Pediatric Wound Care in the Emergency Department - Trauma EXTRA Supplement (Trauma CME)

Table of Contents

 

About This Issue

Wounds and lacerations in children are some of the most common presenting complaints to EDs. Despite significant literature on wound care, there remains a lack of widely accepted standard of care. In this issue, you will learn:

Risk factors that affect wound healing and infection rates

Wound cleansing and solutions that can safely and effectively irrigate wounds

Techniques and treatments to prevent pain and anxiety in children during wound closure

Methods for primary wound closure and how to use them appropriately

Recommendations for postrepair wound care and when to use antibiotic prophylaxis

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Critical Appraisal of the Literature
6. Etiology and Pathophysiology
7. Differential Diagnosis
8. Prehospital Care
9. Emergency Department Evaluation
   1. History
   2. Physical Examination
10. Diagnostic Studies
    1. Laboratory Studies
    2. Imaging Studies
11. Treatment
    1. Timing of Wound Closure
    2. Wound Preparation
       1. Wound Irrigation and Cleansing
       2. Wound Irrigation Solutions
       3. Wound Irrigation Volume and Pressure
    3. Antisepsis
    4. Anesthesia
       1. Topical Anesthesia
       2. Intradermal Anesthesia
       3. Nerve Blocks
       4. Anxiolysis/Sedation
    5. Wound Closure
       1. Gloves
       2. Needle Types
       3. Sutures
          1. Suture Packaging
          2. Suture Material
          3. Suture Size
          4. Suturing Techniques
             • Simple Interrupted Suture
             • Deep Dermal Sutures
             • Running Suture and Locked Running Suture
             • Running Subcuticular Suture
             • Mattress Suture
             • Corner Stitch
          5. Suture Spacing
          6. Eversion
          7. Tissue Adhesive
          8. Staples
          9. Hair Apposition
          10. Adhesive Strips
          11. Zipper-Like Device
    6. Oral Antibiotic Prophylaxis
    7. Tetanus Prophylaxis
    8. Postrepair Wound Care
       1. Topical Antibiotics
       2. Wound Dressing
       3. Discharge Instructions
12. 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
13. Controversies and Cutting Edge
    1. Honey
    2. Scar Management
14. Disposition
15. Summary
16. Time- and Cost-Effective Strategies
17. Risk Management Pitfalls in the Management of Wounds in Pediatric Patients
18. 5 Things That Will Change Your Practice
19. Case Conclusions
20. Clinical Pathway for Emergency Department Management of Wounds in Pediatric Patients
21. Tables and Figures
22. 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, including wound cleansing and irrigation, anxiolysis/sedation techniques, closure methods, and postrepair wound care.

Case Presentations

A 2-year-old boy presents with a forehead laceration that occurred when he tripped and fell onto the edge of a table…

• The boy is very upset and screams and turns away when you try to remove the bandage.
• The resident you are working with asks what sutures they should grab from the supply room. They also ask 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...

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

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) DOI: 10.1016/s0196-0644(88)80246-4

20. * Fernandez R, Green HL, Griffiths R, et al. Water for wound cleansing. Cochrane Database Syst Rev. 2022;9(9):CD003861. (Systematic review; 13 studies) DOI: 10.1002/14651858.CD003861.pub3

47. * 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) DOI: 10.1002/14651858.CD005364.pub2

61. * 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; 18 studies) DOI: 10.1016/j.annemergmed.2010.12.001

65. * Birnie KA, Noel M, Chambers CT, et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev. 2018; 10(10):CD005179. (Meta-analysis; 59 trials) DOI: 10.1002/14651858.CD005179.pub4

82. * Xu B, Xu B, Wang L, et al. Absorbable versus nonabsorbable sutures for skin closure: a meta-analysis of randomized controlled trials. Ann Plast Surg. 2016;76(5):598-606. (Meta-analysis; 19 trials) DOI: 10.1097/SAP.0000000000000418

83. * 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)

99. * 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) DOI: 10.1111/j.1553-2712.2003.tb00027.x

101. * 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) DOI: 10.1197/j.aem.2003.12.029

112. * 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) DOI: 10.1016/j.jemermed.2013.08.155

121. * 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) DOI: 10.1016/0735-6757(95)90122-1

122. * 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) DOI: 10.1016/j.annemergmed.2006.12.014

126. * 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) DOI: 10.1016/S0733-8627(20)31023-3

130. * 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) DOI: 10.1111/j.1553-2712.1995.tb03070.x

140. * 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) DOI: 10.1002/14651858.CD010075.pub3

150. * 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. (Meta-analysis) DOI: 10.1016/j.bjps.2014.05.051

151. * 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) DOI: 10.1093/cid/ciu296

170. * 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) PMID: 17456554

Subscribe to get the full list of 170 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.

Keywords: wounds, skin injuries, wound care, laceration, animal bite, human bite, tissue adhesive, postrepair wound care, epithelialization, primary closure, healing by primary intention, secondary closure, healing by secondary intention, delayed primary closure, healing by tertiary intention, “golden period”, wound preparation, irrigation, antisepsis, intradermal anesthetics, topical anesthesia, nerve blocks, child life specialist, anxiolysis, procedural sedation, sutures, staples, adhesive strips, hair apposition, simple interrupted suture, deep dermal suture, running suture, locked running suture, running subcuticular suture, mattress suture, vertical mattress suture, horizontal mattress suture, corner stitch, eversion, antibiotic prophylaxis, bite wounds, fight bite