Wounds are a common presenting complaint to a Paediatric Emergency Department. Children will be children, and slips, trips and falls resulting in minor injuries are all part of growing up. Most wounds are small and can be easily (a relative term!) dealt with in the ED. This prevents the need for referral to speciality care, reduces the time spent in hospital for patients and parents, and provides the satisfaction of a job well done for the ED doc!
As with any presentation to a healthcare professional, it is important to explore and address patients’ and parents’ concerns and expectations. With wounds, scarring is often a major concern. There are some important points to consider when managing these expectations:
All wounds scar
Scarring is part of the natural healing process of the skin. All full-thickness injuries to the skin will result in scar tissue formation. Multiple factors contribute to the scar that will eventually form – the nature of the injury, the location of the wound, the direction of the wound, some patient-specific factors, the degree tension on closure and lastly, closure technique chosen.
Everyone scars differently
There is no way to tell how each wound will heal. Hypertrophic scars and keloid scarring are patient-specific and often not foreseeable. These can be managed at a later stage by specialist teams. Other patients are at risk of poor healing – smokers (hopefully not too common in a paeds ED), diabetics, long term steroid users and those with other chronic diseases.
The most important part of wound management isn’t the closure but the cleaning
Infected wounds will heal badly (if at all) and can affect the underlying structures. Patients and parents need to aware to look carefully for any redness or exudate that might indicate infection and to seek medical attention appropriately.
Different wounds require different closures
Some parents will be set on the idea that stitches are superior – this is not always the case as we’ll discuss later.
Wounds take longer than a few days to heal
Wounds heal in three phases – inflammatory (day 1-3), proliferative (day 4-21) and remodelling (day 21 – 1 year). Scars can, therefore, take up to 12 months before they reach their final appearance. Because of this patients and parents need to know that the initial appearance is not the final outcome.
That said, measures can be implemented to reduce scarring
For instance, I recommend Steristrip support for a week, and then pinpoint massage with petroleum jelly or other oil-based products for a month to six weeks to provide a moist wound bed and reduce visible scarring. Sun protection is also important – the wound should not be exposed to the sun for at least three weeks, and sun cream used for more than a year on that area.
Scar revision is possible at a later stage
If after initial closure and sufficient healing time has passed, and a scar still remains that is distressing to the patient, referral for scar revision is possible.
It can be often tempting to be distracted by a nasty wound. No doubt the patient will be. But it is important to see the bigger picture and not to miss any important steps in management. Having a structure to work through is always something I find helpful, and the following questions will make sure your patient is treated safely and comprehensively.
- Is there any other associated injury?
Always think of the ABCs and make sure any haemorrhage has been controlled. Has the patient received a head injury, or has another body part been injured?
- How has it been caused?
The history of the injury will lead you to suspect any further damage or special considerations for management. For instance, was the wound caused by a sharp instrument or blunt trauma? Did it happen in a particularly contaminated area (e.g. a farmyard accident) that would prompt the need for surgical washout and antibiotic coverage. If describing wounds in medical notes be careful of nomenclature – if in doubt use ‘wound’. An abrasion is a wound caused by friction (a graze, or road rash for instance). These can be tricky to clean, but it’s important to remove any debris, otherwise a tattoo type scar can remain. A laceration is caused by a shearing force; these are more difficult to repair as there has been surrounding tissue damage. An incisional wound is caused by a sharp object, often more straightforward to repair. A puncture wound is one where the skin has been breached and is deeper than it is wide. Beware of these wounds – they are the icebergs of the wound world – who knows what is going on beneath the surface?
- Is there a foreign body present?
Puncture wounds, in particular, carry a high risk of foreign bodies, and therefore of infection and wound breakdown. If a foreign body is suspected, an x-ray is reasonable as it will pick up metal and most glass, although it won’t demonstrate wood, plastic and clothing. For cases where suspicion is high, ultrasound can be used to pinpoint the material. Often, in this case, speciality services need to be contacted.
- How deep is the wound and might other structures be involved?
The location of the wound and a good knowledge of anatomy is particularly important when it comes to this question. Wounds on the hands and arms, for instance, carry a high risk of underlying tendon and nerve damage. Always make sure to test and document a neurovascular examination distal to the wound.
- Is it safe to close the wound immediately?
If the wound isn’t too old (opinions differ on this, but usually >8hrs) or contaminated then healing by secondary intention is usually preferred in order to avoid sealing in infection.
- How should the wound be best closed?
Factors which help in making this decision include the size of the wound, the location and the degree of tension it is under.
- What dressing should be used?
Usually, a non-adherent dressing for abrasions will facilitate healing as well as less painful dressing changes. Wounds that have been sutured can be covered with a simple bandage. Other wounds on fingers or places likely to get wet (or drooly!) may require a waterproof dressing.
- Does the area need immobilisation?
If the wound is over a joint or subject to movement, it is good practice to immobilise the joint in order to allow healing. Beware wounds overlying joints and ensure that there is no communication with deeper structures.
- Are antibiotics indicated?
There is no evidence for ‘prophylactic’ antibiotics in simple wounds. However, those that are heavily contaminated, or involve joints or underlying structures/fractures will often require specific antimicrobial cover (and surgical washout). Consult with local speciality teams for their preferences.
- Is the child tetanus immune?
Always important to check the immunisation status of any child presenting to a healthcare professional. Consult national guidelines as to the recommendations for tetanus prone wounds and indications for booster shots and immunoglobulin.
First – let us remind ourselves of the structure of the skin. It is composed of the epidermis and dermis, and underlying subcutaneous layers.
Wounds to the epidermis are very superficial; the dermis and epidermis are tightly adherent to each other. Wounds to epidermis need nothing more than a wash and a non-adhesive dressing (a sticking plaster or Band-Aid). Do not be tempted to glue or suture these as they will worsen outcomes.
Wounds that extend through to dermis or subcutaneous layers must be treated with more care. Of course, the age of the patient will determine the approach, but the management remains the same. The following are some techniques to allow us to manage our patients, before the wounds.
If your department is lucky enough to have a play specialist – use them. They can magically turn a difficult situation into a calm and even fun event. Using distraction techniques (I personally turn to the name of the blog for my distraction of choice) a child can be calmed and the wound can either be managed immediately, or anaesthetised.
LAT gel (lidocaine adrenaline and tetracaine) is magical stuff. A mixture of local anaesthetic and adrenaline, it takes about 20-30 minutes to be effective, and it helpfully blanches affected skin (due to the adrenaline) to show you it’s ready. Generally not suitable for under 1s (an infant presenting with a wound that requires suturing should prompt immediate senior review), the doses are 0.5ml/1cm of wound, with a max dose of 2ml in 1-3 year olds and max 3ml in >3 years. It shouldn’t be used on mucous membranes or eyes due to absorption or on extremes of digits, nose, genitalia or ears due to the vasoconstriction effect of the adrenaline, or wounds greater than 8 hours old (as these are likely to need formal washout). LAT gel can also be used to sufficiently numb an area enough for local anaesthetic injection if further anaesthesia is required. Remember the full dose of lidocaine shouldn’t exceed 5mg/kg. Inject local anaesthetic SLOWLY using an orange needle – local anaesthetic is painful when injected, so infiltrate slowly to negate this, and use a small gauge needle.
The other option is procedural sedation. This is department-specific and dependent on the availability of senior clinicians and departmental equipment/space. It can allow for a more thorough washout and definitive closure of wounds without another trip to the hospital.
If there is an obvious underlying fracture or structural (ie nerve or tendon) defect, then the patient requires a referral for speciality treatment, and is not suitable for ED closure, so I don’t see any benefit in further possibly distressing a child by poking and prodding – one such session is enough!
Once the patient is suitably distracted/analgesed/sedated, it’s time for the easy part. Wounds must be cleaned thoroughly, and underlying structures assessed. If there is any risk of underlying fracture, an x-ray is mandatory – a missed open fracture is unacceptable. Normal saline is perfectly fine for wound washout. All large/visible debris should be removed, and then the wound thoroughly irrigated. I find an 18G cannula (with the sharp bit removed) attached to the end of a 20ml syringe for small wounds works well as it gives good pressure effect. For larger wounds, a 50ml syringe on its own can be used. There is no consensus around the amount of fluid needed for a washout. It is often clinician and wound dependent. If in doubt, keep washing it out!
Now for the closure. Depth, length, tension and location are the predominant features that guide the decision for closure materials and techniques. It is important to remember that the goals of wound closure are to eliminate dead space, avoid dehiscence by using appropriate materials and technique, and approximate wound edges without tension.
Paper stitches, butterfly stitches, or Steristrips©, are fantastic when used for wounds with low tension (i.e. the wound edges are easily apposable). They come in a range of sizes to fit different wounds and locations. Make sure to cut them to size; if they are too long the edges can peel away and little fingers can be tempted to peel them off. Place them perpendicular to the wound, sticking down one side first, then gently pinch the wound edges together, and secure the other side down. Ensure the wound edges are everted (the pinching helps). Leave approximately 3mm in between each strip. A parallel strip can be added to the ends of the strips at either side of the wound (not directly over it) to help prevent them peeling away. Cover with a regular dressing. I advise using tincture of Benzoin as an adjunct – it increases the adherence of the Steristrips© (and smells nice). If the area is likely to get wet (i.e. chin), a personal trick is covering the closed wound with a DuoDERM©, or equivalent dressing, as it will help it stay protected. Give the usual infection safety net advice to parents. I generally advise them to leave the Steristrips© in situ until they themselves fall off naturally (usually that gives plenty of time for the wound to heal). Steristrips© aren’t suitable for wounds that are under tension or likely to be subject to movement such as over joints.
Tissue adhesive has been covered in a separate blog post which can be found here
For most wounds being repaired in the ED, simple interrupted sutures are appropriate.
Simple interrupted dermal sutures can be absorbable (eg Vicryl Rapide©) or non-absorbable (eg nylon, Prolene©, Seralon©).
Absorbable sutures are useful under casts, where it’s not possible to remove them after a required time, or for wounds in young children where suture removal could cause distress and the wound is not in an area of cosmetic concern (e.g. scalp).
For facial wounds, non-absorbable sutures should be used, as absorbable sutures may not disintegrate prior to the epithelisation of the suture, leaving the stereotypical ‘dots’ either side of the wound site. Use the smallest suture possible. Holding the needle 2/3 along the curve with the needle-holder, always position the tip of the needle at a 90-degree angle to the skin, and using a supination movement rather than pushing or dragging the needle through the tissue, make a corresponding incision on the other side of the wound and tie the knot. Tying the knot parallel rather than perpendicular to the wound can result in better eversion and therefore better cosmetic outcome. Remember – approximate, don’t strangulate. The base of the suture should be wider than the top in cross-section – this gives strength to the wound and ensures no deep cavities are left. A useful trick in ensuring this shape to the stitch is to gently evert the second side of the wound as you’re passing the needle from deep to superficial. Sutures should be removed between day 3-5 on the face, and around day 7 on the rest of the body.
Geeky Medics have a lovely video on simple interrupted sutures.
Deep dermal sutures are sometimes required if the wound is under tension. In this case, a reverse suture from inside-out for the initial stitch, with a corresponding outside-in stitch on the far side allows you to bury the knot. An absorbable suture such as Vicryl© or Monocryl© is great for this. As the knot is being buried, only three throws should be used. With deep dermal sutures, the superficial dermal sutures should not be under tension and just provide a means to evert the wound edges. Deep sutures are at more risk of infection as you are leaving foreign material in the wound. For simple facial lacerations in children, they are often not necessary. The Children’s Hospital of Philadelphia has a great video on deep dermal sutures.
Bites: Bite wounds are prone to infection and therefore require antibiotic cover. They usually should be left to heal by secondary intention, as closure of these wounds can result in deep-seated infections. If they are deep to subcutaneous tissues, washout in theatre is likely more suitable than in the ED.
Large area superficial abrasion (eg road rash): These are difficult to treat and clean. The use of a porous sponge and surfactant cleaner is useful here. If it is extensive and the patient uncooperative, often sedation or GA is most appropriate.
Delayed presentation: Wounds that present after 24 hours are unsuitable for primary closure due to the high risk of infection. Thorough cleaning with regular dressings and close follow up with possible grafting or scar revision is often necessary.
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