laceration repair as a supplement or replacement for
injected lidocaine. Because of its delivery as a topical solu-
tion without use of needles, it can decrease anxiety and
increase cooperation of pediatric patients while still pro-
viding adequate analgesia. (16,17)
Intradermally injected lidocaine is the most commonly
used anesthetic agent in the emergency department. Its
duration of action is 60 to 90 minutes or 120 to 360minutes
if used with epinephrine. However, lidocaine with epineph-
rine should not be used in distal areas of the body, including
ngers, nose, ears, toes, and penis. (18) Pediatric maximum
doses are 4.5 mg/kg of lidocaine (1% lidocaine is 10 mg/mL),
butwhen used in combinationwith epinephrine, themaximal
dose is increased to 7 mg/kg. (1921) Delivery of the lidocaine
as a buffered solution, use of a small-gauge needle (25-gauge
or smaller), warming the lidocaine to body temperature, and
stimulation of the skin proximally to the injection site can all
decrease the pain associated with local inltration. (17,2224)
Other injectable anesthetics, such as bupivacaine and
prilocaine, have longer durations of action and can be used
in combination with lidocaine or as single agents.
Peripheral nerve blocks can be performed in cooperative
patients but typically require training to avoid nerve damage
or injection into accompanying vasculature. Digital nerve
blocks and facial nerve blocks can be helpful in the pediatric
population in controlling the immediate pain with which
patients present as well as pain associated with wound
repair. Ultrasonographic guidance is becoming more stan-
dard for regional blocks such as femoral nerve blocks and
seems to increase the effectiveness of the block compared to
traditional injection techniques. (17,25)
CLOSURE METHODS
Surgical TapesSurgical tapes are a fast, simple, relatively pain-free, and inex-
pensive method of wound closure. They do not require out-
patient physician follow-up for removal. They do not provide
signicant hemostasis nor do they adhere to areas of the body
withhair, such as scalp lacerations. (26) Surgical tapes should be
considered for simple linear lacerations over low-tensile areas of
the body, conditions for which they are likely underutilized.
Tissue AdhesivesRelatively painless, rapid application makes tissue adhesives,
also known as cyanoacrylate adhesives, ideal for pediatric
patients who sustain wounds that are uncomplicated and less
than 5 cm in length. (27) Although more expensive, tissue
adhesives are faster to apply and have similar cosmetic out-
comes as traditional sutures. (28) Tissue adhesives are often
preferred by families because of the decreased time spent for
the repair, lower perceived pain experienced by the patient,
and less need for postrepair follow-up visits. (26) When
applying the adhesive, careful approximation of wound edges
without bunching or overlapping can improve healing and
minimize scar formation.
Tissue adhesives are not appropriate for all locations.
Their use in areas of the body exposed tomoisture or friction
(mucous membranes or the hands and feet) and those in
areas of the body covered with hair can result in premature
sloughing of the tissue adhesive. Excessive exposure to soap
and water can also shorten adhesive-to-skin time by a day or
more. (29) Recent studies show that tissue adhesives are of
equivalent strength to sutures, but their application over
joints and other high-movement and -tension sites is not
recommended due to the risk of premature dehiscence.
Deep absorbable sutures may be used in conjunction with
tissue adhesives to relieve surface tension before applica-
tion. (26,30) Tissue adhesives may also be combined with
surgical tape for wound repair. Care must be used in the
periocular region to avoid iatrogenic eyelid gluing during
wound repair, especially in young children who may move
around during adhesive drying times. Application of petro-
leum jelly around the eye can prevent both leakage and this
complication. If adhesive does get in the eye or the eyelid is
glued shut, follow-up with ophthalmology and evaluation
for corneal abrasion must be considered. (31) Tissue adhe-
sives also have inherent antimicrobial properties, particu-
larly against Gram-positive organisms, (32) whichmay be an
advantage in the pediatric population.
Surgical StaplesEven with good analgesia, surgical staples can be painful to
insert and remove, making them less desirable for pediatric
laceration repair. However, they can be used in areas of high
tension and hair-covered areas such as the scalp. They can be
placed rapidly, which makes their use in uncooperative
children a good alternative to sutures, surgical tape, or
tissue adhesives. However, staples do not offer rigorous
wound edge approximation and, therefore, are not appro-
priate in many areas of the body. (33)
Hair Apposition TechniqueThe hair apposition technique (HAT) or hair tie technique
has been developed because cyanoacrylate adhesives to the
scalp slough prematurely due to hair. Using hair as short as
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1 cm, 10 to 15 strands on each side of a scalp laceration are
grabbed with pick-ups and twisted around each other. One
drop of cyanoacrylate adhesive is applied to the twisted hair
and allowed to dry. The native hair is used to approximate
the edges of the laceration while the tissue adhesive holds
the hair twist together. (34) The HAT technique has been
shown to perform as well as standard sutures and staples on
scalp lacerations in terms of healing and scarring (35,36) and
is associated with a faster procedure completion time, less
pain, (35,3739) and lower cost. (40) HAT also does not
require staple or suture removal. Clinicians must be mind-
ful not to apply too much tissue adhesive, which may result
in the hair tie remaining for weeks. Tissue adhesive is also
exothermic and theoretically may damage hair follicles and
prevent hair regrowth around the laceration. Getting the
adhesive in the wound itself may also affect future hair
growth at the laceration site. (34)
SuturesSutures are the gold standard of wound closure, offering the
most meticulous skin closure with good strength, particu-
larly on high-tension areas. They also allow for layered
closures of deep wounds and are often expected by patients
and families. However, proper use requires training, su-
tures can be painful even with the use of anesthetics, and
they may require follow-up for removal.
Training is required for suture placement with good
cosmetic outcomes. Care must be taken with the placement
of supercial sutures. If the sutures are too loose, the wound
may widen and lead to larger scar formation. If sutures are
placed too tightly, the woundmay have additional scarring at
the site of suture placement. The clinician must also leave
sufcient suture material to allow for easy removal when
placing nonabsorbable sutures.
Deep sutures are used below the dermis for closure and
approximation of subdermal tissues. Placing deep sutures
can help alleviate tension for surface sutures, close potential
space where hematomas can form, andmay improve overall
skin scarring appearance. (33,41) In contaminated wounds,
deep sutures have been shown to increase the risk of wound
infection in some studies, but this has not been found in
clean wounds. (42,43)
Simple interrupted sutures are the mainstay of surface
suture closure in the primary care and emergency setting.
A single loop of suture is placed through the dermis and
epidermis, allowing good wound edge eversion and approx-
imation. This suturing technique is relatively easy to learn
andmaster, the process is fast, and the sutures produce good
cosmetic outcomes. Running sutures are a variation on
simple sutures where the suture material is not cut.
Accordingly, these sutures are faster to place than simple
interrupted sutures. However, if a knot loosens or suture
breaks, the entire wound may dehisce. Mattress sutures can
help take tension off the wound edges by dispersing the
forces with additional bites of the skin. They can be used for
wounds that gape open or are under high tension. (33)
Suture material can be absorbable or nonabsorbable.
Examples of absorbable products are plain catgut, chromic
catgut, and polyglactin sutures. These are used for deep
sutures because they eventually are absorbed by the body
and do not need to be removed. The rst two are natural
monolaments and begin to lose their strength in approx-
imately 1 week; the synthetic polylament suture retains its
strength for 1 to 2 months.
Fast-absorbing gut sutures can be used for skin closure
on areas of the body that heal quickly (highly vascular areas
such as the face) and are under low tension. These sutures
are thinner than other natural absorbing sutures and begin
to lose tensile strength in 3 to 5 days. This makes them ideal
for pediatric patients with small linear facial wounds in
terms of timing of absorption and the lack of need for suture
removal. There seems to be no difference in long-term
scarring for lacerations repaired with absorbable versus
nonabsorbable sutures. (44)
Nonabsorbing sutures include nylon, polypropylene, silk,
and linen sutures. These retain their tensile strength for
months and require removal after the wound is healed. The
former two are synthetic and the latter two are natural polyla-
ment. Natural sutures cause more skin reactivity than syn-
thetic sutures, and polylament sutures are more prone to
increased rates of wound infection. (45,46) Suture type,
appropriate location, and time to removal are listed in Table 2.
SPECIAL SITUATIONS
Lip LacerationsThe approach to repair of lip lacerations depends on the
complexity of the wound and structures involved. The lip
consists of several layers: the skin, the vermilion border, and
the oral mucosa. The key to proper repair of a lip laceration
is precise alignment of the vermilion border because even
small deviations in this line can have major cosmetic
effects. (47)
Sensation to the upper lip is supplied by the infraorbital
nerve, while sensation to the lower lip is supplied by the
mental nerve. Regional anesthesia is ideal for repairing lip
lacerations because it provides appropriate anesthesia with-
out changing landmarks around the lip. (47) However, in
younger ormore anxious children, this type of blockmay not
be easily achieved and deeper anesthesia may be necessary.
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When repairing a lip laceration, the rst stitchmust align
exactly the edges of the vermilion border. Such alignment
may require several attempts, and the clinician should not
be afraid to place and remove sutures as needed until both
he or she and the family feel condent that cosmetic closure
has been achieved. Through-and-through lacerations should
be closed in layers with absorbable sutures, starting with
the mucosal layer, followed by the muscle layer and the
orbicularis oris, using absorbable sutures. For complicated
and deep lacerations, particularly involving the musculature,
consultation with plastic surgery may be warranted.
Mucosal lip lacerations often do not need to be sutured,
but they do need a full evaluation for foreign bodies, such as
tooth fragments. When closure is necessary for particularly
large lacerations or aps, absorbable sutures should be used.
Tongue and Intraoral LacerationsMost tongue and intraoral lacerations heal rapidly without
repair and do not warrant primary closure. Primary repair is
recommended for intraoral lesions that have a ap, may trap
food particles, and are more than 2 cm in length. Primary
repair of tongue lacerations should be considered for those
involving the tongue border, a large ap or gap in the tongue,
and muscle or all the way through the tongue; those that are
more than 1 cm in length or accompanied by profuse
bleeding; or those that may cause impaired speech (anterior
split in tongue). Tongue and intraoral wounds should be
repaired with absorbable 3-0 or 4-0 sutures, such as poly-
glatin or chromic gut.
Ear LacerationsTrauma to the ear can cause the formation of an auricular
hematoma, which can lead to an external ear deformity
(cauliower ear). This type of injury results from damage to
the underlying cartilage and is especially common among
wrestlers and boxers. The clinician should examine every
patient with an ear laceration for the presence of an auric-
ular hematoma. If present, it must be evacuated to allow for
proper healing of the structures of the ear. Treatment is with
needle aspiration or incision and drainage. A large-bore
needle is inserted at the point of maximal uctuance to
aspirate the hematoma. A scalpel with a #15 blade is used for
incision and drainage, with the incisionmeasuring less than
5 mm at the point of maximal uctuation. The hematoma is
drained, followed by copious irrigation. Regardless of the
chosen technique, a pressure dressing should be applied to
prevent reformation of a second hematoma. After placing
several 44 gauze pads on the posterior aspect of theauricle, multiple layers of soft gauze are placed on the
anterior aspect of the auricle. An elastic dressing is placed
around the head and tied to provide rm constant pressure.
The dressing should remain in place until the patient is
reassessed, preferably within 24 hours. (48)
Ear lacerations should be carefully examined for depth.
Supercial lacerations can easily be repaired in the ofce
setting, but the clinician should thoroughly examine any
deeper lacerations for cartilage involvement. If cartilage is
exposed, the patient may need subspecialist evaluation for
optimum cosmetic closure. Cartilage injuries often are
treated with a prophylactic course of antibiotics to prevent
superinfection.
Nailbed InjuriesInjuries to the ngertip and nail are common. The nail itself
plays an important role in normal hand function by protect-
ing the ngertip, providing counterforce to assist with pick-
ing up small objects, contributing to the tactile sensation of
the ngertip, and helping to regulate nger circulation.
Without careful repair of a nailbed laceration, nail deformity
is likely to occur, which can lead to long-term cosmetic and
functional disability. Subungual hematomas, which are
caused by bleeding under the nail plate, can occur after
a crush injury to the ngertip. Traditional approaches have
required removal of the nail, suture repair of any laceration,
and replacement of the nail (or substitute if the nail is
missing) into the eponychial fold. However, studies have
TABLE 2. Suture Type, Appropriate Location, and Time to Removal
LOCATION SUTURE TYPE SUTURE SIZE DURATION OF SUTURES
Face Monolament, fast-absorbing (fast-absorbing gut), or nonabsorbing(nylon, polypropylene)
5.0 or 6.0 45 days
Subcutaneous (deep) Monolament absorbable (plain or chromic catgut) or polylamentabsorbable (polyglactin)
4.0 or 5.0 N/A
Trunk Nonabsorbing (nylon, polypropylene) 4.0 or 5.0 710 days
Extremities Nonabsorbing (nylon, polypropylene) 4.0 or 5.0 1014 days
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shown that patients have equivalent outcomes when injuries
to the nailbed are managed with trephination alone or
trephination with nail removal and laceration repair. (49)
Trephination is performed bymaking a hole at the base of the
nail or in the center of the subungual hematoma, often via
cautery. A 2008 study found that nailbed repair performed
using a tissue adhesive was signicantly faster than suture
repair and provided similar cosmetic and functional results,
even several months after the original injury. (50)
Nailbed injuries can often be associated with fractures
and warrant special attention. Displaced fractures of the
distal phalangeal physis with overlying nailbed laceration
are considered open fractures. In some cases, the germinal
matrix can become trapped within the fracture site. This
complication should be suspected with any proximal nail
avulsion that involves widening of the dorsal distal phalan-
geal physis in children. (49) Proper treatment requires
removal of the nail plate, irrigation, debridement, admin-
istration of antibiotics, reduction of the fracture, and nailbed
repair and would likely benet from orthopedic consulta-
tion. Complications can include osteomyelitis, growth
arrest, and nail deformity.
Bite WoundsBite wounds are exceedingly common, affecting millions of
people throughout the world, with increased frequency in
young children. The vast majority of these bites are caused
by dogs and cats; dog bites account for more than two thirds
of all animal bites. In adults, they primarily affect the hands
and legs, but the face, neck, or head are frequently involved
in children because they are at the same height as a dogs
mouth. Cat bites account for only 3% to 15% of all animal
bites and usually affect the arms and face. (51) Human bites,
although less common, require special consideration in
management of wounds.
The risk of developing an infection and its severity are
both related to the type of animal, the location and size of the
bite, and the predominant organism in the saliva. Bites
involving the head and neck (particularly when they cause
skull fractures or damage to deeper structures in the neck
and chest) can frequently be accompanied by the rapid
development of severe infections, with bacteremia and
severe sequelae. The same is true of bites involving the
hands because of the complex structures beneath the skin.
The size of the wound is also critical; the risk of infection
increases substantially when wound size exceeds 3 cm. (52)
Although they are signicantly less frequent, cat bites are
more commonly complicated by infections, which occur in
30% to 80% of cases. Cats have sharper teeth that lead to
deeper inoculation of bacteria and subsequent soft-tissue
abscesses or septic arthritis. In contrast, dogs teeth are
broader and atter and cause lacerations that primarily
involve the supercial tissues, which are easier to disinfect.
For this reason, dog bites lead to infection in no more than
25% of cases. (53)
Regardless of their site, dog and cat bitewounds frequently
lead to polymicrobial infections due to aerobic and anaerobic
bacteria that primarily are animal oral ora but also from
the patients skin and environment. Top offenders include
Staphylococcus, Streptococcus, Pasteurella, Capnophytophaga,
and occasionalmixed anaerobes. AlthoughPasteurellamultocida
frequently is found in the mouths of dogs, this pathogen is
signicantly more common in infections associated with cat
bites because it is carried by 90% of cats. Bartonella henselae
is also typical of cats and kittens.
Human bites are the third leading cause of bites seen in
the emergency department (behind cats and dogs) and tend
to be polymicrobial, with anaerobes and aerobes represented
almost equally. Commonly isolated bacteria include Eikenella
corrodens and Staphylococcus, Streptococcus, and Corynebacte-
rium species. S aureus is isolated in up to 30% of infected
human bite wounds and is associated with some of the most
severe infections. In addition to the acute risk of localized
infection, human bites pose the potential for the transmis-
sion of systemic infections such as hepatitis B, which can be
life-threatening. The Infectious Diseases Society of America
clinical practice guidelines state that all human bite wounds
require antibiotic prophylaxis (Table 3), particularly when in
high-risk areas such as the hand (ie, clenched st).
The general management of bites is similar to that for
wounds of any origin. The site of the bite should be washed
thoroughly with water and any devitalized tissues debrided.
There is still no agreement as to whether clinically uninfected
wounds should be sutured immediately or left for 24 hours to
evaluate the possible development of infection. (53,54) The
need for tetanus and rabies prophylaxis should be reviewed
and antibiotics be prescribed empirically to decrease the risk
of wound infection (see Antibiotics section).
Puncture WoundsPuncture wounds, with or without a retained foreign body,
are a common presentation to the emergency department,
urgent care center, or physicians ofce, although most in-
dividuals who sustain a puncture wound never seek medical
care. Patients may treat the wound at home, and some may
develop an infection or realize that something is wrong when
they have increased drainage, redness, or swelling several days
later. Supercial puncture wounds without clinical contami-
nation or necrotic tissue can bemanagedwithout prophylactic
antibiotic coverage.Thewound shouldbe evaluatedby caregivers
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every 6 hours for the rst 48 hours and antibiotics started
if any signs of infection develop.
If the puncture wound has a retained foreign body,
consideration must be given to removal of the object. If
the object, such as a needle, nail, or gravel, is supercial,
removal is simple. The same steps as described for man-
agement of a delayed or contaminated wound should be
performed while removing the object. Deeper objects may
require imaging, deeper sedation, or surgical consultation.
Puncture wounds to the foot warrant special consideration.
When the puncture occurs through footwear, a small piece of the
shoe can be pushed deep into the tissues of the foot and become
a nidus of infection. S aureus and b-hemolytic streptococci are
common causes of skin and soft-tissue infections and can
produce wound infections after puncture. Gram-negative bacte-
ria also have been recovered from infected sites. Pseudomonas
aeruginosa is commonly isolated in patients who suffered plantar
puncture while wearing tennis shoes, perhaps due to the moist
inner sole of the shoe, which provides an excellent environment
for bacterial growth. Prophylactic antibiotics are typically not
warranted, but the clinician must provide adequate coverage for
these organisms if the wound becomes infected.
SEDATION
Laceration repair is a very common indication for procedural
sedation in children younger than 2 years of age. Depending
on the patients developmental age, temperament, and his-
tory as well as the location and complexity of the wound,
sedation may simply involve anxiolysis or the child may
require deeper sedation. The clinician must consider both
the childs and parents levels of anxiety, circumstances in the
emergency department, and duration of repair when creating
an appropriate and effective treatment plan.
Nonpharmacologic methods of anxiolysis (ie, distraction,
hypnosis) have been found to be highly effective and are
supported in a 2013 Cochrane review. (55) Child life special-
ists are especially helpful due to their training as well as their
ability to focus on comforting and distracting the child rather
than the technical aspects of the procedure. Preprocedure
preparation and basic explanations of what will happen
during the repair is helpful in forming family and child
expectations and can decrease the need for medications.
For relatively short procedures in anxious children,
midazolam (either oral or intranasal) or nitrous oxide may
provide sufcient effect. Midazolam can be given intranasally
(0.4mg/kg to amaximumdose of 10mg) or orally (0.5mg/kg
to a maximum dose of 15 mg) with good effect. For longer or
more complicated repairs (eg, vermillion border, facial, lay-
ered closures), a deeper level of anesthesia (ie, ketamine or
propofol) should be considered to allow for adequate cosmetic
closure. All deeper levels of anesthesia should be provided by
clinicians trained and credentialed to provide anesthesia for
the pediatric patient with appropriate safety measures.
TETANUS
Tetanus immunization status should be reviewed with any
wound. Although any open wound is a potential source for
tetanus infection, those contaminated with dirt, soil, feces,
or saliva are at increased risk. Puncture wounds, crush
injuries, avulsions, burns, and necrotic tissues are particularly
conducive to tetanus infection and immunizations status is of
great importance. (56) The clinician must consider the need
for both vaccine and immunoglobulin administration based
on the type of wound and the patients immunization history
(Table 4). Cleanwoundsmerit tetanus toxoid administration if
the patient has had three or fewer immunizations or it has
been 10 years since the last tetanus-containing immunization.
The clinician should consider the need for tetanus immuno-
globulin in any high-risk wound sustained by patients who
have had fewer than three immunizations.
TABLE 3. Common Wound-related Antibiotics
ANTIBIOTIC DOSING COMMON USE
Amoxicillin-clavulanate 90 mg/kg divided BID Bites, intraoral wounds, grossly contaminatedwounds, wounds with devitalized tissue
Ciprooxacin 1020 mg/kg divided BID Puncture wounds through shoes(Pseudomonas), hand bites (cat, human),penicillin-allergic patients
Clindamycin 2040 mg/kg divided every 68 hours Hand bites (cat, human), penicillin-allergicpatients
Trimethoprim/sulfamethoxazole suspension(40/200 per 5 mL)
810 mg/kg/day of trimethoprim dividedevery 12 hours
Hand bites (cat, human), penicillin-allergicpatients
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ANTIBIOTICS
The primary goals of wound management are to achieve rapid
healing with optimal function, avoid wound infection, assist in
hemostasis, and achieve an aesthetically pleasing cosmetic out-
come. This is best accomplished by preventing infection of the
wound during healing. Such care includes copious irrigation,
debridement of devitalized tissue, removal of foreign bodies, and
wound closure. In the vast majority of patients, prophylactic
antibiotics arenotwarrantedanddonot improveoverall outcome.
However, despite good wound care, some infections still occur.
Host and wound characteristics should be considered
(Table 1). Patients who are immunosuppressed (eg, chemo-
therapy, long-term corticosteroid use), have poor wound
healing or collagen vascular disease, or have malnutrition
are at higher risk for infection. Wounds that are substantially
contaminated or cannot be thoroughly cleaned can become
infected in a short period of time.Mammalian bites have high
rates of infection, particularly puncturewounds fromcat bites,
and should always be prescribed prophylactic antibiotics to
cover likely organisms, typically a b-lactamase inhibitor anti-
biotic (ie, amoxicillin-clavulanate). (57) Table 3 lists commonly
used wound-related antibiotics, indications, and dosing.
WOUND CARE
After repair, wound care and appropriate discharge instruc-
tions are important for good cosmetic outcomes. Patients
should be advised to monitor closely for signs of infection.
Wounds repairedwith tissue adhesives should be kept dry, and
antibiotic ointment should not be applied to avoid wound
dehiscence. A moist healing environment has been shown to
improve the rate of re-epithelization, reduce pain, and improve
cosmetic outcomes. (58) No difference has been found when
comparing early postoperative bathing (48 hours). (59) Typically, sunblock products are
recommended for 6 to 12 months after wound healing.
References for this article are at http://pedsinreview.aappublica-
tions.org/content/36/5/207.full.
TABLE 4. Tetanus Prophylaxis in Routine Wound Management
HISTORY OF TETANUSTOXOID (DOSES) CLEAN, MINOR WOUNDS ALL OTHER WOUNDS
DTAP, TDAP, OR TD TIG DTAP, TDAP, OR TD TIG
Fewer than 3 or unknown Yes No Yes Yes
3 or more No if 5 years since last tetanus-containing vaccine dose.
No
DTaPdiphtheria and tetanus toxoids with pertussis; Tdaptetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed; Tdtetanus anddiphtheria toxoids (adult type); TIGtetanus immune globulin.Other woundsSuch as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting frommissiles, crushing, burns, and frostbite.Note: DTAP is used for children
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PIR Quiz
1. Increased risk of infection after laceration repair is associated with which of the following?
A. No surgical mask.B. Nonsterile gloves.C. Powder-covered gloves.D. Tap-water wound irrigation.E. Wound repair between 6 and19 hours after injury.
2. Which of the following wounds should not be closed primarily?
A. A chin laceration that occurred 3 hours ago in a healthy 2-year-old girl.B. A knee laceration that occurred 2 days ago in a healthy 4-year-old boy.C. A thigh laceration that occurred 6 hours ago in a healthy 7-year-old girl.D. A nailbed injury that occurred 1 hour ago in a healthy 8-year-old boy.E. A scalp laceration that occurred 9 hours ago in a healthy 15-year-old girl.
3. Tissue adhesive is an appropriate repair method for which of the following?
A. Dog bite.B. Elbow laceration.C. Forehead laceration.D. Lip laceration.E. Puncture wound.
4. Antibiotic prophylaxis is indicated in which of the following patients?
A. 2-year-old boy with a forehead laceration after tripping onto a tile oor.B. 3-year-old boy with a lip laceration after falling and striking his lip on a table.C. 5-year old girl with a scalp laceration after running into the edge of a door.D. 10-year-old girl with a leg laceration obtained from the pedal of her bicycle.E. 12-year-old boy with a hand laceration after being bitten by a cat.
5. A 17-year-old adolescent presents with a 3-cm laceration on his foot 2 hours after steppingon a nail that pierced through his shoe while working on his family farm. The patientsshoes and wound appear grossly contaminated with horse manure. The patient hasreceived ve prior diphtheria and tetanus toxoids with pertussis (DTap) immunizations anda tetanus toxoid, reduce diphtheria toxoid, and acellular pertussis, adsorbed (Tdap)immunization at age 11 years. In addition to cleaning the wound, which management ismost appropriate for this patient?
A. Close the wound by secondary intention and provide antibiotics for prophylaxis.B. Close the wound by secondary intention, provide antibiotics for prophylaxis, and
give a tetanus immunization.C. Close the wound by secondary intention, provide antibiotics for prophylaxis, give
a tetanus immunization, and give tetanus immune globulin.D. Close the wound with sutures.E. Close the wound with sutures and provide antibiotics for prophylaxis.
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This journal-based CMEactivity is availablethrough Dec. 31, 2017,however, credit will berecorded in the year inwhich the learnercompletes the quiz.
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DOI: 10.1542/pir.36-5-2072015;36;207Pediatrics in Review
Kelly D. Black, Stephen John Cico and Derya CaglarWound Management
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DOI: 10.1542/pir.36-5-2072015;36;207Pediatrics in Review
Kelly D. Black, Stephen John Cico and Derya CaglarWound Management
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