Airway/Cervical Spine

Optimizing oxygenation and ventilation while protecting the cervical spine from potential further injury is of paramount importance. Initially, cervical spine injury should be suspected in any child sustaining multiple, blunt trauma. Children are at risk for such injuries because of their relatively large heads, which augment flexion-extension forces, and weak neck muscles, which predispose them to ligament injuries. To prevent additional spinal injury, the current standard is to immobilize the cervical (and thoracic and lumbar) spine in neutral position with a stiff collar, head blocks, tape or cloth placed across the forehead, torso, and thighs to restrain the child, and a rigid backboard.

Airway obstruction manifests as snoring, gurgling, hoarseness, stridor, and/or diminished breath sounds (even with apparently good respiratory effort). Children are more likely than adults to have airway obstruction because of their smaller oral and nasal cavities, proportionately larger tongues and greater amounts of tonsillar and adenoidal tissue, higher and more anterior glottic openings, and narrower larynxes and tracheas. Obstruction is common in patients with severe head injuries, owing in part to decreased muscle tone, which allows the tongue to fall posteriorly and occlude the airway. With trauma, obstruction can also result from fractures of the mandible or facial bones, secretions such as blood or vomitus, crush injuries of the larynx or trachea, or foreign body aspiration.

If it is necessary to open the airway, a jaw thrust without head tilt is recommended. This procedure minimizes cervical spine motion. In an unconscious child, an oropharyngeal airway can be inserted to prevent posterior displacement of the mandibular tissues. A semiconscious child will gag with an oropharyngeal airway but may tolerate a nasopharyngeal airway. A nasopharyngeal airway is contraindicated when there is a possibility of a cribriform plate fracture. If these maneuvers plus suctioning do not clear the airway, oral endotracheal intubation is indicated. When endotracheal intubation proves difficult, a laryngeal mask airway can be used as a temporary alternative. A laryngeal mask airway consists of a tube with an inflatable cuff that rests above the larynx and thus does not require placement of the tube into the trachea. Emergency cricothyrotomy is needed in <1% of trauma victims.

Breathing

The physician assesses breathing by counting the respiratory rate; visualizing chest wall motion for symmetry, depth, and accessory muscle use; and auscultating breath sounds in both axillae. In addition to looking for cyanosis, pulse oximetry is standard. If ventilation is inadequate, bag-valve-mask ventilation with 100% oxygen must be initiated immediately, followed by endotracheal intubation. End-expiratory carbon dioxide (CO₂) detectors help verify accurate tube placement.

Head trauma is the most common cause of respiratory insufficiency. An unconscious child with a severe head injury may have a variety of breathing abnormalities, including Cheyne-Stokes respirations, slow irregular breaths, and apnea.

Although less common than a pulmonary contusion, tension pneumothorax and massive hemothorax are immediately life-threatening (Tables 66-4 and 66-5). Tension pneumothorax occurs when air accumulates under pressure in the pleural space. The adjacent lung is compacted, the mediastinum is pushed toward the opposite hemithorax, and the heart, great vessels, and contralateral lung are compressed or kinked (Chapter 405). Both ventilation and cardiac output are impaired. Characteristic findings include cyanosis, tachypnea, retractions, asymmetric chest rise, contralateral tracheal deviation, diminished breath sounds on the ipsilateral (more than contralateral) side, and signs of shock. Needle thoracentesis, followed by thoracostomy tube insertion, is diagnostic and lifesaving. Hemothorax results from injury to the intercostal vessels, lungs, heart, or great vessels. When ventilation is adequate, fluid resuscitation should begin before evacuation, because a large amount of blood may drain through the chest tube, resulting in shock.

Circulation

The most common type of shock in trauma is hypovolemic shock due to hemorrhage. Signs of shock include tachycardia; weak pulse; delayed capillary refill; cool, mottled, pale skin; and altered mental status (Chapter 64). Early in shock, blood pressure remains normal because of compensatory increases in heart rate and peripheral vascular resistance (Table 66-6). Some individuals can lose up to 30% of blood volume before blood pressure declines. It is important to note that 25% of blood volume equals 20 mL/kg, which is only 200 mL in a 10-kg child. Losses >40% of blood volume cause severe hypotension that, if prolonged, may become irreversible. Direct pressure should be applied to control external hemorrhage. Blind clamping of bleeding vessels, which risks damaging adjacent structures, is not advisable.

Cannulating a larger vein, such as an antecubital vein, is usually the quickest way to achieve intravenous access. A short, large-bore catheter offers less resistance to flow, allowing for more rapid fluid administration. Ideally, a second catheter should be placed within the first few minutes of resuscitation in a severely injured child. If intravenous access is crucial and not rapidly obtainable, an intraosseous catheter should be inserted; all medications and fluids can be administered intraosseously. Other alternatives are central venous access using the Seldinger technique (e.g., in the femoral vein) and, rarely, surgical cutdown (e.g., in the saphenous vein). Ultrasonography can facilitate central venous catheter placement.

Aggressive, intravenous fluid resuscitation is essential early in shock to prevent further deterioration. Isotonic crystalloid solution, such as lactated Ringer’s injection or normal saline (20 mL/kg), should be infused rapidly. No consensus exists to support the routine use of colloid or hypertonic (3%) saline solution. When necessary, repeated crystalloid boluses should be given. Most children are stabilized with administration of crystalloid solution alone. However, if the patient remains in shock after boluses totaling 40-60 mL/kg of crystalloid, then 10-15 mL/kg of cross-matched, packed red blood cells should be transfused. Although less desirable, type-specific or O-negative cells can be substituted pending availability of cross-matched blood. When shock persists despite these measures, surgery to stop internal hemorrhage is usually indicated.

Neurologic Deficit

Neurologic status is briefly assessed by determining the level of consciousness and evaluating pupil size and reactivity. The level of consciousness can be classified using the mnemonic AVPU: Alert, responsive to Verbal commands, responsive to Painful stimuli, or Unresponsive.

Head injuries account for approximately 70% of pediatric blunt trauma deaths. Primary direct cerebral injury occurs within seconds of the event and is irreversible. Secondary injury is caused by subsequent anoxia or ischemia. The goal is to minimize secondary injury by ensuring adequate oxygenation, ventilation, and perfusion, and maintaining normal intracranial pressure (ICP). A child with severe neurologic impairment—i.e., with a Glasgow Coma Scale (GCS; see Table 62-3) score of 8 or less—should be intubated.

Signs of increased ICP, including progressive neurologic deterioration and evidence of transtentorial herniation, must be treated immediately. Hyperventilation lowers PaCO₂, resulting in cerebral vasoconstriction, reduced cerebral blood flow, and decreased ICP. Brief hyperventilation remains an immediate option for patients with acute increases in ICP. Prophylactic hyperventilation or vigorous or prolonged hyperventilation is not recommended, because the consequent vasoconstriction may excessively decrease cerebral perfusion and oxygenation. Mannitol lowers ICP and may improve survival. Because mannitol acts via osmotic diuresis, it can exacerbate hypovolemia and must be used cautiously. Hypertonic saline may be a useful agent for control of increased ICP in patients with severe head injury and may possibly decrease mortality when compared with mannitol. Neurosurgical consultation is mandatory. If signs of increased ICP persist, the neurosurgeon must decide whether to operate emergently.

Exposure and Environmental Control

All clothing should be cut away to reveal any injuries. Cutting is quickest and minimizes unnecessary patient movement.

Children often arrive mildly hypothermic because of their higher body surface area–mass ratios. They can be warmed with use of radiant heat as well as heated blankets and intravenous fluids.

Head Trauma

A GCS or Pediatric GCS score (see Table 62-3) should be assigned to every child with significant head trauma. This scale assesses eye opening and motor and verbal responses. In the Pediatric GCS, the verbal score is modified for age. The GCS further categorizes neurologic disability, and serial measurements identify improvement or deterioration over time. Patients with low scores 6-24 hr after injuries have poorer prognoses.

In the ED, CT scanning of the head without a contrast agent has become standard to determine the type of injury. Diffuse cerebral injury with edema is a common and serious finding on CT scan in severely brain-injured children. Focal evacuable hemorrhagic lesions (e.g., epidural hematoma) occur less commonly but may require immediate neurosurgical intervention (Fig. 66-3).

Figure 66-3 According to the history provided, the 7-month-old girl whose head CT scan is shown here did not wake up for her nightly feeding and began vomiting in the morning. The mother’s boyfriend reported that the infant had fallen from a chair the previous day. The CT scan shows a large epidural hematoma on the right and marked shift of the midline from right to left. The right lateral ventricle is compressed as a result of the mass effect, and the left lateral ventricle is slightly prominent. The infant underwent emergency surgical evacuation of the epidural hematoma and recovered uneventfully.

(From O’Neill JA Jr: Principles of pediatric surgery, ed 2, St Louis, 2003, Mosby, p 191.)

Monitoring of ICP should be strongly considered for children with severe brain injury, particularly for those with a GCS score of 8 or less and abnormal head CT findings (Chapter 63). An advantage of an intraventricular catheter over an intraparenchymal device is that cerebrospinal fluid can be drained to treat acute increases in ICP. Hypoxia, hypercarbia, hypotension, and hyperthermia must be aggressively managed to prevent secondary brain injury. Cerebral perfusion pressure should be maintained >40 mm Hg at least (although some experts recommend an even higher minimum).

A child with a severe brain injury must be treated aggressively in the ED because it is very difficult to accurately predict long-term neurologic outcome. Compared with adults with similar injuries, children are thought to have better functional outcomes.

Cervical Spine Trauma

Cervical spine injuries occur in <3% of children with blunt trauma—with the risk being substantially higher in those with GCS scores ≤8—but they are associated with significant mortality and morbidity. Bony injuries occur mainly from C1 to C4 in children younger than 8 yr. In older children, they occur equally in the upper and lower cervical spine. The mortality rate is significantly higher in patients with upper cervical spine injuries. Spinal cord injury without radiographic (vertebral body) abnormalities (SCIWORA) may be present. Patients with SCIWORA have neurologic symptoms, and spinal cord abnormalities are nearly always noted on MRI. Approximately 30% of all patients with cervical spine injuries have permanent neurologic deficits.

Evaluation begins with a detailed history and neurologic examination. Identifying the mechanism of injury helps in estimating the likelihood of a cervical spine injury. Both the patient and the paramedic should be asked whether any neurologic symptoms or signs, such as weakness or abnormal sensation, were present before arrival in the ED. In a child with neurologic symptoms and normal findings on cervical spine plain radiographs and CT scan, SCIWORA must be considered.

Whenever the history, physical examination, or mechanism of injury suggests a cervical spine injury, radiographs should be obtained after initial resuscitation. In adults, the Canadian C-spine rule helps identify low-risk patients who may not require radiographs (Fig. 66-4). The standard series of plain radiographs includes lateral, anteroposterior, and odontoid views. Some centers use cervical spine CT as the primary diagnostic tool, particularly in patients with abnormal GCS scores and/or significant injury mechanisms, recognizing that CT is more sensitive in detecting bony injury than plain radiographs. CT is also helpful if an odontoid fracture is suspected, because young children typically do not cooperate enough to obtain an “open-mouth” (odontoid) radiographic view. Use of cervical spine CT scan must be balanced with the knowledge that CT exposes thyroid tissue to 90-200 times the amount of radiation from plain films. MRI is indicated in a child with suspected SCIWORA.

Figure 66-4 The Canadian C-spine rule. For adult patients with trauma who are alert (as indicated by a score of 15 on the Glasgow Coma Scale) and in stable condition and in whom cervical spine injury is a concern, determination of risk factors and physical examination guide the use of cervical spine radiography. MVC, motor vehicle collision.

(From Stiell IG, Clement CM, McKnight RD, et al: The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma, N Engl J Med 349:2510–2518, 2003.)

Rapid diagnosis of spinal cord injury is essential. Initiating high-dose intravenous methylprednisolone within 8 hr of spinal cord injury has been shown to improve motor outcome and remains standard therapy.

Thoracic Trauma

Pulmonary contusions occur frequently in young children with blunt chest trauma. A child’s chest wall is relatively pliable; therefore, less force is absorbed by the rib cage, and more is transmitted to the lungs. Respiratory distress may be noted initially or may develop during the first 24 hr after injury.

Rib fractures result from significant external force. They are noted in patients with more severe injuries and are associated with a higher mortality rate. Flail chest, which is caused by multiple rib fractures, is rare in children. Indications for operative management in thoracic trauma are listed in Table 66-7. The differential diagnosis of immediately life-threatening cardio-pulmonary injuries is shown in Table 66-5.

Abdominal Trauma

Liver and spleen contusions, hematomas, and lacerations account for the majority of intra-abdominal injuries from blunt trauma. The kidneys, pancreas, and duodenum are relatively spared because of their retroperitoneal location. Pancreatic and duodenal injuries are more common after a bicycle handlebar impact or a direct blow to the abdomen (Table 66-8).

Although a thorough examination for intra-abdominal injuries is essential, achieving it often proves difficult. Misleading findings can result from gastric distention after crying or in an uncooperative toddler. Calm reassurance, distraction, and gentle, persistent palpation help with the examination. Important findings include distention, bruises, and tenderness. Specific symptoms and signs give insight into the mechanism of injury and the potential for particular injuries. Pain in the left shoulder may signify splenic trauma. A lap belt mark across the abdomen suggests a bowel or mesentery injury. The presence of certain other injuries, such as lumbar spinal fractures and femur fractures, increases the likelihood of intra-abdominal injury. Other risks are listed in Table 66-9.

An abdominal CT scan with intravenous contrast medium enhancement rapidly identifies structural and functional abnormalities and is the preferred study in a stable child. It has excellent sensitivity and specificity for splenic (Fig. 66-5), hepatic (Fig. 66-6), and renal injuries but is not as sensitive for diaphragmatic, pancreatic, or intestinal injuries. Small amounts of free fluid or air or a mesenteric hematoma may be the only sign of an intestinal injury. Administration of an oral contrast agent is not routinely recommended for all abdominal CT scans, but it sometimes aids in identifying an intestinal, especially a duodenal, injury.

Figure 66-5 CT scan with intravenous and gastrointestinal contrast enhancement shows an isolated splenic rupture that resulted from blunt trauma. This injury responded to nonoperative management, as do most splenic injuries.

(From O’Neill JA Jr: Principles of pediatric surgery, ed 2, St Louis, 2003, Mosby, p 166.)

Figure 66-6 CT scan performed after severe blunt injury of the abdomen shows a bursting injury of the liver. The patient was stable, and no operative intervention was required. The decision to perform surgery should be based on the patient’s physiologic stability.

(From O’Neill JA Jr: Principles of pediatric surgery, ed 2, St Louis, 2003, Mosby, p 168.)

Although focused assessment with sonography in trauma (FAST) examination helps detect hemoperitoneum, the variably low sensitivity of this test in children suggests that it should not be used to exclude intra-abdominal injury in patients with a high pretest probability for injury. Serial FAST exams over time may be used by skilled ultrasonographers to rule out injury in need of intervention. FAST is most useful in patients who have blunt trauma and are hemodynamically unstable or patients who require operative intervention for nonabdominal injuries, because in these cases the performance of a CT scan may not be feasible.

Nonoperative treatment has become standard for hemodynamically stable children with splenic, hepatic, and renal injuries from blunt trauma. The majority of such children can be treated nonsurgically. In addition to avoiding perioperative complications, nonoperative treatment decreases the need for blood transfusions and shortens hospital stay. When laparotomy is indicated, splenic repair is preferable to splenectomy.

Pelvic Trauma

Pelvic fractures in children are much less common than in adults, occurring in approximately 5% of children with more severe blunt trauma. Pelvic fractures are typically caused by high forces (e.g., from high-speed motor vehicle crashes or pedestrian impacts) and are often associated with intra-abdominal and/or vascular injuries. The pelvis itself forms a ring, and high-force impacts can lead to disruption of this ring. When the ring is disrupted in more than one location, such as the symphysis pubis and the sacroiliac joint, the ring can become unstable and displaced, potentially injuring large pelvic vessels and leading to massive blood loss. Catheter-directed embolization performed in the radiology department to control bleeding may be required.

The pelvis should be assessed for stability by means of compression-distraction maneuvers. If instability is noted, immediate external fixation with a pelvis-stabilizing device or a sheet should be applied, and orthopedic consultation sought. Most trauma patients should receive an AP pelvic radiograph in the trauma bay. Children without pelvic tenderness, instability, ecchymosis, abrasions, and bleeding, and in whom no is blood coming from the urethra, may be at low risk for significant pelvic fractures.

Lower Genitourinary Trauma

The perineum should be inspected, and the stability of the bones of the pelvis assessed. Urethral injuries are more common in males. Findings suggestive of urethral injury include scrotal or labial ecchymoses, blood at the urethral meatus, gross hematuria, and a superiorly positioned prostate on rectal examination (in an adolescent male). Certain pelvic fractures also increase the risk for potential genitourinary injury. Any of these findings is a contraindication to urethral catheter insertion and warrants consultation with a urologist. Retrograde urethrocystogram and CT scan of the pelvis and abdomen are used to determine the extent of injury.

Extremity Trauma

Extremity fractures may initially be missed as clinicians attend to more life-threatening injuries. Thorough examination of the extremities is essential because extremity fractures are among the most frequently overlooked injuries in children with multiple trauma. All limbs should be inspected for deformity, swelling, and bruises; palpated for tenderness; and assessed for active and passive range of motion, sensory function, and perfusion.

Before radiographs are obtained, suspected fractures and dislocations should be immobilized, and an analgesic administered. Splinting a femur fracture helps alleviate pain and may decrease blood loss. An orthopedic surgeon should be consulted immediately to evaluate children with compartment syndrome, neurovascular compromise, open fracture, and most traumatic amputations.

Radiologic and Laboratory Evaluation

Some authorities recommend ordering multiple studies in the ED that include lateral cervical spine, anteroposterior chest, and anteroposterior pelvis radiographs; arterial blood gas analysis; serum lactate determinations; complete blood cell count; electrolyte measurements; blood glucose and blood urea nitrogen measurements; serum creatinine, amylase, and lipase determinations; liver function tests; prothrombin and partial thromboplastin time determinations; blood typing and cross-matching; and urinalysis. One benefit of standardizing the evaluation of patients with major trauma is that fewer decisions need to be made on an individual basis, possibly expediting ED management.

Some of these studies have prognostic importance. A large base deficit is associated with a higher mortality rate, and elevated lactate values correlate with poor prognosis.

There are limitations of standard tests. The lateral cervical spine radiograph can miss significant injuries. Hemoglobin and hematocrit values provide baseline values in the ED, but they may not have yet equilibrated after a hemorrhage. Abnormal liver function test results or elevated serum amylase and lipase values may be noted in patients with significant abdominal trauma, but most patients with significant trauma to the abdomen already have clinical indications for CT scanning or surgery. The majority of previously healthy children have normal coagulation profiles; these may become abnormal after major head trauma. Although routine urinalysis or dipstick urine testing for blood has been recommended for children, other data suggest that this evaluation may be unnecessary in patients without gross hematuria, hypotension, or other associated abdominal injuries.

Clinical prediction rules that combine patient history with physical exam findings have been developed to identify those at low risk of injury for whom specific radiographic and laboratory studies may not be necessary. The Canadian C-spine rule for adults is one such rule (see Fig. 66-4). In children, a clinical prediction rule for the identification of children with intra-abdominal injuries following blunt trauma has been validated. The presence of any of the risk factors in this prediction rule had a sensitivity of 95% for identifying children with intra-abdominal injury (see Table 66-9). Several clinical prediction rules have also been developed to predict traumatic brain injury following blunt head trauma. These rules, if successfully validated, may allow for more appropriate use of CT in pediatric trauma patients and may potentially reduce unnecessary radiation exposure.

Epidemiology

More than half of the 12 million wounds treated annually in U.S. EDs are lacerations. Approximately 30% occur in children younger than 18 yr.

Evaluation

The history should include the mechanism of injury, the amount of force, and the time the injury occurred. The mechanism helps determine whether there may be foreign material in the wound, which would increase the risk for infection. Particularly in children, it is essential to determine whether the injury was inflicted intentionally. If nonaccidental trauma is suspected, the state or local child protective services agency should be notified. The type of force causing the laceration also influences the risk of infection, as a significant crush injury is more likely to become infected than a shearing one. Blunt injury, such as bumping the head, is a common cause of lacerations in children and is less likely to become infected. Theoretically, the amount of bacteria in the wound should increase exponentially with the time from injury to repair; however, the length of time that results in a clinically significant increase in wound infection is unclear. The patient or parent should be asked about any special host factors that may predispose to infection or impede healing, such as diabetes, malnutrition, obesity, and steroid therapy.

The laceration’s location also is important with regard to both the risk for infection and the cosmetic outcome. Compared with lacerations in adults, those in children occur more commonly on the face and scalp and less commonly on the upper extremities. Because the face and scalp are more vascular, wounds located there are less likely to become infected. Lacerations overlying joints are more likely to develop wider scars as a result of tension during healing.

Treatment

The goals of treatment are to minimize the risk of infection, to restore skin and underlying tissue integrity, and to produce the most functionally and cosmetically acceptable result possible. In adults, the infection rate for uncomplicated lacerations is approximately 3-7%.

Any significant bleeding must be controlled (with external pressure usually) before a thorough evaluation of the wound can occur. If there is a skin flap, it should be returned to its original position before application of pressure. Clothing over the injury should be removed to minimize wound contamination. Jewelry encircling an injured extremity should be removed to prevent the jewelry from forming a constricting band when the extremity swells.

It is best to administer a local anesthetic early, before exploration and more meticulous cleansing of the wound. This anesthetic can be applied topically (e.g., lidocaine, epinephrine, and tetracaine gel) or infiltrated locally or as a regional nerve block (e.g., lidocaine or bupivacaine), depending on the location of the laceration and the complexity of the repair. Sometimes procedural sedation and analgesia are required for a young uncooperative child. The wound should be examined under proper light to allow identification of foreign bodies or damage to nerves or tendons.

Many lacerations, especially heavily contaminated ones, benefit from irrigation to reduce the risk of infection. It is important to recognize that many traumatic lacerations treated in the ED or office are only minimally contaminated, containing less than 10² bacterial colonies. In fact, in one of the few human studies on irrigation, irrigation did not decrease the infection rate of minimally contaminated scalp or facial lacerations in patients who presented to an ED within 6 hours of injury. Another concern is that higher-pressure irrigation may actually increase tissue damage, making the wound and adjacent tissue more susceptible to infection and delaying healing. These caveats notwithstanding, irrigation has benefits, although which technique to use—i.e., which device, what size syringe, what size needle, which solution, how much volume, how much pressure—remains to be determined. These features may vary for different types of lacerations. In heavily contaminated wounds, the benefit of higher-pressure irrigation likely outweighs the harm of tissue damage. For heavily contaminated lacerations, a typical recommendation is to use a 35- to 65-mL syringe attached to a plastic splatter shield, or a 19-gauge needle if a splatter shield is unavailable, and to irrigate with 250-1,000 mL of normal saline. Conversely, for relatively clean wounds, lower-pressure irrigation minimizes tissue damage, which may be more important for outcome than any decrease in bacterial clearance that may ensue. Debridement of devitalized tissue with higher-pressure irrigation, scrubbing, or surgical excision can also be necessary in certain cases, such as crush injuries.

Most lacerations seen in the pediatric ED or office should be closed primarily. Contraindications to primary closure (e.g., certain bite wounds) do exist (Chapter 705). Although it is commonly accepted that the time from injury to repair should be as brief as possible to minimize the risk of infection, there is no universally accepted guideline as to what length of time is too long for primary wound closure. Also, this length of time varies for different types of lacerations. A prudent recommendation is that higher-risk wounds should be closed within 6 hr at most after the injury but that some low-risk wounds (e.g., clean facial lacerations) may be closed as late as 12-24 hr.

Many lacerations can be closed with simple, interrupted, 4-0, 5-0, or 6-0, nonabsorbable sutures. For lacerations under tension, horizontal or vertical mattress sutures—which provide added strength and may evert the wound edges better—can be used instead. For lacerations in cosmetically significant areas, a running intradermal stitch may produce a less conspicuous, more aesthetic scar than simple or mattress skin sutures, which leave unattractive track marks. Deeper lacerations may need repair with an absorbable dermal and/or fascial layer. Other complex lacerations—e.g., those involving the ear, eyelid, nose, lip, tongue, genitalia, or fingertip—sometimes require more advanced techniques as well as subspecialty consultation.

Staples, topical skin adhesives, and surgical tape are acceptable alternatives to sutures, depending on the laceration’s location and the health care provider’s preference. Staples are particularly useful for lacerations of the scalp, where the appearance of the scar tends to be less important. Topical skin adhesives (e.g., octyl cyanoacrylates or butyl cyanoacrylates) are ideal for linear, relatively superficial lacerations, with easily approximated edges that are not under tension, particularly when these lacerations are located in areas where suture track marks are especially undesirable.

Maintaining a warm, moist, wound environment following repair accelerates wound healing without increasing the risk of infection. A topical antimicrobial ointment (e.g., bacitracin or a bacitracin, neomycin, and polymyxin B combination) and conventional gauze dressing provide such an environment and reduce the infection rate as well. Compared with conventional dressings, occlusive dressings (e.g., hydrocolloids, hydrogels, polyurethane films) may be better at accelerating healing, reducing infection, and decreasing pain but are more expensive; occlusive dressings that adhere (e.g., hydrocolloids or polyurethane films) are impractical for lacerations with protruding sutures. If the laceration overlies or is near a joint, splinting helps limit mobility and can speed healing and minimize dehiscence.

For most routine lacerations evaluated in the ED or office that are repaired early and carefully, prophylactic systemic antibiotics are unnecessary because they do not decrease the rate of infection. Antibiotic prophylaxis is or may be indicated for human and many animal bites, for open fractures and joints, and for grossly contaminated wounds, as well as for wounds in patients who are immunosuppressed or have prosthetic devices. Tetanus prophylaxis should be administered, if indicated, according to Centers for Disease Control and Prevention guidelines (Chapter 203).

Treatment

All abrasions should be cleansed thoroughly, and any debris or foreign material removed. If debris is not removed, abnormal skin pigmentation, known as post-traumatic tattooing, can occur and can be difficult to treat. A nonadherent occlusive dressing or a topical antibiotic and conventional dressing should be applied. Tetanus prophylaxis should be administered, if indicated (Chapter 203). Large and/or deep abrasions that have not healed in a few weeks require consultation with a plastic surgeon for more advanced care.