Clinical Presentation of Lacerations, Wounds and Bites in Children
Taking the history
When a child presents to the emergency department with a laceration or a wound, a detailed history should be obtained from either the child and/or the caregiver. Very young children might provide an unreliable history, especially when the cause of the lacerations involves a conflict with an adult, i.e., physical abuse.
It is vital to establish when and how the laceration happened. A small superficial laceration that is older than one day is usually not sutured. When a child presents with a small wound, the “ABCDE” protocol should be followed to not miss any life-threatening less obvious injuries.
Therefore, before one provides definite care for the wound, the child’s
- airway patency,
- breathing adequacy,
- disability and
- exposure risk
need to be assessed. Once the child is considered as stable and any other significant injuries have been excluded, definitive care of the wound can be provided.
Part of the history taking is to confirm the tetanus immune status of the child. Children who are old enough might be able to provide a reliable history about their most recent tetanus shot. If the child is too young to co-operate, such questions should be directed towards the parents or the caregivers. If you cannot find any records of the child’s tetanus status of immunization, it is safe to assume the child is not immunized.
The physical examination
The physical examination of the laceration consists of:
- inspection of the laceration,
- identification of the shape of the wound, and
- its length.
The location of the wound plays an important role in the choice of sutures afterwards. The physical examination should also aim to exclude arterial injuries by checking for adequate peripheral perfusion, i.e., capillary refill time is a good test here. If arterial compromise has happened, efforts should aim to stop any ongoing bleeding before any further diagnostic workup.
Formal neuromuscular examination
Lacerations can also severe nerves and muscles. Tendons might be cut in a deep laceration; therefore, a formal neuromuscular examination of the affected limb is indicated. This is also important for legal reasons, as one might expect.
Injuries of the Scalp
Injuries in hair-dense areas such as the scalp might be difficult to assess. Whenever possible, try to assess the injury without shaving. If shaving is a must, remember two things. Children, especially adolescent girls, can have an objection to head shaving; therefore, you should shave as little as possible; and, secondly, shaving can increase the risk of infection. Most centers do not do any shaving.
In many cases, the laceration is caused by a piercing injury. Metallic parts might still be inside the wound. The detection of foreign materials is facilitated by the palpation and examination of the wound after administering a local anesthetic.
Plain radiography can also be used to assess the integrity of bony structures close to the laceration and to look for any metallic foreign bodies. Foreign bodies inside the wound are a major risk factor for wound infection.
Ultrasonography can be used to look for any radiolucent foreign bodies within the wound.
Management of Lacerations, Wounds and Bites in Children
The management of skin lacerations and wounds in children can be classified into:
- wound-care before closure,
- treatment of wound pain,
- closure of the wound,
- wound dressing after closure, and
- wound-care instructions to the patient before discharge.
Following this systemic approach can help in minimizing many complications of wounds, including infection and dehiscence.
Wound-Cleaning in Children
Before you attempt to provide any definitive care of the wound, the wound should be thoroughly cleaned. In this article, we can open wounds that are not caused by surgical instruments. These “street” wounds might be contaminated.
Tap water and soap should be used to completely clean the wound. Deep lacerations can be cleaned with a pressured sterile water supply. The use of sterile saline to clean superficial wounds is not recommended as it was not associated with a lower risk of infection.
Managing Wound Pain
Wound pain is a very important concern. It can affect the child’s mood and can make him or her less co-operative. Additionally, the examination of the wound might be impossible without adequate analgesia. Wound pain is mainly managed with local anesthetics.
Lidocaine or prilocaine are the most commonly used local anesthetics for wound pain management. They can be used topically or infiltrated into the wound edges. Injection of lidocaine into deeper layers might be needed for deep wounds.
To minimize bleeding in the area, most physicians choose to add epinephrine to the lidocaine. This mixture is thought to provide adequate hemostasis with optimal pain control. Patients with ear, face, finger, or toe injuries might need a regional block.
Young children who are uncooperative and are in severe pain should receive a sedative. Propofol or ketamine can be used for deep sedation. If deep sedation is not needed, then a low-dose Propofol plus benzodiazepine combination can be used. Children who are very anxious should receive a benzodiazepine to help with anxiety.
The use of acetaminophen after discharge is recommended. Non-steroidal anti-inflammatory drugs might interfere with wound healing; therefore, they should be avoided whenever possible.
A simple gauze dressing is recommended whenever possible. Infected wounds, leaking wounds, bite wounds, and deeper lacerations should be dressed with a dry-to-air or non-adhesive dressing. Paraffin gauze can be used when absorbing dressing is needed. The addition of antiseptics such as iodine is recommended only after the wound has been fully cleaned with water and closure was offered if needed.
When to not Close a Wound?
- injuries that happened more than 24 hours ago,
- animal and human bites,
- infected wounds,
- deep small punctate wounds,
- abrasions, and
- wounds with ongoing bleeding.
should not be repaired with primary closure.
Patient Education at Discharge
The caregivers might have questions about the normal healing process of the wound; therefore, you should provide instructions about when they should seek the emergency department and who they can contact if they have any questions.
A common question by children and parents is when the child can get a bath or a shower. Showering the wound is usually recommended 24 hours after wound closure. This is the period required for complete epithelization to occur.
If bathing or showering of the wound is going to be performed after 24 hours, the patient should be instructed to be gentle. Superficial grazes should be protected from ultraviolet light exposure for up to three months to avoid impaired wound healing or abnormal pigmentation.
Repair Options for Wound Closure in Children
Rapid drying glue can be used for the closure of small lacerations of the face. Low-tension wounds can be easily glued together and the result is usually cosmetically satisfactory. Glue should not be used for the closure of wounds in the hands or feet. Glue closure is associated with an increased risk of wound infection.
Suturing is the most common repair performed for the closure of wounds in children. The type of the suture and size is dependent on the location of the wound. Additionally, the duration you are expected to leave the sutures in place before removal are also dependent on the site of the wound.
Face lacerations can be closed with 6.0 nylon sutures which should be left in place for 3 to 5 days. Low-tension lacerations can be closed with fast absorbing gut sutures which do not need to be removed.
Scalp lacerations can be closed with a stapler or with 5.0 polypropylene sutures. The sutures need to be removed 7 days after their placement.
Upper and lower extremities’ wounds are usually repaired with 4.0 or 5.0 polypropylene sutures. The sutures are typically left in place for 7–10 days.
|Location||Suture||Leave in for|
|Face||6.0 nylon or polypropylene; fast absorption gut is good for low tension lacerations||3–5 days|
|Scalp||Staple, or 5.0 polypropylene||7 days|
|Extremities||4.0 or 5.0 polypropylene||7–10 days|
If the wound is over a joint, splinting should be used in addition to suturing. Sutures from over the joint wounds should be removed two weeks after closure.
The best suturing technique should get the wound edges opposed to each other and slightly everted. Simple interrupted stitches are used for small lacerations. Mattress and buried sutures are used for deep lacerations.
Antibiotic Prescription for Wounds
Antibiotics are generally reserved for children who present with:
- bite wounds,
- wounds in the hand, foot or face,
- open fractures,
- contaminated wounds, and
- immunocompromised children.
Amoxicillin/clavulanate is the antibiotic of choice for the outpatient management of wounds that are at an increased risk of infection. Hospitalized patients with skin wounds that are at an increased risk of infection should receive ampicillin/sulbactam or clindamycin.
Tetanus vaccination status should be determined in the patient. If the patient has received at least three previous tetanus vaccinations; however, the last vaccine was more than five years ago, then a Tdap booster is recommended.
Additionally, children who received less than 3 previous vaccinations should also receive a booster Tdap. Children, who received less than 3 previous vaccinations against tetanus who present with puncture, crush, or dirty wounds or who present more than 24 hours after the injury should receive a Tdap booster dose in addition to tetanus immunoglobulin.