In this lecture, we’ll discuss lacerations,
wounds and bite wounds in children.
So kids are at increased risk
to fall and lacerate themselves
and this happens more in
children than it does in adults.
Children present with as many as two-thirds
of bite wounds in the
emergency room as well.
They're constantly getting bitten.
They even bite each other
on the playground.
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.
Generally, we don’t primarily repair
wounds that are more than a day old.
Find out the details of the event,
what exactly happened,
and determine when the patient was
last immunized against tetanus
and what immunization
It’s important to know their
tetanus status as well.
Note the laceration shape and length.
Unusually, shape of laceration
such as stellate lacerations
will be repaired slightly differently
than longer and more simple lesions.
Note if there is an arterial injury or if
there is an underlying soft tissue injury.
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.
An ultrasound is very useful for looking for
radiolucent foreign bodies such as wood,
especially in the feet.
Oftentimes, kids are
running around barefoot.
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.
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.
So another one that classically
we have to find is glass.
Generally, glass will not show up on x-ray
unless it’s leaded glass
which is less common now.
We will also obtain x-rays to rule out potential
broken bones underneath the laceration,
so certainly if there
has been an injury.
So a patient comes in, they’ve got
the laceration, what do we do?
Infection is the biggest
concern in most lacerations,
so clean thoroughly
with soap and water.
We have to really rinse
these things out.
For deeper lacerations, we will sometimes
use sterile water under pressure
and spray it directly
into the wound.
There’s a number of different
ways you can do this effectively.
All the ERs have
their own tricks,
but clearly large volume irrigation is
critical to cleaning out these lacerations.
So after we have cleaned them up,
we’re going to provide pain control.
Often for superficial
wounds, LET is sufficient.
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.
That usually works really well on
face and other areas of thinner skin.
In thick skin sometimes you
have to inject lidocaine.
Certainly for deeper wounds,
we will inject the lidocaine and sometimes
we will create a regional block.
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.
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.
In theory, this can increase
risk of end-organ damage,
although that’s incredibly rare.
Regional blocks are great for
things like external ears
or for the face or
for fingers or toes.
We can block off whole nerves and that
requires a little bit of experience.
Now remember, it’s for fine for an adolescent
to hold still while getting sutured
they'd want to watch.
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.
That child will not hold still
and will be utterly terrified.
So each case you have to judge and
guess what’s the best thing to do.
Sometimes, patients need
full on deep sedation.
Sometimes anxiolysis is
needed or moderate sedation
and sometimes none is needed at all.
It really depends on the child
and sometimes the parents are your best clue
as to what they think the child will need.
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.
Propofol is nice because
you can titrate it
and when you stop it, the patients
wake up very quickly.
Low dose propofol,
benzodiazepines and morphine
and fentanyl are all useful
for moderate sedation
and benzodiazepines are useful for
anxiolysis in older children.
But I generally avoid
it in younger children
because of the possibility
of an idiosyncratic reaction.
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.
So here are few times however when you
do not want to repair a laceration
and it’s important
to review those.
The first is if it has been
more than 20 hours from injury
or even longer in clean
you generally don’t want to suture that
cause these healings already been done.
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.
Sometimes, if it’s a huge open
area, we might put one or two sutures
with some gaps in the
middle to allow drainage.
If the injury is already infected, we
generally don’t want to close it off.
That will make things worse potentially
and certainly, small deep punctate wounds,
we often won’t suture for
again the same reason.
They are harder to clean out.
Superficial abrasions without any
clear edges, you can’t really repair.
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.