Treatment of Lacerations

00:02 So what about glue? Glue is fantastic.

00:06 It is just as good cosmesis as sutures and if applied intelligently and correctly can be very effective.

00:14 It’s fast, however, it requires some digital dexterity.

00:19 Most practitioners at one point have come close to gluing their fingers on the face of a child.

00:25 You have to be very careful and sometimes they can run, although there are newer preparations that don’t run as easy, they are a little bit thicker.

00:32 It has excellent cosmesis and good for low tension wounds.

00:37 It’s great for the face, if you can apply it well and get those edges approximated nicely when you apply the glue.

00:44 It’s really not for use on hands or feet or over joints.

00:49 Any area that where they could stretch it and rip open that lesion is going to have worse cosmetic effect.

00:56 So you want to only use it in areas where it’s relatively low tension.

01:00 And certainly, there is an increased risk for infection with glue as opposed to suturing, so make sure you clean it up extremely well if you wish to glue a wound.

01:11 Let’s say you’re suturing someone, how do you choose your suture material and how long do you leave it in? Well, the longer a suture is in place, the slightly less cosmesis you can have and you may have those little dots along the side of the lac.

01:26 So in the face, we’re going to use shorter acting sutures.

01:31 Often, people will use 6-0 nylon or polypropylene for the face and then remove it in three to five days.

01:38 Personally, I think one of the best sutures is fast absorbing gut and that’s nice especially with these young kids with face wounds because that will absorb and they don’t have to go back in for suture removal which can be scary for these kids again for lesions around their face.

01:54 For the scalp, usually, we’ll just staple the scalp and clean it out really well and then pound in a few staple and you'll will be done.

02:02 Or you can use 5-0 polypropylene and that generally we'll leave in for around a week.

02:08 For the extremities and certainly for those areas of our joints, we’re going to use a larger suture, like a 4-0, and again polypropylene is usually the easiest to use.

02:18 And then, we will generally leave it in for 7-10 days or maybe even 14 days and the splint if it’s over a joint.

02:26 If a lesion is over like the elbow right on the edge and that patient's going to start moving it, you’re going to have problems with those sutures coming out, so we either splint or in that case, you might just sling a patient and tell them don’t move your arm until 14 days and we can take those sutures out so we can prevent the lesion from reopening.

02:47 So when you are suturing, there’s a lot of experience and requires a lot of technique and some practice.

02:54 Often times, you can practice on pig ears and other things like that and then having some supervision is important while you’re learning first the suture.

03:02 The edge should be end up apposed and slightly everted, so those edges that you are approximating should be up a little bit and everted out.

03:13 Simple interrupted sutures are the easiest for small and straightforward lacerations, but for deeper lacerations, you may do something like this which is a mattress suture or you may do deep lacerations with absorbing suture and then superficial other sutures to keep the top layers approximated.

03:33 Let’s talk a little bit about antibiotics.

03:35 Antibiotics are generally indicated in human or animal bites on the hand, the foot or the face and if it’s a puncture wound.

03:47 We should generally give antibiotics after cleaning extremely thoroughly.

03:52 Cleaning is the most important thing.

03:55 We will give antibiotics when there is an open fracture and certainly if there’s a very badly contaminated wound.

04:01 And we give antibiotics if a patient is immunocompromised, if they have a problem with skin infection such as Job syndrome.

04:11 For bacteria and bites, we think about the following bacteria and there is one tricky one about dog and cat bites.

04:18 So typically, it’s Staph aureus, group A strep and anaerobes, but the Pasteurella organism is found in dog bites in particular.

04:27 You can worry about that.

04:29 And rarely, Eikenella although that can be very severe.

04:33 So if you’re thinking about all of these organisms after a bite wound, you can realize that we need to cover with a fairly broad spectrum agent.

04:42 So, we will start with oral amoxicillin clavulanic acid.

04:46 This can be given at usual 40-50 mg per kilo dose per day divided and it’s generally provided as a treatment for bite wounds to the hands, face, or all the other reasons we talked about previously.

05:00 If the patient is hospitalized because of particularly severe wound, we may give IV ampicillin/sulbactam and then transition to amoxicillin clavulanic acid at the time of discharge.

05:11 If they are allergic to penicillin, I’ll usually start with clindamycin which is a reasonable alternative.

05:17 Remember, human bites are the dirtiest bites and the most risk for infection and we’re going to treat human bites.

05:26 So what about tetanus? I talked about tetanus a little bit at the beginning and I want to review it again.

05:33 Tetanus is a completely devastating infection.

05:37 It causes severe muscular spasms and incredibly uncomfortable death.

05:43 Here’s a patient who is dying of tetanus, every muscle in his body is contracted.

05:47 He cannot move and he is dying very uncomfortably.

05:51 Tetanus is effectively prevented through immunization or provision of antibodies directed against it.

05:58 So there are certain circumstances we will provide extra vaccination.

06:03 Other circumstances where we will not and other circumstances we will provide vaccination and tetanus antibodies.

06:10 Let’s go through that.

06:13 If we have a patient who is coming with a potentially risky wound, we’re going to do a couple of different things.

06:20 We’re going to booster them with a TDAP if they have three previous tetanus vaccinations and it has been more than five years since the last vaccination.

06:31 We will give him a booster with a TDAP if they have less than 3 previous immunizations total.

06:38 And we will give them a TDAP and tetanus immunoglobulin if they have less than 3 previous immunizations and it’s a risky injury, like a dirty puncture wound or a crush wound, somewhere where there has been a lot of dirt exposure or if they haven’t had care in more than 24 hours after the wound.

06:59 So that’s my review of lacerations in children.

07:03 Thanks for your attention.