Lacerations, Wounds and Bites in Children

00:01 In this lecture, we’ll discuss lacerations, wounds and bite wounds in children.

00:07 So kids are at increased risk to fall and lacerate themselves and this happens more in children than it does in adults.

00:16 Children present with as many as two-thirds of bite wounds in the emergency room as well.

00:22 They're constantly getting bitten.

00:23 They even bite each other on the playground.

00:26 So here’s what we have to look for in terms of when we see a laceration, what do we worry about? First, you have to know how long ago this event happened.

00:36 Generally, we don’t primarily repair wounds that are more than a day old.

00:41 Find out the details of the event, what exactly happened, and determine when the patient was last immunized against tetanus and what immunization they received.

00:50 It’s important to know their tetanus status as well.

00:53 Note the laceration shape and length.

00:56 Unusually, shape of laceration such as stellate lacerations will be repaired slightly differently than longer and more simple lesions.

01:05 Note if there is an arterial injury or if there is an underlying soft tissue injury.

01:10 Is the perfusion okay distally? Is bleeding stopped? And is there any distal nerve or motor function disruption? So sometimes we will do other studies to patients who present with lacerations.

01:25 An ultrasound is very useful for looking for radiolucent foreign bodies such as wood, especially in the feet.

01:33 Oftentimes, kids are running around barefoot.

01:35 They step on a stick, it hurts, they’re still having a lot of pain and you can’t tell if there’s a piece of wood in there on an x-ray.

01:42 Metal will show up on x-ray though, so certainly we’ll get x-rays as well depending on what the story is about the foreign body, but it’s nice to get foreign bodies out of there before we sew them up.

01:54 So another one that classically we have to find is glass.

01:57 Generally, glass will not show up on x-ray unless it’s leaded glass which is less common now.

02:03 We will also obtain x-rays to rule out potential broken bones underneath the laceration, so certainly if there has been an injury.

02:13 So a patient comes in, they’ve got the laceration, what do we do? First, clean.

02:19 Infection is the biggest concern in most lacerations, so clean thoroughly with soap and water.

02:25 We have to really rinse these things out.

02:28 For deeper lacerations, we will sometimes use sterile water under pressure and spray it directly into the wound.

02:36 There’s a number of different ways you can do this effectively.

02:39 All the ERs have their own tricks, but clearly large volume irrigation is critical to cleaning out these lacerations.

02:48 So after we have cleaned them up, we’re going to provide pain control.

02:53 Often for superficial wounds, LET is sufficient.

02:57 This is a topical lido-containing substance that is smeared onto the skin and then an adhesive bandage is placed over like a Tegaderm, then you wait a half hour and usually those patients are nice and numb.

03:10 That usually works really well on face and other areas of thinner skin.

03:14 In thick skin sometimes you have to inject lidocaine.

03:17 Certainly for deeper wounds, we will inject the lidocaine and sometimes we will create a regional block.

03:25 But when we’re injecting the lidocaine, we first clean it up and then we will inject the lidocaine in a region around the area so we block off the wound for adequate suturing.

03:36 We add epi to the lidocaine for better hemostasis because then it would lead less bleeding as a result, but we avoid epi in areas like penises and fingers and toes.

03:48 In theory, this can increase risk of end-organ damage, although that’s incredibly rare.

03:53 Regional blocks are great for things like external ears or for the face or for fingers or toes.

04:00 We can block off whole nerves and that requires a little bit of experience.

04:07 Now remember, it’s for fine for an adolescent to hold still while getting sutured and sometimes they'd want to watch.

04:14 But in little children, certainly those ridden with face injuries, you’re going to need to sedate that child in order to sew up that wound.

04:21 That child will not hold still and will be utterly terrified.

04:25 So each case you have to judge and guess what’s the best thing to do.

04:30 Sometimes, patients need full on deep sedation.

04:33 Sometimes anxiolysis is needed or moderate sedation and sometimes none is needed at all.

04:39 It really depends on the child and sometimes the parents are your best clue as to what they think the child will need.

04:46 Propofol or ketamine are fantastic for deep sedation because they are short-acting and they are very safe to use, especially ketamine, which not only provides sedation but also pain and the nice thing about ketamine is that it does somewhat reserve the protection of the airway so patients don’t often have complications.

05:08 Propofol is nice because you can titrate it and when you stop it, the patients wake up very quickly.

05:15 Low dose propofol, benzodiazepines and morphine and fentanyl are all useful for moderate sedation and benzodiazepines are useful for anxiolysis in older children.

05:27 But I generally avoid it in younger children because of the possibility of an idiosyncratic reaction.

05:33 Many times when you give a little benzo to a child under three and instead of becoming sedated, they become hyper and very afraid and very loud and screaming and you’ve gone backwards.

05:44 So here are few times however when you do not want to repair a laceration and it’s important to review those.

05:51 The first is if it has been more than 20 hours from injury or even longer in clean facial injuries, you generally don’t want to suture that cause these healings already been done.

06:02 In human or animal bites, we typically prefer not to repair those unless it’s cosmetically important because the risk of infection is so great that we want to allow drainage of that lesion.

06:15 Sometimes, if it’s a huge open area, we might put one or two sutures with some gaps in the middle to allow drainage.

06:23 If the injury is already infected, we generally don’t want to close it off.

06:27 That will make things worse potentially and certainly, small deep punctate wounds, we often won’t suture for again the same reason.

06:35 They are harder to clean out.

06:37 Superficial abrasions without any clear edges, you can’t really repair.

06:41 It can’t be done because there is no area to approximate and certainly if you cannot achieve hemostasis, that patient needs to go to the OR, that’s not a case for the emergency room.