- In assessing a child with a minor wound, exclude more serious, sometimes occult, injuries that take precedence in management.
- Physical examination of the wound must assess the length and depth of the injury, circulatory status, motor and sensory function, the presence of foreign bodies and contaminants, and the involvement of underlying structures.
- Topical anesthetics provide effective anesthesia and should be considered as a necessary adjuvant for pediatric lacerations.
- Irrigation with 5 to 8 psi is the appropriate method of choice for removing bacteria and debris from most wounds. Low-pressure irrigation does not adequately clean wounds.
- Many lacerations are suitable for closure using noninvasive methods of closure. With careful consideration, wounds closed in noninvasive fashion produce satisfying cosmetic results.
- Splint a wound overlying a joint in the position of function for 7 to 10 days.
- Antibiotics are indicated for patients who have significant host factors (immune-compromising disease), who present with a wound infection, who present for care late (12–24 hours), and in certain specific instances (intraoral lacerations, wounds of the hand, and cat bites).
- Outcome is dependent on wound care after discharge from the emergency department (ED). Patient and parents should be given thorough after-care instructions about care of the wound and what to expect.
Lacerations and soft tissue injuries are the most common reasons for children to present to the ED.1 These encounters, if handled incorrectly, can be difficult for the child, parent, and physician. To maximize cosmetic and functional results, one should ensure meticulous wound care and repair. Many techniques exist to maximize the satisfaction and clinical results achieved in the ED and a solid understanding of the basic tenets of wound care is a necessary part of the emergency practitioner's arsenal.2
The skin is composed of the dermis, which provides most of the skin's tensile strength, and the epidermis, which protects the dermis from infection and desiccation. Dermal capillaries are fed by the nutrient vessels of the skin, and the epidermis, which has no blood supply, is fed by diffusion of nutrients from the dermis. The subcutaneous tissue beneath the dermis is composed of loose connective and adipose tissue, large vessels, and nerves.3
The appearance and function of a healed wound is somewhat predicted by the magnitude of the tension on the surrounding skin, but there is great intra- and interindividual variability. The most cosmetically pleasing scar results when the long axis of the wound is in the direction of maximal static skin tension, along “Langer's lines” (Fig. 39–1). Examination of the wound in the ED is a reliable method to predict the appearance of the healed wound in the absence of confounding variables, such as the development of an infection or keloid. Dynamic skin tension (caused by joint movement and muscle contraction) also has an impact on the degree of scar formation and postrepair function. A wound intersecting the transverse axis of a joint may result in a significant contracture, ...