Traumatic wounds and lacerations are common pediatric presenting complaints to emergency departments. Although there is a large body of literature on wound care, many emergency clinicians base management of wounds on theories and techniques that have been passed down over time. Therefore, controversial, conflicting, and unfounded recommendations are prevalent. This issue reviews evidence-based recommendations for wound care and management, including wound cleansing and irrigation, anxiolysis/sedation techniques, closure methods, and post-repair wound care.
A 2-year-old boy presents with a chin laceration that occurred when he ran into a wall 23 hours ago. The family cleaned the wound with water and applied a bandage. The boy is very upset and screams and runs away when you try to remove the bandage. The resident you are working with asks if the wound should be closed primarily or if it should be allowed to heal via secondary intention. He also asks you what the best way is to handle toddlers who require local wound care.
A 12-month-old girl presents with 2 C-shaped lacerations on her upper arm with some surrounding bruising. The family reports that she fell. After evaluating the child and the wound, you have some concerns that this wound may have been inflicted. The medical student shadowing you asks why you think that.
Wounds and skin injuries are among the most common presenting complaints to emergency departments (EDs). More than 6 million lacerations are treated each year in United States EDs.1 Most children, at some point, are likely to sustain accidental trauma and minor wounds due to their developmental states, curious nature, and risk-taking behavior.
Despite a large body of literature on wound care, controversial, conflicting, and unfounded recommendations still remain.2 Clinicians may develop their wound care practice based on dogma or word-of-mouth, and there is great variability among emergency clinicians on the preparation and treatment of wounds.3 A widely accepted standard of care does not exist.
Most wounds heal well, which is more likely due to the body’s innate ability for healing than to medical intervention. Nevertheless, it is prudent to know ideal methods and recommendations for wound care. This issue of Pediatric Emergency Medicine Practice reviews major aspects of wound care, including cleansing, repair methods, and post wound care. Evidence-based recommendations are distinguished from unfounded traditional practices.
A search was performed in PubMed for articles pertaining to, but not limited to, children using multiple combinations of the search terms wound, laceration, traumatic wound, animal bite, human bite, tissue adhesive, cyanoacrylate, adhesive strips, staples, hair apposition, and antibiotic prophylaxis. The Cochrane Database of Systematic Reviews was also searched and articles relevant to traumatic wound care were reviewed. Over 300 articles were reviewed, 146 of which were chosen for inclusion, including a number of randomized controlled trials, meta-analyses, and clinical practice guidelines.
1. “I use topical antibiotic ointment on all the wounds I close.”
Topical creams and ointments will dissolve tissue adhesives. Patients and families should be encouraged not to apply ointments over tissue adhesives.
2. “The patient wouldn’t sit still, so I called the plastic surgeon.”
While specialist consultation may be appropriate depending on the wound and the family’s wishes, managing anxiety and pain will be necessary whether the repair is done by a specialist or the emergency clinician.
3. “The family said that no glass got into the wound, so I proceeded with the repair.”
If the index of suspicion for a foreign body is high, the emergency clinician should proceed with appropriate imaging to evaluate whether a foreign body is present. Retained foreign bodies are a risk factor for wound infection.
4. “The bite wound on the child’s hand was small and appeared clean, so I closed it using tissue adhesive.”
Tissue adhesives are not recommended for use on animal-bite repairs, stellate wounds, infected wounds, mucosal surfaces, or areas of high moisture or dense hair.70
5. “I thought the hand wound was trauma from a punch. I did not consider that it might have been a fight bite.”
Clenched-fist injuries occur when a closed fist strikes the teeth of another (ie, fight bite), which can result in a hand infection. A careful history can help to determine whether there was any contact with teeth. Because 10% to 15% of human bites become infected, these patients should be given prophylactic antibiotics. Fight bites may also incur tendon injury that may not be readily apparent on initial examination.
6. “Wound adhesives cause increased infectious complications and have a poorer cosmetic outcome compared to sutures, so I don’t use them”
Recent randomized controlled trials have shown that wound adhesive has no increased rates of infection compared to sutures.71,72,76 Studies have also found similar cosmetic outcomes when comparing wound adhesive to sutures.62,66
7. “Use of an absorbable suture to close a wound will result in a poorer cosmetic outcome, so I always use nonabsorbable sutures.”
Several studies have evaluated the cosmetic outcome and patient satisfaction with absorbable and nonabsorbable sutures, and have found absorbable sutures to be noninferior to nonabsorbable sutures.63 Some studies have found that caregivers prefer absorbable sutures over nonabsorbable sutures.64
8. “I give systemic antibiotics to all of my patients with traumatic lacerations.”
Evidence has not shown benefit in prescribing systemic antibiotics for clean, simple lacerations.
9. “The wound looked dirty, so I squirted some povidone-iodine in the wound to clean it.”
Many antiseptics have been found to have detrimental effects on wound healing at the cellular level,19,130,131 with no significant difference in infection rates.132 Wounds that appear dirty or contaminated should be thoroughly irrigated to remove debris.
10. “My patient had a simple chin laceration, so I didn’t take a thorough medical history.”
Obtaining a thorough past medical history can reveal conditions that may cause poor wound healing. Patients and families should be made aware that wounds may not heal as quickly or as well if there are pre-existing conditions that affect wound healing.
Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.
To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference.
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Wound closure types are categorized into primary, secondary, or tertiary. Primary closure is healing by primary or first intention in clean wounds with minimal tissue loss that are amenable to approximation of wound edges. Primary closure is ideally performed within 6 to 8 hours of trauma, but wounds in vascular areas may be delayed to up to 24 hours after trauma.
Secondary closure is healing by secondary or second intent. The wound is left open to heal largely by the formation of granulation tissue and contraction. These wounds often have significant tissue loss precluding tension-free approximation of edges, with devitalized edges, ulcerations, or abscess cavities. Wound dressings are changed at least daily to aid in the formation of granulation tissue and subsequent contraction.
Tertiary closure, also known as delayed primary closure, is healing by tertiary or third intention. The decision is made to perform a delayed closure of a wound after a variable period of time for which the wound has been left open. These wounds are grossly contaminated but do not have significant tissue loss, and can potentially be closed after the wound is thoroughly explored, irrigated, debrided, and observed for 3 to 7 days before surgical closure or skin grafting. The closure of these wounds can potentially be expedited with negative-pressure vacuum therapy (Kugler 2016, Vargo 2012, Kaushik 2017, Cherubino 2017).
Why to Use
The type and timing of wound closure in traumatic or contaminated wounds plays a role in the incidence of surgical site infections. Surgical site infections are a source of significant morbidity to the patient and result in increased health care costs.
When to Use
Management will depend on the diagnosed pathology or injury, and wound closure will differ depending on the clinical scenario, as previously mentioned.
Jennie Kim, MD
Ronald Simon, MD
Primary Closure (PC) versus Delayed Primary Closure (DPC)
In 2013, Bhangu et al performed a systematic review and meta-analysis of 8 randomized control trials (RCTs) comparing primary versus delayed primary skin closure in specifically contaminated (United States Centers for Disease Control and Prevention’s National Healthcare Safety Network wound class III) and dirty/infected (United States Centers for Disease Control and Prevention’s National Healthcare Safety Network wound class IV) abdominal incisions. The review concluded that DPC may represent a simple, reliable, and potentially cost-effective method of reducing surgical site infections (SSI), but the analysis was inconclusive due to the poor study designs, high risk of bias, and clinical heterogeneity.
Timing of Wound Closure in Open Fractures
In 2015, Halawi and Morwood performed an evidence-based review of the acute management of open fractures. When looking specifically at the timing of wound closure, the review referenced the following 2 studies:
David Leaper, MD, ChM, DSc, FRCS, FACS, FLS
Copyright © MDCalc • Reprinted with permission.
Jennifer E. Sanders, MD
October 2, 2017
November 1, 2020
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma CME, 1 Pain Management CME, 0.25 Infectious Disease CME, and 0.5 Pharmacology CME credits
Date of Original Release: October 1, 2017. Date of most recent review: September 15, 2017. Termination date: October 1, 2020.
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