Paediatric Acute care Guidelines PMH Emergency Department

Background

  • Minor wounds and lacerations are common injuries in children
  • Goals of treatment include:
    • Restoring function and structural integrity
    • Prevention of infection
    • Cosmetically acceptable healing
    • Minimising distress to the child and parents during wound repair  

Assessment 

History 
To determine the best management for the child’s wound the following information should be considered: 
Mechanism of Injury – will assist in determining the degree of devitalised tissue in the surrounding area
  Shearing sharp cuts, high velocity missiles
  Tension flap lacerations, avulsion injuries
  Compression direct blow causing both laceration and haematoma 
Patient Factors – identify risk factors that may delay healing or cause infection / complications
  General health e.g. diabetes, malnutrition, shock, anaemia, renal failure, tendency to form keloid scars
  Medication e.g. steroids or immunosuppressive drugs
  Tetanus status Refer to Tetanus Prophylaxis
 Environment – where the wound occurred  will determine likely contamination 
  Age of wound  
Examination 
Assess wound  Extent of Wound  Size, shape, site, structure and sensation
  Deeper structures Tendons, nerves, bones – check distal function, check for fractures – X-Ray if indicated
  Blood supply Flaps may be dusky, be mindful of damage to end arteries
  Contamination  Dirt, foreign bodies – may require X-Ray or Ultrasound
Tetanus prone wounds Tetanus can follow apparently trivial, even unnoticed wounds. However, some wounds tend to favour the growth of tetanus organisms: refer to Tetanus Prophylaxis for information regarding tetanus prone wounds. 

Management 

Wounds Requiring Surgical Referral 
Signs of vascular injury or compromise
Wounds requiring exploration and possible repair of deeper structures
Extremely large wounds – e.g. face > 3cm laceration 
Extensive repair in sensitive areas eg perineum, medial canthus eye 
Compound fractures
Highly contaminated wounds which require thorough debridement
Uncooperative patient unable to be adequately sedated by conscious sedation
Wounds requiring optimal cosmetic repair  

 

Specific Wounds
Lip 
Requires exact approximation of the Vermillion border. May require plastics referral.

Tongue and Intraoral
Most of these lacerations in children will heal without suturing. Exceptions are free edge of 
tongue involved or involving facial nerve and salivary ducts.

Eyelids 
May require referral to Ophthalmology, especially if fat exposed, deep involving muscles
or medial lacerations affecting tear duct structures  – refer to Eye Trauma
Bites
Common injuries prone to infection. All require prophylactic antibiotics – refer to Antibiotics
  • Human Bites
    • Often involved in high impact mechanisms i.e. fist fights or sports injuries
      resulting in tissue crush and devitalisation.
    • Should not be closed unless thoroughly irrigated and debrided. 
  • Animal Bites
    • Most common dog bite, then cat
    • Requires meticulous wound preparation
    • Rabies prophylaxis not required for bites in Australia, but beware patients
      presenting from Asian destinations – refer to Rabies and Lyssavirus
Foreign Body 
  • X-Ray if foreign body (FB) is radio-opaque for identifying position
  • Ultrasound may be necessary for determining presence of radiolucent FB
  • Wound exploration is essential, this often requires local anaesthetic (nerve block
    useful for difficult to inject areas) or general anaesthesia
  • Deep foot FB to be referred to Orthopaedics
Contaminated
  • Thorough irrigation with 0.9% saline and debridement is essential – may require antiseptic liquid (Chlorhexidine 0.05% or 1% Providine-Iodine)
  • Delayed primary closure for 4-5 days may be useful in grossly contaminated wounds

Procedure

  • Minimise distress to the child and parent during the procedure with appropriate analgesia, local anaesthesia and/or sedation
  • Obtain necessary resources for treatment. If in doubt, consult with a senior medical officer or nurse.

Local Anaesthetic

  • Infiltration with local anaesthetic (e.g. 1% lignocaine)
  • ALA or Laceraine- refer to Anaesthesia – Topical
  • Regional nerve blocks – refer to appropriate guideline

Analgesia and sedation

Cleaning and irrigation

  • Irrigate with 0.9% saline using a large bore needle and syringe to remove obvious foreign material.
  • Antiseptics may damage tissue defences and potentially impede healing. Exception – contaminated wounds may benefit from Chlorhexidine 0.05% or Povidone-iodine irrigation. 

Debridement 

  • Can reduce wound infections by removing debris, bacteria and devitalised tissues
  • May make a jagged wound into a long wound requiring too much tension and wider scar
  • Hair can be trimmed around lacerations but avoid shaving large patches
  • Never shave eyebrows
Wound Repair Options
  Suitable wound  Comments
Wound tapes (Steristrips or Skinlinks)

Suitable for simple linear lacerations with minimal tension. 

Not useful on wet (oozing) areas or lacerations with surrounding abrasions.  

Prepare intact adjacent skin with tincture of benzoin to aid adhesion, but avoid contaminating wound with it (causes severe pain). 
Use Leukosan ™ Skinlink as per directions

Tissue adhesive (e.g. Dermabond)

Suitable for simple superficial lacerations (less than 3cm) especially on the face. 

Avoid accidental spillage into the eye by careful positioning of patient and use of gauze. The applicator tip should never be pressed into the wound. 

Suturing 

Suitable for clean uninfected wounds where the depth will lead to excess scarring if the edges are not properly opposed. Typically this is when the laceration extends through the dermis. 

Absorbable (chromic) sutures are suitable for deep structures. 

In general use interrupted sutures. 
Nylon monofilament preferable to silk to reduce suture marks. 
To avoid the need for removal absorbable (chromic) sutures maybe appropriate if the wound is not under tension, particularly in the frightened and uncooperative child. 

Staples

Suitable alternative for linear lacerations through the dermis that have straight edges on the scalp, trunk, arms and legs.
Staples will create artefacts on CT scans if imaging is required. 

Can be more painful and cosmetically may cause more scarring. Can be placed more rapidly than sutures. Place staples approximately 0.5 – 1cm apart.  

 

Post Repair Wound Care 
Dressings Wounds and dressing guide
Antibiotics  Not a substitute for meticulous irrigation and debridement. If indicated initiate early. 
Elevation  
Immobilisation   
Tetanus  Ensure Tetanus prophylaxis +/‐ Ig for tetanus prone wounds in non immunised patients   
refer to Tetanus prophylaxis
Sun Exposure Healing wounds are more sensitive to the sun. Sun protection maybe required for at least two years post injury. 
Removal of sutures 3-5 days face, 7 days scalp, upper limb, anterior trunk, 10-14 days lower limb and back. 
Removal of staples  1 week (provide staple remover to parents for LMO to remove)
Tissue adhesive Remains for 1-2 weeks. Does not require removal.
Leukosan™ Skinlink™ Remain for up to 10 days. Does not require removal. If Skinlink™ begins to curl, the edges may be trimmed with scissors. Limited bathing. Always pat dry if exposed to moisture. Do not scrub.
Wound tapes Do not remain in place for long periods. Keep dry for 24 hours. Limit bathing. Always pat dry if exposed to moisture. 
Health fact sheet

Steristrip
Wound closure with Leukosan™ Skinlink™
Wound closure with Dermabond™ (glue)
Suture Care
Staple care
Care of minor lacerations/abrasions

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