Paediatric wound management

Goals of management

• Avoid infection
• Minimise discomfort
• Facilitate healing
• Minimise scar formation
• Fast all children from arrival
  • Fasting times (RCH guideline)
    • Oral agents: 2 hours solids and liquids
    • Nitrous oxide: 2 hours solids, 2 hours breastfed, 2 hours clear fluids
    • IV midazolam: 6 hours solids, 4 hours breastfed, 2 hours clear fluids 

Wound infection

• Relatively uncommon. 5% of ED wounds
• Less likely than adult wounds to become infected
• Risk factors
  • Severe wound contamination
  • Inadequate wound cleansing
  • Inadequate debridement of dead tissue (especially crush injuries)
  • Subcutaneous suture use
  • Larger lacerations >5cm
  • Site of injury (axillae, perineum, groin and feet
  • Limb > head/neck

Assessing distal nerve function

• Two-point discrimination in older children
  • Paper clip 4-8mm apart
• In younger children, noxious stimulus noted in nerve distribution suggests intact nerve function
  • Alternative is to check for sweating in area of skin innervated by nerve through ophthalmoscope OR running cleaned body of pen along skin with less resistance in dry skin vs. sweating (denervated skin will not sweat)

Assessment of wound

• Site, size, depth, nature of edges, cleanliness and debris
• Any underlying structural involvement
• X-ray if suspicious for FB or fracture
  • Most glass >2mm should be visible
• USS if radiolucent FB suspected

Anaesthesia

• ALA (adrenaline, lignocaine and amethocaine)
  • On cotton wool pledget in wound and occlusive dressing for 30 min
• EMLA
• Buffered lignocaine
  • 1mL 8.4% sodium bicarbone with 10mL 1% lignocaine
  • 25G or smaller needles
  • Lignocaine lasts 30 min – 1 hour (longer if adrenaline)
  • Lignocaine max 3mg/kg (or 6mg/kg with adrenaline)
• Nerve block
  • Lignocaine or Bupivacaine 0.5% max dose 2mg/kg
  • Digital blocks can be done under nitrous for more comfort
  • Single injection digital block preferred
• Bier’s block

Wound preparation and cleansing

• Hair only removed if necessary
  • Clipped, not shaved, as shaving disrupts follicle and increases infection risk
• Eyebrow hair should not be removed as leads to delayed abnormal regrowth
• Clean surrounding skin and wound edges with iodine or chlorhexidine (minimise entry into wound itself as impairs wound healing and may increase risk of infection)
• Debride any dead tissue
• Grease can be removed with bacitracin or polysporin ointment
• Thoroughly clean by irrigation with N/saline or tap water
  • 100-200mL per 2cm of laceration via 50mL syringe (10-20mL as per RCH) via 18 or 20G cannula
    • Any higher pressure may cause tissue damage and increase wound infection

Antibiotic prophylaxis

• Indications
  • Bites
  • Extensive tissue devitalisation
  • Stellate lacerations
  • Contamined with body fluids or organic matter/dirt
  • High risk for endocarditis
  • Immunocompromised
• Procaine penicillin 25-50mg/kg IM once then amoxicillin 10-20mg/kg q8h for 5 days (RCH)
• If contamined with faeces, cover coliforms and anaerobes

Wound closure

• Delayed primary closure for 3-5 days
  • Infected
  • Heavily contaminated
  • High-energy projectiles
  • Delayed presentation >24 hours
• Secondary intention
  • Puncture wounds
  • Bite wounds
  • Contaminated wounds in areas of poor perfusion

Wound closure – Sutures

• When to use absorbable?
  • Deep tissue layers
  • Difficult to remove
  • Procedural sedation required for placement
• When to use non-absorbable?
  • Fascial layers (slow healing so 60 days required)
  • Skin closure

Wound closure – sutures

• Size of suture
  • 6-0 over facial skin and subcutaneous tissue with light tension
  • 4-0 for limbs/trunk, mucous membranes and subcutaneous tissue
  • 3-0 on sole of foot and over large joints
• Tying
  • Initial 2 wraps of needle holder then wrapped once each time
  • Synthetic sutures require 4-5 throws per knot
• How close together?
  • Facial: 3mm apart and enter skin 3mm from wound edge
  • Other areas: 4-5mm and enter skin 5mm from wound edge
  • Can place them closer together, the better the blood supply

Wound closure – Correction of dog ears

• Dog ears can occur at one end of a wound that has been sutured
• Direct overlap excision technique
  • Redundant skin is pulled across wound from one side and excised along line of wound
  • Same done on other side
  • Suture placed

Wound closure – Staples

• More rapid application, lower rate of foreign body reaction and infection
• Useful for scalp, trunk and limbs
• More painful to remove
• Cosmetic outcome not as meticulous and should never be used on face or cosmetically crucial site

Wound closure – Skin adhesives

• Cyanoacrylate polymer
• Best for wounds <3cm and under minimal tension
• Polymerases in presence of hydroxyl ions
• Only external use. Never mucous membranes or within wounds
• Cosmetic results as good as suturing, with no risk of causing suture scars
• Slough off in 7-10 days
• If wound edges cannot be approximated with minimal tension then NOT appropriate
• Contact with excess blood causes polymerisation above skin, rather than adherence to the skin
• Repeated thin layers is best, holding approximated for 30 seconds
• Have intrinsic antimicrobial activity and act as their own dressing, providing moist environment for wound healing

Wound closure – skin tapes

• Used for small small wounds under minimal tension
• Prepare skin with tincture of benzoic compound to aid skin adhesion
• Cannot be used over joints
• Adhesive agents are often required to anchor skin tapes to neighbouring skin
• Not suitable for small children, as often pull them off
• Can be used on top of tissue adhesives to decrease tension across wound OR after suture removal

Post-wound closure care

• All patients should receive written information
• Dressings
  • Non-adherent dressing to prevent wound from bacterial invaion and provide moist healing environment
  • Ideally, dressing left intact until removal of sutures
  • Remove if saturated or needs inspection for ? Infection
  • Can remove every few days for showering if not water-proof
  • Wounds closed with tissue adhesives should not be covered in dressings as leads to glue breakdown due to moisture
• Keep wound dry for 2-3 days, after which can shower (but not bathe)
• Wounds closed with skin tape should be kept dry to prevent premature removal for at least 72 hours
• Splint should be applied if wound crosses joint i.e. POP or bulky dressing

Suture removal

• Face – 4 days
• Scalp – 5 days
• Upper limbs/trunk – 7-10 days
• Lower limbs– 8-10 days
• Over joints – 10-14 days

Abrasion management

• Cleansing is important to prevent infection and tattooing
• Large abrasions/heavily contaminated may require sedation/GA/nerve block
• Cover with non-adherent dressing as moist environment aids healing
• Children with large or deep abrasions should be reviewed in 2-3 days then once or twice weekly

Scalp lacerations

• Vaseline or comb hair away
• Close in two layers
  • Galea – Absorbable 3-0 to 5-0 PDS (30 days) or chromic cat gut
  • Skin – Nylon 4-0 to 5-0
  • Removal of sutures in 7 days (RCH) (5 days in Cameron)

Eyelid lacerations

• Must consider underlying eye injury
• VA must be documented
• Any wound that penetrates the tarsal plate, lid margins or inner canthus requires specialist review
• If cannot assess adequately, refer
• Superficial wounds require 6-0 fast absorbing gut with care not to penetrate tarsal plate or deeper structures

Lip lacerations

• Must inspect teeth and oral mucosa
• Missing teeth require confirmation that they have not been inhaled or imbedded in soft tissues of mouth
• 6-0 suture through vermillion border should be used
• Wet mucosal surface of lip only closed if gaping
• Deep or through-and-through lacerations require deep sutures to repair orbicularis oris muscle
  • Absorbable 6-0 suture should be used

Gum margin/gingiva laceration

• Requires referral to Dental/maxillo-facial surgery

Tongue lacerations

• Most left to heal by secondary intention
• When to repair
  • Large lacerations involving tongue edge (heal with a notch)
  • Large flaps that gape when tongue in resting position
  • Ongoing bleeding
• Heavy sedation or GA often required
• Interrupted 4-0 absorbable sutures should be used with full thickness bites including both mucosal surfaces and lingual muscle in each stitch
• Multiple knots should be used to prevent untying

Palatal lacerations

• Require suturing if gaping widely, extending through posterior free margin or continuing to bleed

Ear lacerations

• If full thickness or involving cartilage, consult Plastic surgery

Fingertip amputation

• Always evaluate for underlying fracture
• If amputated fragment retained and involves any of the nailbed, 50% chance of reimplantation
• If tissue not retained or is small and there is no bone on view, mostly secondary intention
• Fingertips allowed to heal naturally have better tip sensation and greater length than grafts
  • If >1cm2, refer for plastic surgery opinion
• Thoroughly clean and debride any dead tissue
• Cover with non-adherent occlusive dressing to allow moist healing
• Any injury with bone on view should be referred

Nailbed lacerations

• Always assess for underlying fracture
• If nail lacerated, completely avulsed or only loosely attached MUST assess the nailbed
  • Nail must be removed after ring block/single digital block and nailbed repaired with 5-0 or 6-0 absorbable suture
  • Can use dermabond glue as an alternative (esp. stellate lacerations)
  • Space between nailbed and nailfold must be packed with paraffin gauze or nail replaced to prevent adhesions
• If fracture present, needs cefazolin
• If nail partially avulsed and tightly adhered, leave in place to splint and maintain apposition of nailbed injury

Subungual haematoma

• Drainage of haematoma indicated if causing considerable pain and >50% of nail area
• If <50% of nail area treat with ice and analgesia only
• Cautery or needle burring with 19G needle
• If underlying fracture, cephazolin required
• Nail removal for inspection of nailbed should NOT be undertaken

Puncture wounds to foot

• High infection risk and FB risk
• Local or posterior tibial nerve block required for assessment
• Leave open
• Clean with antibacterial solution and apply non-adherent dressing
• Close clinical review
• Prophylactic antibiotics do not prevent infection and predispose to Pseudomonas

Dog bites

• Dog bites
  • 6x more common than cats
  • Usually facial/scalp/neck in children
  • 10% infection rates (face around 5% rate)
  • Cleanse and close most dog bites, with antibiotic prophylaxis only if high risk for infection
    • Hand/over joint/below knee/through-and-through oral, puncture, extensive crush injury or >24 hours old
  • Augmentin if indicated

Cat Bites

• Cat bites
  • Typically puncture wounds with less surrounding soft tissue damage
  • Bacteria inoculated deep in wound and higher risk of infection (2x at least)
  • Mostly hand
  • Pasteurella multocida found in 80% of cats mouths (Facultative anaerobic gram-negative rod causing rapidly progressive celllulitis
  • Sensitive to penicillins. Treatment failures with first-gen cephalosporins and erythromycin have been reported

Human bites

• Most probably not at increased risk of infection than ordinary lacerations
• Prophylactic antibiotics HAVE been shown to prevent infection
• Augmentin is appropriate
• Fight bites is very high risk
• Prophylactic antibiotics recommended if:
  • Some practitioners cover all
  • Hand/over joint/through and through oral
  • Puncture
  • Extensive crush injury
  • >24 hours old

Management of bite wounds

High risk criteria include:

• Hand, over joint, through-and-through oral
• Puncture wounds, extensive crush injury or >24 hours old

Tetanus prophylaxis

Tetanus boosters

• <8 years old: DTPa-IPV (<10 in RCH guideline)
• >8 years old: dTpa
• If <10yo: Only need boosters. No requirement for Tetanus Ig (RCH) unless significant humoral immunodeficiency
• Can use ADT if pertussis vaccination contraindicated
• Should consider DTPa in expectant mothers/soon-to-be or new fathers/grandparents/carers
• Tetanus vaccinations are delivered at 2,4,6 and18 months, 4 years and 10-15 year booster
• Therefore, any child over 6 months of age, should have received 3 doses

Last Updated on October 13, 2021 by Andrew Crofton