Pediatric Wound Care and Management in the Emergency Department

Table of Contents

 

Although wounds and lacerations are some of the most common presenting complaints to EDs, recommendations for proper wound management can be contradictory and are often not supported by the literature. In this issue, you will learn:

Risk factors that affect wound healing and infection rates

Solutions that can safely and effectively irrigate wounds

Techniques and treatments to prevent pain and anxiety during wound closure

Methods for primary wound closure and how to use them appropriately

When antibiotic prophylaxis is necessary

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
6. Differential Diagnosis
7. Prehospital Care
8. Emergency Department Evaluation
   1. History
   2. Physical Examination
9. Diagnostic Studies
   1. Laboratory Studies
   2. Imaging Studies
10. Treatment
    1. Timing of Wound Closure
    2. Wound Irrigation and Cleansing
       1. Wound Irrigation Solutions
       2. Wound Irrigation Volume and Pressure
    3. Anesthesia
       1. Topical Anesthesia
       2. Intradermal Anesthesia
       3. Nerve Blocks
    4. Anxiolysis/Sedation
    5. Wound Closure
    6. Sutures
       1. Suture Materials
       2. Suturing Techniques
          • Simple Interrupted Suture
          • Running Suture and Locked Running Suture
          • Running Subcuticular Suture
          • Mattress Suture
          • Corner Stitch
    7. Tissue Adhesive
    8. Staples
    9. Hair Apposition
    10. Adhesive Strips
    11. Antibiotic Prophylaxis
    12. Tetanus Prophylaxis
    13. Post-Repair Wound Care
11. Special Circumstances
    1. Specialist Consultation
    2. Bite Wounds
       1. History and Physical Examination for Bite Wounds
       2. Treatment of Bite Wounds
       3. Human Bites
    3. Surgical Site Infections
12. Controversies and Cutting Edge
    1. Honey
    2. Scar Management
13. Disposition
14. Key Points
15. Summary
16. Risk Management Pitfalls in the Management of Wounds in Pediatric Patients
17. Time- and Cost-Effective Strategies
18. Case Conclusions
19. Clinical Pathway for Management of Wounds in Pediatric Patients
20. Tables and Figures
    1. Table 1. Irrigation Methods and Delivered Pressure
    2. Table 2. Maximum Lidocaine Dosage
    3. Table 3. Types and Properties of Suture Materials
    4. Table 4. Recommended Suture Material Sizes and Duration, Based on Location
    5. Table 5. High-Risk Wound Characteristics
    6. Table 6. Post Wound Tetanus Vaccination Guidelines
    7. Figure 1. Simple Interrupted Suture
    8. Figure 2. Locked Running Suture
    9. Figure 3. Running Subcuticular Suture
    10. Figure 4. Vertical Mattress Suture
    11. Figure 5. Horizontal Mattress Suture
    12. Figure 6. Corner Stitch
    13. Figure 7. Hair Apposition Technique
    14. Figure 8. Zig-Zag Technique
21. References

Abstract

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.

Case Presentations

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.

Introduction

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.

Critical Appraisal of the Literature

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.

Risk Management Pitfalls in the Management of Wounds in Pediatric Patients

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.

Tables and Figures

References

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.

1. Hollander JE, Singer AJ. Laceration management. Ann Emerg Med. 1999;34(3):356-367. (Review)
2. Berk WA, Welch RD, Bock BF. Controversial issues in clinical management of the simple wound. Ann Emerg Med. 1992;21(1):72-80. (Review)
3. Howell JM, Chisholm CD. Outpatient wound preparation and care: a national survey. Ann Emerg Med. 1992;21(8):976-981. (Survey; 151 responses)
4. Childs DR, Murthy AS. Overview of wound healing and management. Surg Clin North Am. 2017;97(1):189-207. (Review)
5. Nicks BA, Ayello EA, Woo K, et al. Acute wound management: revisiting the approach to assessment, irrigation, and closure considerations. Int J Emerg Med. 2010;3(4):399-407. (Review)
6. * Berk WA, Osbourne DD, Taylor DD. Evaluation of the ‘golden period’ for wound repair: 204 cases from a Third World emergency department. Ann Emerg Med. 1988;17(5):496-500. (Prospective study; 372 patients)
7. van den Baar MT, van der Palen J, Vroon MI, et al. Is time to closure a factor in the occurrence of infection in traumatic wounds? A prospective cohort study in a Dutch Level 1 trauma centre. Emerg Med J. 2010;27(7):540-543. (Prospective study; 425 patients)
8. Waseem M, Lakdawala V, Patel R, et al. Is there a relationship between wound infections and laceration closure times? Int J Emerg Med. 2012;5(1):32. (Prospective study; 297 patients)
9. Quinn JV, Polevoi SK, Kohn MA. Traumatic lacerations: what are the risks for infection and has the ‘golden period’ of laceration care disappeared? Emerg Med J. 2014;31(2):96-100. (Prospective study; 2663 patients)
10. Stevenson TR, Thacker JG, Rodeheaver GT, et al. Cleansing the traumatic wound by high pressure syringe irrigation. JACEP. 1976;5(1):17-21. (Comparative study)
11. Block L, King TW, Gosain A. Debridement techniques in pediatric trauma and burn-related wounds. Adv Wound Care (New Rochelle). 2015;4(10):596-606. (Review)
12. Angeras MH, Brandberg A, Falk A, et al. Comparison between sterile saline and tap water for the cleaning of acute traumatic soft tissue wounds. Eur J Surg. 1992;158(6-7):347-350. (Randomized controlled trial; 705 patients)
13. Thompson S. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Wound cleaning methods. J Accid Emerg Med. 1999;16(1):63-64. (Review)
14. Weiss EA, Oldham G, Lin M, et al. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013;3(1):1-6. (Randomized controlled trial; 663 patients)
15. * Fernandez R, Griffiths R. Water for wound cleansing. Cochrane Database Syst Rev. 2012(2):CD003861. (Meta-analysis; 11 trials)
16. Valente JH, Forti RJ, Freundlich LF, et al. Wound irrigation in children: saline solution or tap water? Ann Emerg Med. 2003;41(5):609-616. (Prospective study; 271 patients)
17. Roberts AH, Roberts FE, Hall RI, et al. A prospective trial of prophylactic povidone iodine in lacerations of the hand. J Hand Surg Br. 1985;10(3):370-374. (Randomized controlled trial; 418 patients)
18. Gravett A, Sterner S, Clinton JE, et al. A trial of povidone-iodine in the prevention of infection in sutured lacerations. Ann Emerg Med. 1987;16(2):167-171. (Randomized controlled trial; 500 patients)
19. Brennan SS, Leaper DJ. The effect of antiseptics on the healing wound: a study using the rabbit ear chamber. Br J Surg. 1985;72(10):780-782. (In vivo rabbit study; 10 rabbit ears)
20. Van den Broek PJ, Buys LF, Van Furth R. Interaction of povidone-iodine compounds, phagocytic cells, and microorganisms. Antimicrob Agents Chemother. 1982;22(4):593-597. (In vivo study)
21. Bennett LL, Rosenblum RS, Perlov C, et al. An in vivo comparison of topical agents on wound repair. Plast Reconstr Surg. 2001;108(3):675-687. (Comparative study)
22. Liu JX, Werner JA, Buza JA 3rd, et al. Povidone-iodine solutions inhibit cell migration and survival of osteoblasts, fibroblasts, and myoblasts. Spine (Phila Pa 1976). 2017. (In vitro study)
23. Balin AK, Pratt L. Dilute povidone-iodine solutions inhibit human skin fibroblast growth. Dermatol Surg. 2002;28(3):210-214. (Prospective in vitro study)
24. Wilson JR, Mills JG, Prather ID, et al. A toxicity index of skin and wound cleansers used on in vitro fibroblasts and keratinocytes. Adv Skin Wound Care. 2005;18(7):373-378. (Prospective in vitro study)
25. Chisholm CD, Cordell WH, Rogers K, et al. Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Ann Emerg Med. 1992;21(11):1364-1367. (Randomized controlled trial; 550 patients)
26. Lammers RL, Hudson DL, Seaman ME. Prediction of traumatic wound infection with a neural network-derived decision model. Am J Emerg Med. 2003;21(1):1-7. (Prospective study; 1142 wounds)
27. Chatterjee JS. A critical review of irrigation techniques in acute wounds. Int Wound J. 2005;2(3):258-265. (Review)
28. Longmire AW, Broom LA, Burch J. Wound infection following high-pressure syringe and needle irrigation. Am J Emerg Med. 1987;5(2):179-181. (Letter to the Editor)
29. Edlich RF, Rodeheaver GT, Morgan RF, et al. Principles of emergency wound management. Ann Emerg Med. 1988;17(12):1284-1302. (Review)
30. Brown LL, Shelton HT, Bornside GH, et al. Evaluation of wound irrigation by pulsatile jet and conventional methods. Ann Surg. 1978;187(2):170-173. (Prospective study; 234 rats)
31. Wheeler CB, Rodeheaver GT, Thacker JG, et al. Side-effects of high pressure irrigation. Surg Gynecol Obstet. 1976;143(5):775-778. (In vivo study)
32. Rodeheaver GT, Smith SL, Thacker JG, et al. Mechanical cleansing of contaminated wounds with a surfactant. Am J Surg. 1975;129(3):241-245. (Animal study)
33. Singer AJ, Hollander JE, Subramanian S, et al. Pressure dynamics of various irrigation techniques commonly used in the emergency department. Ann Emerg Med. 1994;24(1):36-40. (Matched experimental trial; 10 patients)
34. Morse JW, Babson T, Camasso C, et al. Wound infection rate and irrigation pressure of two potential new wound irrigation devices: the port and the cap. Am J Emerg Med. 1998;16(1):37-42. (Randomized controlled trial; 208 patients)
35. Moscati RM, Reardon RF, Lerner EB, et al. Wound irrigation with tap water. Acad Emerg Med. 1998;5(11):1076-1080. (Randomized blinded crossover study; 10 animals)
36. Hollander JE, Singer AJ, Valentine SM, et al. Risk factors for infection in patients with traumatic lacerations. Acad Emerg Med. 2001;8(7):716-720. (Cross-sectional study; 5521 patients)
37. Gross A, Cutright DE, Bhaskar SN. Effectiveness of pulsating water jet lavage in treatment of contaminated crushed wounds. Am J Surg. 1972;124(3):373-377. (Comparative study; 200 rats)
38. Fry DE. Pressure irrigation of surgical incisions and traumatic wounds. Surg Infect (Larchmt). 2017;18(4):424-430. (Review)
39. * Eidelman A, Weiss JM, Baldwin CL, et al. Topical anaesthetics for repair of dermal laceration. Cochrane Database Syst Rev. 2011(6):CD005364. (Meta-analysis; 23 trials)
40. Pryor GJ, Kilpatrick WR, Opp DR. Local anesthesia in minor lacerations: topical TAC vs lidocaine infiltration. Ann Emerg Med. 1980;9(11):568-571. (Randomized controlled trial; 158 patients)
41. Grant SA, Hoffman RS. Use of tetracaine, epinephrine, and cocaine as a topical anesthetic in the emergency department. Ann Emerg Med. 1992;21(8):987-997. (Review)
42. Ernst AA, Marvez-Valls E, Nick TG, et al. LAT (lidocaine-adrenaline-tetracaine) versus TAC (tetracaine-adrenaline-cocaine) for topical anesthesia in face and scalp lacerations. Am J Emerg Med. 1995;13(2):151-154. (Randomized controlled trial; 95 patients)
43. Schilling CG, Bank DE, Borchert BA, et al. Tetracaine, epinephrine (adrenalin), and cocaine (TAC) versus lidocaine, epinephrine, and tetracaine (LET) for anesthesia of lacerations in children. Ann Emerg Med. 1995;25(2):203-208. (Randomized controlled trial; 171 patients)
44. Adler AJ, Dubinisky I, Eisen J. Does the use of topical lidocaine, epinephrine, and tetracaine solution provide sufficient anesthesia for laceration repair? Acad Emerg Med. 1998;5(2):108-112. (Randomized controlled trial; 60 patients)
45. Ernst AA, Marvez E, Nick TG, et al. Lidocaine adrenaline tetracaine gel versus tetracaine adrenaline cocaine gel for topical anesthesia in linear scalp and facial lacerations in children aged 5 to 17 years. Pediatrics. 1995;95(2):255-258. (Randomized controlled trial; 95 patients)
46. Harman S, Zemek R, Duncan MJ, et al. Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled trial. CMAJ. 2013;185(13):E629-E634. (Randomized controlled trial; 221 patients)
47. Ilicki J. Safety of epinephrine in digital nerve blocks: a literature review. J Emerg Med. 2015;49(5):799-809. (Review)
48. * Cepeda MS, Tzortzopoulou A, Thackrey M, et al. WITHDRAWN: Adjusting the pH of lidocaine for reducing pain on injection. Cochrane Database Syst Rev. 2015(5):CD006581. (Meta-analysis; 23 studies; withdrawn because study non-compliant with updated Commercial Sponsorship Policy)
49. Scarfone RJ, Jasani M, Gracely EJ. Pain of local anesthetics: rate of administration and buffering. Ann Emerg Med. 1998;31(1):36-40. (Prospective study; 42 patients)
50. Bartfield JM, Sokaris SJ, Raccio-Robak N. Local anesthesia for lacerations: pain of infiltration inside vs outside the wound. Acad Emerg Med. 1998;5(2):100-104. (Randomized controlled trial; 63 patients)
51. * Hogan ME, vanderVaart S, Perampaladas K, et al. Systematic review and meta-analysis of the effect of warming local anesthetics on injection pain. Ann Emerg Med. 2011;58(1):86-98 e81. (Meta-analysis; 19 studies)
52. Antevy PM, Zuckerbraun NS, Saladino RA, et al. Evaluation of a transthecal digital nerve block in the injured pediatric patient. Pediatr Emerg Care. 2010;26(3):177-180. (Prospective study; 48 patients)
53. Lynch MT, Syverud SA, Schwab RA, et al. Comparison of intraoral and percutaneous approaches for infraorbital nerve block. Acad Emerg Med. 1994;1(6):514-519. (Randomized controlled trial; 12 patients)
54. * Uman LS, Birnie KA, Noel M, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2013(10):CD005179. (Meta-analysis; 39 trials)
55. Tsze DS, Woodward HA. The “facemask blinder”: a technique for optimizing anxiolysis in children undergoing facial laceration repair. Pediatr Emerg Care. 2016. (Case report)
56. Connors K, Terndrup TE. Nasal versus oral midazolam for sedation of anxious children undergoing laceration repair. Ann Emerg Med. 1994;24(6):1074-1079. (Randomized controlled trial; 58 patients)
57. Tsze DS, Ieni M, Fenster DB, et al. Optimal volume of administration of intranasal midazolam in children: a randomized clinical trial. Ann Emerg Med. 2016. (Randomized controlled trial; 99 patients)
58. Nemeth M, Jacobsen N, Bantel C, et al. Intranasal analgesia and sedation in pediatric emergency care-a prospective observational study on the implementation of an institutional protocol in a tertiary children’s hospital. Pediatr Emerg Care. 2017. doi:10.1097/PEC.0000000000001017. (Prospective; 100 patients)
59. Peerbhay F, Elsheikhomer AM. Intranasal midazolam sedation in a pediatric emergency dental clinic. Anesth Prog. 2016;63(3):122-130. (Prospective; 118 patients)
60. Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med. 1989;18(2):177-181. (Randomized controlled trial; 34 children)
61. Luhmann JD, Kennedy RM, Porter FL, et al. A randomized clinical trial of continuous-flow nitrous oxide and midazolam for sedation of young children during laceration repair. Ann Emerg Med. 2001;37(1):20-27. (Randomized controlled trial; 204 patients)
62. Perelman VS, Francis GJ, Rutledge T, et al. Sterile versus nonsterile gloves for repair of uncomplicated lacerations in the emergency department: a randomized controlled trial. Ann Emerg Med. 2004;43(3):362-370. (Randomized controlled trial; 816 patients)
63. * Xu B, Xu B, Wang L, et al. Absorbable versus nonabsorbable for skin closure: a meta-analysis of randomized controlled trials. Ann Plast Surg. 2016;76(5):598-606. (Meta-analysis; 19 trials)
64. * Luck R, Tredway T, Gerard J, et al. Comparison of cosmetic outcomes of absorbable versus nonabsorbable sutures in pediatric facial lacerations. Pediatr Emerg Care. 2013;29(6):691-695. (Randomized controlled trial; 89 patients)
65. Hochberg J MK, Marion MD. Suture choice and other methods of skin closure. Surg Clin North Am. 2009(89):627-641. (Review)
66. Quinn J, Wells G, Sutcliffe T, et al. A randomized trial comparing octylcyanoacrylate tissue adhesive and sutures in the management of lacerations. JAMA. 1997;277(19):1527-1530. (Randomized controlled trial; 130 patients)
67. Bruns TB, Worthington JM. Using tissue adhesive for wound repair: a practical guide to dermabond. Am Fam Physician. 2000;61(5):1383-1388. (Review)
68. Mattick A, Clegg G, Beattie T, et al. A randomised, controlled trial comparing a tissue adhesive (2-octylcyanoacrylate) with adhesive strips (Steristrips) for paediatric laceration repair. Emerg Med J. 2002;19(5):405-407. (Randomized controlled trial; 44 patients)
69. Leahey AB, Gottsch JD, Stark WJ. Clinical experience with N-butyl cyanoacrylate (Nexacryl) tissue adhesive. Ophthalmology. 1993;100(2):173-180. (Prospective, 44 patients)
70. Beam JW. Tissue adhesives for simple traumatic lacerations. J Athl Train. 2008;43(2):222-224. (Meta-analysis; 11 studies)
71. Singer AJ, Hollander JE, Valentine SM, et al. Prospective, randomized, controlled trial of tissue adhesive (2-octylcyanoacrylate) vs standard wound closure techniques for laceration repair. Acad Emerg Med. 1998;5(2):94-99. (Prospective randomized controlled trial; 124 patients)
72. Bruns TB, Robinson BS, Smith RJ, et al. A new tissue adhesive for laceration repair in children. J Pediatrics. 1998;132(6):1067-1070. (Randomized controlled trial; 83 patients)
73. Quinn JV, Drzewiecki A, Li MM, et al. A randomized, controlled trial comparing a tissue adhesive with suturing in the repair of pediatric facial lacerations. Ann Emerg Med. 1993;22(7):1130-1135. (Randomized controlled trial; 81 patients)
74. Applebaum JS, Zalut T, Applebaum D. The use of tissue adhesion for traumatic laceration repair in the emergency department. Ann Emerg Med. 1993;22(7):1190-1192. (Prospective study; 143 patients)
75. Farion KJ, Osmond MH, Hartling L, et al. Tissue adhesives for traumatic lacerations: a systematic review of randomized controlled trials. Acad Emerg Med. 2003;10(2):110-118. (Review)
76. * Farion K, Osmond M, Hartling L, et al. Tissue adhesives for traumatic lacerations in children and adults. Cochrane Database Syst Rev. 2002(3):CD003326. (Meta-analysis; 8 studies)
77. Bruns TB, Simon HK, McLario DJ, et al. Laceration repair using a tissue adhesive in a children’s emergency department. Pediatrics. 1996;98(4 Pt 1):673-675. (Randomized controlled trial; 61 patients)
78. * Karounis H, Gouin S, Eisman H, et al. A randomized, controlled trial comparing long-term cosmetic outcomes of traumatic pediatric lacerations repaired with absorbable plain gut versus nonabsorbable nylon sutures. Acad Emerg Med. 2004;11(7):730-735. (Randomized controlled trial; 95 patients)
79. Osmond MH, Klassen TP, Quinn JV. Economic comparison of a tissue adhesive and suturing in the repair of pediatric facial lacerations. J Pediatr. 1995;126(6):892-895. (Comparative study)
80. Kanegaye JT, Vance CW, Chan L, et al. Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations: a randomized study of cost and time benefits. J Pediatr. 1997;130(5):808-813. (Randomized controlled trial; 45 children)
81. Khan AN, Dayan PS, Miller S, et al. Cosmetic outcome of scalp wound closure with staples in the pediatric emergency department: a prospective, randomized trial. Pediatr Emerg Care. 2002;18(3):171-173. (Randomized controlled trial; 42 patients)
82. Hock MO, Ooi SB, Saw SM, et al. A randomized controlled trial comparing the hair apposition technique with tissue glue to standard suturing in scalp lacerations (HAT study). Ann Emerg Med. 2002;40(1):19-26. (Randomized controlled trial; 189 patients)
83. Karaduman S, Yuruktumen A, Guryay SM, et al. Modified hair apposition technique as the primary closure method for scalp lacerations. Am J Emerg Med. 2009;27(9):1050-1055. (Prospective study; 102 patients)
84. Ozturk D, Sonmez BM, Altinbilek E, et al. A retrospective observational study comparing hair apposition technique, suturing and stapling for scalp lacerations. World J Emerg Surg. 2013;8:27. (Retrospective observational study; 134 patients)
85. Katz KH, Desciak EB, Maloney ME. The optimal application of surgical adhesive tape strips. Dermatol Surg. 1999;25(9):686-688. (Prospective study; 12 patients)
86. Rodeheaver GT, McLane M, West L, et al. Evaluation of surgical tapes for wound closure. J Surg Res. 1985;39(3):251-257. (Prospective study; 4 surgical tapes)
87. D’Ettorre M, Bracaglia R, Gentileschi S, et al. A trick in steri-strips application: the zig-zag pattern. Int Wound J. 2015;12(2):233. (Letter)
88. * Andreana L, Isgro G, Metaxa V. Wound care of pretibial thin-skin lacerations with the combined use of sterile adhesive strips and sutures. J Emerg Med. 2015;49(3):345-346. (Techniques and procedures report)
89. Davis M, Nakhdjevani A, Lidder S. Suture/steri-strip combination for the management of lacerations in thin-skinned individuals. J Emerg Med. 2011;40(3):322-323. (Techniques and procedures)
90. Zempsky WT, Zehrer CL, Lyle CT, et al. Economic comparison of methods of wound closure: wound closure strips vs. sutures and wound adhesives. Int Wound J. 2005;2(3):272-281. (Comparative study)
91. Hollander JE, Singer AJ, Valentine S, et al. Wound registry: development and validation. Ann Emerg Med. 1995;25(5):675-685. (Prospective study; 1000 patients)
92. Moran GJ, Talan DA, Abrahamian FM. Antimicrobial prophylaxis for wounds and procedures in the emergency department. Infect Dis Clin North Am. 2008;22(1):117-143. (Review)
93. Hutton PA, Jones BM, Law DJ. Depot penicillin as prophylaxis in accidental wounds. Br J Surg. 1978;65(8):549-550. (Randomized controlled trial; 285 patients)
94. Thirlby RC, Blair AJ 3rd, Thal ER. The value of prophylactic antibiotics for simple lacerations. Surg Gynecol Obstet. 1983;156(2):212-216. (Randomized controlled trial; 499 patients)
95. Day TK. Controlled trial of prophylactic antibiotics in minor wounds requiring suture. Lancet. 1975;2(7946):1174-1176. (Randomized controlled trial; 160 patients)
96. Baker MD, Lanuti M. The management and outcome of lacerations in urban children. Ann Emerg Med. 1990;19(9):1001-1005. (Prospective study; 2834 patients)
97. * Cummings P, Del Beccaro MA. Antibiotics to prevent infection of simple wounds: a meta-analysis of randomized studies. Am J Emerg Med. 1995;13(4):396-400. (Meta-analysis; 7 trials)
98. * Zehtabchi S. Evidence-based emergency medicine/critically appraised topic. The role of antibiotic prophylaxis for prevention of infection in patients with simple hand lacerations. Ann Emerg Med. 2007;49(5):682-689. (Meta-analysis; 4 trials)
99. Mark DG, Granquist EJ. Are prophylactic oral antibiotics indicated for the treatment of intraoral wounds? Ann Emerg Med. 2008;52(4):368-372. (Review)
100. Ong S, Moran GJ, Krishnadasan A, et al. Antibiotic prescribing practices of emergency physicians and patient expectations for uncomplicated lacerations. West J Emerg Med. 2011;12(4):375-380. (Prospective study; 436 patients)
101. Nakamura Y, Daya M. Use of appropriate antimicrobials in wound management. Emerg Med Clin North Am. 2007;25(1):159-176. (Review)
102. * Edlich RF, Kenney JG, Morgan RF, et al. Antimicrobial treatment of minor soft tissue lacerations: a critical review. Emerg Med Clin North Am. 1986;4(3):561-580. (Review)
103. Steele MT, Sainsbury CR, Robinson WA, et al. Prophylactic penicillin for intraoral wounds. Ann Emerg Med. 1989;18(8):847-852. (Randomized controlled trial; 62 patients)
104. Kraus SJ, Eron LJ, Bottenfield GW, et al. Mupirocin cream is as effective as oral cephalexin in the treatment of secondarily infected wounds. J Fam Pract. 1998;47(6):429-433. (Randomized controlled trial; 706 patients)
105. Dire DJ, Coppola M, Dwyer DA, et al. Prospective evaluation of topical antibiotics for preventing infections in uncomplicated soft-tissue wounds repaired in the ED. Acad Emerg Med. 1995;2(1):4-10. (Randomized controlled trial; 465 patients)
106. Markovchick V. Suture materials and mechanical after care. Emerg Med Clin North Am. 1992;10(4):673-689. (Review)
107. Committee on Infectious Diseases. Tetanus. In: Kimberlin DW, Long SS, Brady MT, et al, eds. Red Book. 30th ed. Elk Grove Village: American Academy of Pediatrics. 2015:773-778. (Textbook chapter)
108. Sibbald RG, Goodman L, Woo KY, et al. Special considerations in wound bed preparation 2011: an update(c). Adv Skin Wound Care. 2011;24(9):415-436. (Review)
109. Okan D, Woo K, Ayello EA, et al. The role of moisture balance in wound healing. Adv Skin Wound Care. 2007;20(1):39-53. (Review)
110. Chrintz H, Vibits H, Cordtz TO, et al. Need for surgical wound dressing. Br J Surg. 1989;76(2):204-205. (Randomized controlled trial; 1202 patients)
111. Merei JM. Pediatric clean surgical wounds: is dressing necessary? J Pediatr Surg. 2004;39(12):1871-1873. (Randomized controlled trial; 451 patients)
112. Heal C, Buettner P, Raasch B, et al. Can sutures get wet? Prospective randomised controlled trial of wound management in general practice. BMJ. 2006;332(7549):1053-1056. (Randomized controlled trial; 857 patients)
113. Noe JM, Keller M. Can stitches get wet? Plast Reconstr Surg. 1988;81(1):82-84. (Prospective study; 100 patients)
114. Goldberg HM, Rosenthal SA, Nemetz JC. Effect of washing closed head and neck wounds on wound healing and infection. Am J Surg. 1981;141(3):358-359. (Case-control study; 200 patients)
115. * Toon CD, Sinha S, Davidson BR, et al. Early versus delayed post-operative bathing or showering to prevent wound complications. Cochrane Database Syst Rev. 2015(7):CD010075. (Meta-analysis; 1 trial)
116. Ardeshirpour F, Shaye DA, Hilger PA. Improving posttraumatic facial scars. Otolaryngol Clin North Am. 2013;46(5):867-881. (Review)
117. Geyer AS, Pasternack F, Adams C, et al. Use of a skin-fat composite graft to prevent alar notching: an alternative to delayed postoperative repair. Dermatol Surg. 2005;31(5):602-607. (Case report)
118. Fetter-Zarzeka A, Joseph MM. Hand and fingertip injuries in children. Pediatr Emerg Care. 2002;18(5):341-345. (Retrospective study; 17;859 charts)
119. Spitzer RF, Kives S, Caccia N, et al. Retrospective review of unintentional female genital trauma at a pediatric referral center. Pediatr Emerg Care. 2008;24(12):831-835. (Retrospective study; 105 patients)
120. Townes DA. Human and animal bites. In: Strange GR, Ahrens WR, Schafermeyer RW, et al, eds. Pediatric Emergency Medicine. 3rd ed. New York, NY: The McGraw-Hill Companies; 2009. (Textbook chapter)
121. Committee on Infectious Diseases. Bite Wounds. In: Kimberlin DW, Long SS, Brady MT, et al, eds. Red Book. 30th ed. Elk Grove Village: American Academy of Pediatrics. 2015:205-210. (Textbook chapter)
122. Talan DA, Citron DM, Abrahamian FM, et al. Bacteriologic analysis of infected dog and cat bites. Emergency Medicine Animal Bite Infection Study Group. N Engl J Med. 1999;340(2):85-92. (Prospective study; 50 patients)
123. Rui-feng C, Li-song H, Ji-bo Z, et al. Emergency treatment on facial laceration of dog bite wounds with immediate primary closure: a prospective randomized trial study. BMC Emerg Med. 2013;13 Suppl 1:S2. (Randomized controlled trial; 600 patients)
124. Paschos NK, Makris EA, Gantsos A, et al. Primary closure versus non-closure of dog bite wounds. a randomised controlled trial. Injury. 2014;45(1):237-240. (Randomized controlled trial; 168 patients)
125. * Cheng HT, Hsu YC, Wu CI. Does primary closure for dog bite wounds increase the incidence of wound infection? A meta-analysis of randomized controlled trials. J Plast Reconstr Aesthet Surg. 2014; 67(10):1448-1450. (Meta-analysis)
126. * Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):147-159. (Practice guideline)
127. Goldstein EJ. Bite wounds and infection. Clin Infect Dis. 1992;14(3):633-638. (Review)
128. Rothe K, Tsokos M, Handrick W. Animal and human bite wounds. Dtsch Arztebl Int. 2015;112(25):433-442. (Review)
129. Aziz H, Rhee P, Pandit V, et al. The current concepts in management of animal (dog, cat, snake, scorpion) and human bite wounds. J Trauma Acute Care Surg. 2015;78(3):641-648. (Review)
130. Lineaweaver W, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg. 1985;120(3):267-270. (Comparative study)
131. Heggers JP, Sazy JA, Stenberg BD, et al. Bactericidal and wound-healing properties of sodium hypochlorite solutions: the 1991 Lindberg Award. J Burn Care Rehabil. 1991;12(5):420-424. (In vivo study)
132. * Dire DJ, Welsh AP. A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med. 1990;19(6):704-708. (Randomized controlled trial; 531 patients)
133. Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalized patients. Results of the Harvard Medical Practice Study I. N Engl J Med. 1991;324(6):370-376. (Cross sectional study; 30,121 records)
134. Centers for Disease Control and Prevention. Surgical Site Infections (SSI) Event. 2017. Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/9pscssicurrent.pdf. Accessed August 15, 2017. (Review)
135. Huizinga WK, Kritzinger NA, Bhamjee A. The value of adjuvant systemic antibiotic therapy in localised wound infections among hospital patients: a comparative study. J Infect. 1986;13(1):11-16. (Randomized controlled trial; 73 patients)
136. Jull AB, Cullum N, Dumville JC, et al. Honey as a topical treatment for wounds. Cochrane Database Syst Rev. 2015(3):CD005083. (Meta-analysis; 26 trials)
137. Molan P, Rhodes T. Honey: a biologic wound dressing. Wounds. 2015;27(6):141-151. (Review)
138. Curran JN, Crealey M, Sadadcharam G, et al. Vitamin E: patterns of understanding, use, and prescription by health professionals and students at a university teaching hospital. Plast Reconstr Surg. 2006;118(1):248-252. (Questionnaire; 208 responses)
139. Tanaydin V, Conings J, Malyar M, et al. The role of topical vitamin E in scar management: a systematic review. Aesthet Surg J. 2016;36(8):959-965. (Review)
140. 140. Khansa I, Harrison B, Janis JE. Evidence-based scar management: how to improve results with technique and technology. Plast Reconstr Surg. 2016;138(3 Suppl):165S-178S. (Review)
141. Lee DW, Ku SK, Cho HJ, et al. Effects of Noscarna on hypertrophic scarring in the rabbit ear model: histopathological aspects. Arch Pharm Res. 2012;35(11):1999-2006. (Comparative study; 24 rabbit ears)
142. Karagoz H, Yuksel F, Ulkur E, et al. Comparison of efficacy of silicone gel, silicone gel sheeting, and topical onion extract including heparin and allantoin for the treatment of postburn hypertrophic scars. Burns. 2009;35(8):1097-1103. (Randomized controlled trial; 45 patients)
143. Bloemen MC, van der Veer WM, Ulrich MM, et al. Prevention and curative management of hypertrophic scar formation. Burns. 2009;35(4):463-475. (Review)
144. Phillips JP, Eilbert WP. Laceration repair using rapid absorbing suture in the emergency department improves resource utilization: saving time and money. Ann Emerg Med. 2012;60(4):S61-S62. (Review)
145. Shehab N, Patel PR, Srinivasan A, et al. Emergency department visits for antibiotic-associated adverse events. Clin Infect Dis. 2008;47(6):735-743. (Cross-sectional survey; 6614 cases)
146. * Moscati RM, Mayrose J, Reardon RF, et al. A multicenter comparison of tap water versus sterile saline for wound irrigation. Acad Emerg Med. 2007;14(5):404-409. (Randomized controlled trial; 715 patients)