So what about glue?
Glue is fantastic.
It is just as good
cosmesis as sutures
and if applied intelligently and
correctly can be very effective.
It’s fast, however, it requires
some digital dexterity.
Most practitioners at one
point have come close
to gluing their fingers
on the face of a child.
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.
It has excellent cosmesis and
good for low tension wounds.
It’s great for the face,
if you can apply it well
and get those edges approximated
nicely when you apply the glue.
It’s really not for use on
hands or feet or over joints.
Any area that where they could
stretch it and rip open that lesion
is going to have worse
So you want to only use it in areas
where it’s relatively low tension.
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.
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.
So in the face, we’re going to
use shorter acting sutures.
Often, people will use 6-0 nylon
or polypropylene for the face
and then remove it in
three to five days.
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.
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.
Or you can use 5-0 polypropylene and that
generally we'll leave in for around a week.
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.
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.
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.
So when you are suturing,
there’s a lot of experience
and requires a lot of
technique and some practice.
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.
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.
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.
Let’s talk a little bit about antibiotics.
Antibiotics are generally indicated
in human or animal bites
on the hand, the foot or the face
and if it’s a puncture wound.
We should generally give antibiotics
after cleaning extremely thoroughly.
Cleaning is the most important thing.
We will give antibiotics when
there is an open fracture
and certainly if there’s a
very badly contaminated wound.
And we give antibiotics if a
patient is immunocompromised,
if they have a problem with skin
infection such as Job syndrome.
For bacteria and bites, we think
about the following bacteria
and there is one tricky one
about dog and cat bites.
So typically, it’s Staph aureus,
group A strep and anaerobes,
but the Pasteurella organism is
found in dog bites in particular.
You can worry about that.
And rarely, Eikenella although
that can be very severe.
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.
So, we will start with oral
amoxicillin clavulanic acid.
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.
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.
If they are allergic to penicillin,
I’ll usually start with clindamycin
which is a reasonable alternative.
Remember, human bites are the dirtiest
bites and the most risk for infection
and we’re going to
treat human bites.
So what about tetanus?
I talked about tetanus a little bit at the
beginning and I want to review it again.
Tetanus is a completely
It causes severe muscular spasms and
incredibly uncomfortable death.
Here’s a patient who is dying of tetanus,
every muscle in his body is contracted.
He cannot move and he is
dying very uncomfortably.
Tetanus is effectively
prevented through immunization
or provision of antibodies
directed against it.
So there are certain circumstances
we will provide extra vaccination.
where we will not
and other circumstances we will provide
vaccination and tetanus antibodies.
Let’s go through that.
If we have a patient who is coming
with a potentially risky wound,
we’re going to do a couple
of different things.
We’re going to booster them with a TDAP
if they have three previous
and it has been more than five
years since the last vaccination.
We will give him a booster with a TDAP
if they have less than 3
previous immunizations total.
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.
So that’s my review of
lacerations in children.
Thanks for your attention.