1 What are the major considerations in wound assessment?

2 How does location of injury affect assessment?

3 Why are bites and crush injuries of special concern?

Bites and crush injuries are more difficult to repair. They are often associated with devitalized tissue and are more likely to become infected. Injury over a metacarpophalangeal joint from a fist punch should be managed as a human bite.

4 How do disease states affect wound assessment?

Higher infection rates are seen in conditions such as diabetes, immunosuppressed states (e.g., AIDS, long-term steroid use), and chronic disease (e.g., renal insufficiency, cyanotic heart disease). Exposure to smoke delays proper healing.

5 Which allergies are of particular relevance to wound assessment?

Allergy to latex, anesthetic agents, and antibiotics.

6 What is the ideal time frame for repair of wounds?

Ideally wounds should be repaired within 6 hours of injury. Clean wounds can be closed within 12–24 hours after injury.

7 When should delayed closure of a wound be considered?

Delayed closure is usually carried out 3–5 days after the original injury. Wounds that should be considered for delayed closure are those with high potential for infection (heavily contaminated wounds, bite wounds, puncture wounds) and wounds in immunocompromised patients in areas of low cosmetic concern. Facial and scalp wounds should be considered for primary closure for best results.

8 Which wounds are allowed to heal by secondary intention?

Infected wounds and small puncture wounds in areas of low cosmetic concern may be allowed to close by secondary intention. A small wick of iodoform gauze may be placed in the wound to decrease chances of infection.

9 How should the emergency physician approach sedation and pain control?

Options, risks, and benefits should be discussed with parents and older children. Parents often can predict the level of cooperation expected from the child.

10 When should a consultation be obtained for wound care?

Consider consultation with a surgical or orthopedic specialist for wounds associated with:

Selbst SM, Attia M: Minor trauma—lacerations. In Fleisher GR, Ludwig S, Henretig FM (eds): Textbook of Pediatric Emergency Medicine, 5th ed. Philadelphia, Lippincott Williams & Wilkins, 2006, pp 1571–1586.

11 When are radiographic studies indicated as a part of wound management?

Radiographs should be obtained for wounds associated with fractures or joint disruption or if a foreign body is suspected. Plain radiographs identify fragments of metal and glass if they are larger than 0.5 cm. Wood is identified in only 15% of cases because air trapped in the wood is resorbed within 48 hours. Ultrasonography has 90% sensitivity and specificity for nonopaque foreign bodies if the location is not near a bony or gaseous structure. Computed tomography or magnetic resonance imaging should be considered if a surgical approach is planned for the removal of a foreign body near vital structures.

12 How can you decrease the chances of missing a retained foreign body in a wound?

A detailed history of the mechanism and circumstances surrounding the injury is important. Good exploration with visualization of the base of the wound significantly reduces the risk. In one study, wounds less than 0.5 cm deep had a low risk of an embedded foreign body.

13 What are the signs of retained foreign body?

Extreme pain, pain on passive movement, or a mass with discoloration at the site of a wound is highly suggestive of a retained foreign body.

14 When should a retained foreign body be removed?

The material, location, and tissue response to a foreign body determine the necessity of its removal. Attempts at removal in the emergency department (ED) should be limited to 30 minutes. The foreign bodies listed below should be removed.

15 What are the contraindications to the removal of a foreign body in the ED?

Foreign bodies associated with penetrating injuries to the abdomen, neck, or chest should be explored and removed in the operating room. Small, deeply embedded foreign bodies may be difficult to locate without ultrasound guidance. They can be left in place with close follow-up or removed electively.

16 Should hair be removed from a wound site before repair?

The presence of hair usually does not interfere with repair of the wound. Petroleum jelly can be used to keep hair away from the wound site during repair. If hair removal is needed, clippers should be used because they have a lower rate of infection than do razors. Eyebrows should not be removed because regrowth can be slow or absent.

17 Outline the steps in preparing a wound for closure

18 How is irrigation and cleansing of the wound best achieved?

Irrigation is best achieved with normal saline or tap water under pressure using a 20- or 30-mL syringe on a 19- or 22-gauge plastic intravascular catheter. Splash shields (e.g., Zerowet) decrease splattering of irrigation fluid. A volume of 50–100 mL/cm of laceration should be used; for contaminated wounds, larger volumes may be needed. Avoid excessive pressure during irrigation because it can distort the anatomy and damage the tissues. Road rash (tar), dirt, and foreign material should be removed gently with irrigation and mild scrubbing to prevent tattooing. Scrubbing should be limited because it can damage tissues, leading to poor cosmetic outcome. The use of povidone-iodine is controversial. Several studies have shown that it affects fibroblasts and hence wound defenses. A study by Gravett et al showed that use of 1% of povidone-iodine for 1 minute reduces the risk of infection. If irrigation is not well tolerated, repeat it after giving a local anesthetic.

Gravett A, Stener S, Clinton JE, et al: A trial of povidone-iodine in the prevention of infection in sutured lacerations. Ann Emerg Med 16:167, 1987.

Valente JH, Forti RJ, Freundlich LF, et al: Wound irrigation in children: Saline solution or tap water? Ann Emerg Med 41:609–616, 2003.

19 What agents are used for local anesthesia?

Topical anesthetics such as LET (lidocaine 4%, epinephrine 1:1000, tetracaine 0.5%) are very useful. When applied to the wound locally in the form of a gel for 15–20 minutes, LET produces local anesthesia with 97% efficacy. It can be used for all superficial wounds as the sole local anesthetic agent. Topical agents should be avoided in areas of end-blood supply, such as the fingers, ears, nose, toes, and penis (do not use epinephrine for end-arterial structures). Occasionally, deeper wounds require infiltration with another agent, such as lidocaine 1% with or without epinephrine. Bupivacaine is an alternative in lidocaine-allergic patients. Bupivacaine has a longer duration of action.

20 What is the maximum dose of epinephrine in local anesthetic medications?

The does of lidocaine with epinephrine should not exceed 7 mg/kg body weight; the dose of lidocaine alone should not exceed 4 mg/kg.

21 How can the pain of infiltration of a local anesthetic be decreased?

The pain of infiltration can be decreased by:

Ernst AA, Gershoff L, Miller P, et al: Warmed versus room temperature saline for laceration irrigation—a randomized clinical trial. South Med J 96:436–439, 2003.

22 What is the best method of obtaining hemostasis during wound repair?

A tourniquet, such as a rubber band or blood pressure cuff, and a local anesthetic with epinephrine can decrease the amount of bleeding during wound repair. The blood pressure cuff should be inflated to just above systolic blood pressure. A tourniquet should be used for only 20–30 minutes at a time. It should be released periodically for 2–3 minutes to allow reperfusion. Prolonged continuous use can lead to nerve and vascular damage, with subsequent thrombosis and gangrene.

23 What are the key points for proper wound approximation?

Some physicians find it helpful to place the first suture at midpoint for good alignment, but this technique is not necessary as long as the approximation is preplanned. Slight eversion of the wound edges throughout the procedure is important to avoid future tethering of the scar line. Removal of clot from gaping wounds also helps to avoid tethering and decrease tension. Keep the amount of tension on the wound to a minimum. In layered closure, close each layer individually.

24 What are the appropriate types of sutures and techniques for closure of various wounds?

For skin closure, synthetic nonabsorbable, monofilament nylon (Ethilon or Dermalon) should be used. Fine absorbable synthetic sutures (e.g., coated Vicryl or Dexon) are used for deeper layers or nail-bed repairs. Suture size depends on the site and size of the wound. Smaller needles (e.g., PS or P1) are used for wounds that require fine cosmetic outcome. Table 57-1 lists suggested suture types for various locations.

25 How do alternative wound care techniques compare?

See Table 57-2.

26 When can tissue adhesives be used?

Tissue adhesives are nearly painless, do not require local anesthesia or removal, and have cosmetic results similar to those of sutures in most instances. They should be used in wounds with straight edges that are less than 5–6 cm long. Wounds should be no wider than 2–4 mm, and should not be located over a joint or hair-bearing area. During application, good approximation of the wound must be ensured, and care must be taken to prevent the adhesive from dripping into the wound, eyes, or eyelashes. The presence of adhesive in the wound acts like a foreign body and can produce intense inflammation. Parents should be instructed to avoid the use of ointments or cream at the site of the wound because they lead to premature peeling of the adhesive. Tissue adhesive (cyanoacrylate) polymerize on the surface of the approximate wound edges, forming a strong bond to maintain the achieved approximation.

Mattick A, Clegg G, Beattie T, et al: A randomized controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for pediatric laceration repair. Emerg Med J 19:405–407, 2003.

27 What are the complications of tissue adhesives?

Occasionally, skin folds are inadvertently glued together, the glove of the operator may become glued to the patient’s skin, or adhesive drips into the patient’s eyelashes. If these complications occur, petroleum jelly or eye ointment should be massaged into the site to help dissolve the glue. Refrain from clipping the eyelashes because their regrowth is uncertain. The strength of the wound after repair with an adhesive is 10–15% less than that of wounds closed by sutures. Dehiscence occurs in 1–5% of all wounds, closed by adhesives. If the wound dehisces, it should be left to heal by secondary intention unless the result will be cosmetically unacceptable.

28 What are some important considerations in the evaluation of puncture wounds?

Puncture wounds account for 3–5% of all injuries. The most common site is the forefoot (50%). The rate of complications is directly proportional to the depth of penetration. Infection occurs in 6–10% of all puncture wounds, with staphylococci, streptococci, and anaerobes being the most common organisms. Injuries penetrating through a foam or rubber insole of a sneaker are often contaminated by Pseudomonas aeruginosa. The most common offending object in puncture wounds is a nail (> 90%). It is essential to examine the wound well for the possibility of damage to deeper structures and for retained foreign bodies. Puncture wounds have a greater incidence of infectious complications, such as cellulitis, soft tissue abscess, pyarthrosis, osteomyelitis (0.4–0.6% of wounds), and foreign-body granuloma.

29 A 10-year-old boy presents with persistent pain in his right forefoot after sustaining a puncture wound from a nail 10 days ago. Some redness and swelling are seen at the site. What are your major concerns and management course?

Osteomyelitis is a major concern with a puncture wound when persistent pain is accompanied by local signs of infection, even without systemic involvement. A complete blood count and erythrocyte sedimentation rate, along with imaging studies, should be obtained. Bone scanning or MRI is more sensitive in detecting periosteal reaction or bony destruction than radiography in the first week. Osteomyelitis should be treated with IV antistaphylococcal and antipseudomonal antibiotics. If no improvement is noted in 48 hours, surgical debridement may be necessary.

30 What is coring of a puncture wound?

Coring removes a 2-mm circular rim of the puncture track. The area should be prepared with povidone-iodine, local anesthetic, or regional nerve block, followed by irrigation and packing with iodoform gauze. The patient should be instructed to avoid weight-bearing for 5 days. Coring should be considered in wounds that are grossly contaminated or have a foreign body in an area of low cosmetic concern and high risk for infection, such as the foot.

31 How are forehead lacerations repaired?

Superficial transverse lacerations of the forehead are easy to repair with interrupted or continuous cuticular sutures using 6–0 nonabsorbable materials. Deeper transverse lacerations involving the deep fascia, frontalis muscle, or periosteum should be repaired in layers. If the deeper tissue planes are not closed, the function of the frontalis muscle (eyebrow elevation) may be compromised. Vertical forehead lacerations tend to have wider scars because they traverse the tension lines if proper tension and coaptation are not achieved. Forehead lacerations are rarely associated with skull fractures, but facial, neck, and intracranial injuries should be ruled out.

32 Describe the appropriate technique for repair of eyebrow lacerations

The eyebrow should not be shaved for wound preparation because it serves as a landmark during repair. In addition, eyebrow regrowth is unpredictable; it may be slow or incomplete, leading to poor cosmetic outcome. 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 along the eyebrow wound.

33 How are lacerations of the eyelid repaired?

Lacerations of the eyelid are mostly simple transverse wounds of the upper eyelid just inferior to the eyebrow. Repair does not require special skills. Consider ophthalmology referral for complicated lacerations potentially involving the levator palpebrae muscle or medial canthal ligament or those close to the lacrimal duct. Evaluation for associated injuries to the globe is imperative.

34 How are lacerations of the external ear treated?

To avoid necrosis and auricular deformity, every attempt must be made to minimize debridement and to cover the perichondrium with the lacerated thin but vascular skin. Simple closure with the least possible tension is usually advised. The perichondrium should be included in the sutures to ensure that the suture material does not tear through the friable cartilage and to restore nutrient and oxygen supply. If ear trauma has led to auricular hematoma, it should be drained promptly to avoid necrosis of the cartilage, which leads to a deformed auricle or cauliflower ear. After repair of ear lacerations or evacuation of an auricular hematoma, a pressure dressing should be applied. Follow-up in 24 hours is recommended to evaluate vascular integrity.

35 What is the recommended technique for repair of lip lacerations?

Lip lacerations are important because of their highly visible nature. The vermilion border is a relatively paler line that identifies the junction of the dry oral mucosa and facial skin. It is an important landmark for proper repair. The use of epinephrine with local anesthesia should be avoided because it causes local swelling that distorts the border. A mental nerve block provides good anesthesia while preserving the landmarks. Lacerations involving the vermilion border should be precisely aligned. Parents should be warned that, while the lip is still anesthetized, the child might bite off the sutures. They should distract the child from doing so. After local anesthesia has worn off, the site typically is sore enough that the child does not attempt to manipulate the area.

36 Describe the proper approach to lacerations of the tongue and buccal mucosa

37 How are fingertip avulsions repaired?

Most fingertip avulsions are contused lacerations or partial avulsions. Sharp injuries are more common in older children and less likely to be associated with fractures. Evaluate for associated nail bed injury and obtain radiographs for possible fracture of the phalanx. In general, this type of injury is managed by the emergency physician. The management is mostly conservative, especially in preadolescent children, because tissue regeneration is remarkable.

38 Describe the approach to nail bed injuries

Trauma to the distal fingers is often associated with nail and nail bed (matrix) injuries. Nail avulsion may be partial or complete; it may or may not be associated with nail bed laceration. An underlying fracture of the distal phalanx is not uncommon. Injury to the fingertip often is associated with subungual hematoma. Unrepaired nailbed lacerations may permanently disfigure new nail growth from the cicatrix nail bed. If the nail is partially avulsed but is firmly attached to its bed, exploring the nail bed is difficult and probably not warranted. Good outcome is expected because the nail holds the underlying lacerated nail bed tissues in place.

When the nail is completely avulsed or attached loosely, the nail should be lifted and the nail bed assessed for laceration. If the nail bed is lacerated, it should be repaired by using 6–0 or smaller absorbable material. After its soft proximal portion is cleansed and trimmed, the nail should be replaced between the nail bed and nail fold (eponychium) and then anchored in place with a few stitches. This technique splints the nail fold away from the nail bed and prevents obliteration of the space between the two. Preserving this space allows the new nail to grow undisturbed. The preferred method of local anesthesia for nail bed repair is digital block, and use of a finger tourniquet during repair allows a bloodless field. Application of a finger splint after repair, especially in patients with an associated fracture, is recommended.

39 How should a subungal hematoma be managed?

Subungual hematoma (Fig. 57-1) is a collection of blood in the interface of the nail and nail bed. It is commonly seen with blunt fingertip injuries. The usual presentation is throbbing pain and discoloration of the nail. Subungual hematoma may be associated with nail bed injury or fracture of the distal phalanx. A subungual hematoma involving 50% or more of the nail should be drained. Drainage of the hematoma relieves symptoms. In general, no local anesthesia is required for a simple trephination by cauterization of the nail. Postdrainage care includes elevation of the hand and warm soaks for a few days. The possibility of nail deformity in the future should be discussed with the family.

Figure 57-1 Subungual hematoma.

When the injury is more involved, digital block is advised. If the hematoma is large and extends to the tip of the nail, separation of the nail from the nail bed allows drainage. In the presence of a distal phalangeal fracture, be careful not to transform a closed fracture into an open fracture by communicating a subungual hematoma to the exterior surface of the nail. If this possibility exists, antibiotic coverage and close follow-up are appropriate.

Roser SE, Gellman H: Comparison of nailbed repair versus nail trephination for subungual hematomas in children. J Hand Surg 24:1166–1170, 1999.

40 What are the signs of wound infection?

Signs of wound infection include marked or worsening pain or tenderness at the wound site beyond that expected from the initial trauma. Local erythema, warmth, swelling, and discharge, such as pus or serosanguineous fluid, also are signs of infection. In severe infections, fever, phlebitis (streaking), regional lymphadenopathy, and other systemic manifestations may be seen.

41 For which wounds should prophylactic antibiotics be considered?

Use a first-generation cephalosporin to cover staphylococci and streptococci or use clindamycin or trimethoprim-sulfamethoxazole if methicillin-resistant Staphylococcus aureus is a concern. Amoxicillin–clavulanic acid should be used for bites to provide additional coverage against anaerobes. Clindamycin is a suitable alternative.

42 What are the key elements of postrepair wound care?

43 When does a wound regain its strength?

A wound regains 5% of its strength in 2 weeks, 30% in 1–2 months, and full strength by 6–8 weeks. The scar achieves its final appearance in 6–12 months.

44 What are the indications for tetanus prophylaxis?

Tetanus is a potential risk in all wounds. Wounds at a higher risk for tetanus are those contaminated by soil or feces and those with devitalized tissue (e.g., puncture, crush, missile, or avulsion wounds). Burns and frostbite are also prone to tetanus. Prophylaxis depends on the type of wound and the patient’s immunization status (Table 57-3).

Advisory Committee on Immunization Practices (ACIP): Preventing tetanus, diphtheria, and pertussis among adolescents: Use of tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccines recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep. 55:1–34, 2006.

45 A young boy is brought to the ED after being stuck by a needle on the playground. The needle has crusted blood along the metallic edge. What are your concerns? What is the best course of management?

A needlestick injury raises concerns about exposure to tetanus and blood-borne pathogens, such as hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). HBV can survive on fomites for several days. Table 57-4 summarizes the American Academy of Pediatrics Red Book recommendations for hepatitis prophylaxis after a needlestick exposure.

Table 57-4 Hepatitis Prophylaxis After a Needlestick Exposure

HBIG = hepatitis B immunoglobulin, HBV = hepatitis B.

For HCV exposure, the risk of transmission from a discarded needle is low and the need for testing is uncertain. If testing is done, antibodies for anti-HCV should be assessed by enzyme immunoassay at the time of injury and 1 month later. The risk of infection with HIV is low but causes the greatest concern to the family and victim. No data evaluate the risk of acquiring HIV in this scenario. Baseline testing is controversial, and testing the syringe is neither practical nor reliable. Consult a specialist in HIV before using prophylaxis. Antiretroviral therapy should be started if the syringe had fresh blood. Testing the patient for HIV is controversial, but if testing is elected, it should be done at the time of injury, 6 weeks, 12 weeks, and 6 months after exposure.

American Academy of Pediatrics: Red Book Online: http://aapredbook.aappublications.org

46 When is rabies prophylaxis indicated?

Various animals transmit rabies. The virus is shed in the saliva of infected animals for 10–14 days before they become symptomatic. Postexposure guidelines are summarized in Table 57-5.Bites from animals such as squirrels, hamsters, guinea pigs, gerbils, chipmunks, rats, mice, rabbits, hares, and other rodents rarely require rabies prophylaxis.

Table 57-5 Guidelines for Rabies Prophylaxis

HDCV = human diploid cell vaccine, RIG = rabies immunoglobulin.

American Academy of Pediatrics: Red Book Online: http://aapredbook.aappublications.org

47 What is the regimen for postexposure rabies prophylaxis?

Active immunization with rabies human diploid cell (HDCV) vaccine is given on the day of injury and on days 3, 7, 14, and 28. The vaccines are administered as a 1.0-mL intramuscular injection in the deltoid. In small infants, the gluteal area is used. If the vaccine is not available, rabies immunoglobulin (RIG) should be given. The dose of RIG is 20 IU/kg body weight. It is given concomitantly with the first does of vaccine but at a different site. Infiltrate as much as possible of the total dose of RIG at the wound site and inject the remainder intramuscularly. RIG should be given as soon as possible, and within 7 days after exposure. Patients previously immunized with rabies vaccine should receive only two doses of HDCV on days 0 and 3.

48 What is the best course of management for a fishhook embedded in soft tissue?

Fishhooks have a straight shank and a curved belly that has an eyelet with a barb pointed away from the tip. Do not attempt removal in the ED if the fishhook is buried near vital structures. If the fishhook is not in a dangerous location, use a digital block or local infiltration. Wear protective eyewear to avoid injury during the removal. Remove lures and additional hooks first with a hemostat and wire cutter.

There are several methods of removal. The push-through method is most effective when the barb is close to the skin. The barb is pushed forward (antegrade) through the skin. It is then clipped with a wire cutter and the rest of the barb is pulled back through the original wound.

With the string technique, a long piece of string is looped around the hook at the point of entry and around the clinician’s finger. While the clinician applies pressure downward over the straight part of the fishhook to disengage the barb, the hook is pulled away rapidly.

49 What is the best way to remove a ring that is stuck on a child’s finger?

If vascular compromise is present, the constricting ring should be removed as soon as possible. Risk of gangrene is present in any obstruction that persists beyond 10–12 hours. A ring cutter is useful. It is easiest to cut the thinnest portion of the ring or on the palmar surface of the hand. Once cut, the ends should be separated manually. The string-pull method is best used for broad or metallic bands. One end of a suture is slipped under the band. After application of lubricant, the string is grasped with a hemostat and pulled in a circular motion until it slides off.