wound management

Wound ManagementKelly D. Black, MD, MSc,* Stephen John Cico, MD, MEd, Derya Caglar, MD

*Department of Pediatrics, University of South Dakota Sanford School of Medicine, and Department of Emergency

Medicine, Sanford USD Medical Center and Sanford Childrens Hospital, Sioux Falls, SD.Departments of Pediatrics and Family Medicine, University of South Dakota Sanford School of Medicine, and

Department of Emergency Medicine, Sanford USD Medical Center and Sanford Childrens Hospital, Sioux Falls, SD.Department of Pediatrics, University of Washington School of Medicine, and Department of Emergency Medicine,

Seattle Childrens Hospital, Seattle, WA.

Practice Gap:

Clinicians should be familiar with the principles of wound management,

including repair methods, risks for infection, tetanus prophylaxis, and

appropriate use of antibiotics and diagnostic studies.

Objectives After completing this article, the reader should be able to:

1. Identify important history and physical examination ndings

pertaining to wounds.

2. Know the indications for diagnostic studies in the management of

wounds.

3. Dene primary and secondary wound closure and know the

indications for each type of closure.

4. Understand the different anesthesia options for woundmanagement.

5. Know the different closure options and indications for the use of each

method of closure.

6. Recognize the importance of special care when treating wounds of

the lips, tongue and intraoral cavity, ears, and nailbeds.

7. Recognize the risk of infection related to bite wounds and the

indications for repair.

8. Understand the management of puncture wounds.

9. Know the indications for tetanus prophylaxis after sustaining

a wound.

10. Know the indications for antibiotics after sustaining a wound.

Abstract

The care of wounds is common in pediatric practice. Most simple wounds

can be handled by clinicians in the ofce or by trained emergency

AUTHOR DISCLOSURE Drs Black, Cico, andCaglar have disclosed no nancialrelationships relevant to this article. Thiscommentary does not contain a discussion ofan unapproved/investigative use ofa commercial product/device.

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medicine clinicians. Knowledge of appropriate wound care, wound repair

techniques, and judicious use of antibiotics for prophylaxis ensures the

best possible long-term outcomes. The following review describes

appropriate recommendations for acute and long-term wound care,

management, and special circumstances common to pediatric practice.

CASE

The parents of a 3-year-old boy bring their son to the pediatric

emergency department after he fell and hit his mouth on their

glass coffee table approximately 30 minutes ago. The child has

a laceration to his lower lip and tongue. The parents state that the

wounds initially were bleeding profusely but by applying pressure,

they were able to stop the bleeding. You examine the child and

take the history from the parents. The child has a past medical

history of ear infections with tympanostomy tube placement

under general anesthesia 1 year ago. He is otherwise healthy

and up to date on his immunizations. Physical examination

shows the child to be at his neurologic baseline without evidence of

other injuries. The parents ask if emergency department physi-

cians routinely repair these types of injuries or if a plastic surgeon

may be needed for the repair. You consider how to answer the

parents question while also wondering if both lacerations need to

be repaired and if the child will need to be sedated for the repair.

INTRODUCTION AND EPIDEMIOLOGY

Pediatric wounds are common presenting complaints in

primary care ofces, urgent care facilities, and emergency

departments. According to Centers for Disease Control and

Prevention (CDC) National Center for Health Statistics data,

more than 80 million ambulatory visits for injuries occurred

in 2009 through 2010. (1) In this same time period, 41million

visits for injuries occurred across United States emergency

departments. (1) According the CDCs web-based Injury

Statistics Query and Reporting System data for ages 0 to

18 years, more than 140,000 nonfatal dog bite injuries and

more than 528,000 nonfatal cut/pierce injuries occurred in

2012. (2) Rates of injuries to males were higher than injuries to

females in all categories. (2) An estimated 4.5 million dog bites

occur annually, half of which involve children, and one in ve

dog bites requires medical attention. (3) Dog bites occur more

often than cat bites and the two combined account for the

majority of nonhuman bite wounds.

Pediatric wounds tend to be categorized into three etiology-

based categories in the medical literature: injury-related

wounds, bites, and burns. Injury-related wounds include lac-

erations, avulsions, and punctures. This review examines

injury-related wounds and bites; chronic wounds are out-

side the scope of the article.

HISTORY AND PHYSICAL EXAMINATION FINDINGS

As with any diagnosis and evaluation, history and physical

examination ndings are important to the management and

outcome of wound repair. Key historical points are similar to

other conditions and include current medications, allergies,

immunization status, developmental stage, and coexisting

medical conditions. Developmental delays or chronic medical

conditions (eg, autism, collagen-vascular disease) may affect

the clinicians ability to repair the wound or alter wound

healing. Other key history items are the time elapsed since the

wound, mechanism of injury, and environment in which the

injury occurred to identify potential wound contamination.

Vital signs should be reviewed for indications of hem-

orrhage, such as unexplained tachycardia or hypotension.

The physical examination should include assessment for

neurovascular compromise, tendon injury, and underlying

fractures. Wounds should also be carefully inspected for

retained foreign bodies.

DIAGNOSTIC STUDIES

Diagnostic studies are rarely needed for thechildwith a simple

laceration or wound. However, indications do exist for both

radiographic imaging and laboratory studies in the acute

management of wounds. Laboratory studies may be indicated

if concerns arise, such as prolonged bleeding or difculty in

achieving hemostasis that may indicate an underlying disor-

der.However, studies are rarely needed in routinewound care.

Radiographs may be helpful if the clinician has concerns

about retained glass or metal. Ultrasonography can be par-

ticularly helpful to evaluate for a radiolucent foreign body or to

assist in removal of a foreign body during the procedure.

WOUND CLOSURE

PrimaryPrimary closure of a wound involves denitive repair at the

time of presentation. Generally, trainees are taught sterile

208 Pediatrics in Review at Gazi University on May 1, 2015http://pedsinreview.aappublications.org/Downloaded from

technique for primary wound closure, but Ruthman et al

found that the use of surgical caps and masks did not

decrease the rate of infection for lacerations when compared

to their nonuse. (4) Sterile glove use also did not decrease

infection rates compared to nonsterile gloves, although the

use of powder-covered or dusted gloves, which are becom-

ing increasingly rare in the medical setting, is associated

with higher rates of infection compared to the more com-

monly used powder-free gloves. (5)

Most patients present early with traumatic wounds; only

1% to 2% present to the emergency department seeking care

for a wound that is more than 19 hours old. (6) One study

found no signicant difference in the rate of infection for

wounds that were repaired within 6 hours of occurrence

compared to those that were repaired more than 6 hours

after the injury occurred. (6) This is contrary to common

lore on wound repair passed down in medical training. The

best current recommendation for time to wound closure is

that wounds of the head and face should be closed whenever

they present to a clinician, assuming there is no evidence of

infection. Other wounds may be closed up to 19 hours after

their occurrence, which covers nearly 100% of wounds

encountered by clinicians.

Wound irrigation with tap water has been associated with

equivalent infection rates as irrigation with sterile normal

saline solutions in the pediatric population, (79) and these

two solutions are the standards for wound care in the

medical setting. Tap water remains themost common home

treatment of lacerations and wounds. High-pressure irriga-

tion (>8 psi) can be obtained with either syringe-driven

uids (2535 psi) or use of a standard faucet (45 psi). (7,10)

Standard-concentration povidone-iodine solution (10%) has

been found to be toxic to skin broblasts, and 1% diluted

solutions of povidone-iodine and hydrogen peroxide solu-

tions have not been denitively shown to be advantageous in

decreasing rates of infection compared with saline and tap-

water irrigation. (11)

SecondaryWound closure by secondary intention describes allowing

the laceration to heal naturally without any attempt at

primary wound closure. Allowing a laceration to heal by

secondary intention is a reasonable option for lacerations

that present late to the clinician. The rates of infection at

3 months postinjury, approximately 3% with good wound

care, are similar for small lacerations (

ANESTHESIA

Anesthesia can be applied topically to open wounds. Lido-

caine, epinephrine, and tetracaine (LET) is commonly used

in laceration repair as a supplement or replacement for

injected lidocaine. Because of its delivery as a topical solu-

tion without use of needles, it can decrease anxiety and

increase cooperation of pediatric patients while still pro-

viding adequate analgesia. (16,17)

Intradermally injected lidocaine is the most commonly

used anesthetic agent in the emergency department. Its

duration of action is 60 to 90 minutes or 120 to 360minutes

if used with epinephrine. However, lidocaine with epineph-

rine should not be used in distal areas of the body, including

ngers, nose, ears, toes, and penis. (18) Pediatric maximum

doses are 4.5 mg/kg of lidocaine (1% lidocaine is 10 mg/mL),

butwhen used in combinationwith epinephrine, themaximal

dose is increased to 7 mg/kg. (1921) Delivery of the lidocaine

as a buffered solution, use of a small-gauge needle (25-gauge

or smaller), warming the lidocaine to body temperature, and

stimulation of the skin proximally to the injection site can all

decrease the pain associated with local inltration. (17,2224)

Other injectable anesthetics, such as bupivacaine and

prilocaine, have longer durations of action and can be used

in combination with lidocaine or as single agents.

Peripheral nerve blocks can be performed in cooperative

patients but typically require training to avoid nerve damage

or injection into accompanying vasculature. Digital nerve

blocks and facial nerve blocks can be helpful in the pediatric

population in controlling the immediate pain with which

patients present as well as pain associated with wound

repair. Ultrasonographic guidance is becoming more stan-

dard for regional blocks such as femoral nerve blocks and

seems to increase the effectiveness of the block compared to

traditional injection techniques. (17,25)

CLOSURE METHODS

Surgical TapesSurgical tapes are a fast, simple, relatively pain-free, and inex-

pensive method of wound closure. They do not require out-

patient physician follow-up for removal. They do not provide

signicant hemostasis nor do they adhere to areas of the body

withhair, such as scalp lacerations. (26) Surgical tapes should be

considered for simple linear lacerations over low-tensile areas of

the body, conditions for which they are likely underutilized.

Tissue AdhesivesRelatively painless, rapid application makes tissue adhesives,

also known as cyanoacrylate adhesives, ideal for pediatric

patients who sustain wounds that are uncomplicated and less

than 5 cm in length. (27) Although more expensive, tissue

adhesives are faster to apply and have similar cosmetic out-

comes as traditional sutures. (28) Tissue adhesives are often

preferred by families because of the decreased time spent for

the repair, lower perceived pain experienced by the patient,

and less need for postrepair follow-up visits. (26) When

applying the adhesive, careful approximation of wound edges

without bunching or overlapping can improve healing and

minimize scar formation.

Tissue adhesives are not appropriate for all locations.

Their use in areas of the body exposed tomoisture or friction

(mucous membranes or the hands and feet) and those in

areas of the body covered with hair can result in premature

sloughing of the tissue adhesive. Excessive exposure to soap

and water can also shorten adhesive-to-skin time by a day or

more. (29) Recent studies show that tissue adhesives are of

equivalent strength to sutures, but their application over

joints and other high-movement and -tension sites is not

recommended due to the risk of premature dehiscence.

Deep absorbable sutures may be used in conjunction with

tissue adhesives to relieve surface tension before applica-

tion. (26,30) Tissue adhesives may also be combined with

surgical tape for wound repair. Care must be used in the

periocular region to avoid iatrogenic eyelid gluing during

wound repair, especially in young children who may move

around during adhesive drying times. Application of petro-

leum jelly around the eye can prevent both leakage and this

complication. If adhesive does get in the eye or the eyelid is

glued shut, follow-up with ophthalmology and evaluation

for corneal abrasion must be considered. (31) Tissue adhe-

sives also have inherent antimicrobial properties, particu-

larly against Gram-positive organisms, (32) whichmay be an

advantage in the pediatric population.

Surgical StaplesEven with good analgesia, surgical staples can be painful to

insert and remove, making them less desirable for pediatric

laceration repair. However, they can be used in areas of high

tension and hair-covered areas such as the scalp. They can be

placed rapidly, which makes their use in uncooperative

children a good alternative to sutures, surgical tape, or

tissue adhesives. However, staples do not offer rigorous

wound edge approximation and, therefore, are not appro-

priate in many areas of the body. (33)

Hair Apposition TechniqueThe hair apposition technique (HAT) or hair tie technique

has been developed because cyanoacrylate adhesives to the

scalp slough prematurely due to hair. Using hair as short as


1 cm, 10 to 15 strands on each side of a scalp laceration are

grabbed with pick-ups and twisted around each other. One

drop of cyanoacrylate adhesive is applied to the twisted hair

and allowed to dry. The native hair is used to approximate

the edges of the laceration while the tissue adhesive holds

the hair twist together. (34) The HAT technique has been

shown to perform as well as standard sutures and staples on

scalp lacerations in terms of healing and scarring (35,36) and

is associated with a faster procedure completion time, less

pain, (35,3739) and lower cost. (40) HAT also does not

require staple or suture removal. Clinicians must be mind-

ful not to apply too much tissue adhesive, which may result

in the hair tie remaining for weeks. Tissue adhesive is also

exothermic and theoretically may damage hair follicles and

prevent hair regrowth around the laceration. Getting the

adhesive in the wound itself may also affect future hair

growth at the laceration site. (34)

SuturesSutures are the gold standard of wound closure, offering the

most meticulous skin closure with good strength, particu-

larly on high-tension areas. They also allow for layered

closures of deep wounds and are often expected by patients

and families. However, proper use requires training, su-

tures can be painful even with the use of anesthetics, and

they may require follow-up for removal.

Training is required for suture placement with good

cosmetic outcomes. Care must be taken with the placement

of supercial sutures. If the sutures are too loose, the wound

may widen and lead to larger scar formation. If sutures are

placed too tightly, the woundmay have additional scarring at

the site of suture placement. The clinician must also leave

sufcient suture material to allow for easy removal when

placing nonabsorbable sutures.

Deep sutures are used below the dermis for closure and

approximation of subdermal tissues. Placing deep sutures

can help alleviate tension for surface sutures, close potential

space where hematomas can form, andmay improve overall

skin scarring appearance. (33,41) In contaminated wounds,

deep sutures have been shown to increase the risk of wound

infection in some studies, but this has not been found in

clean wounds. (42,43)

Simple interrupted sutures are the mainstay of surface

suture closure in the primary care and emergency setting.

A single loop of suture is placed through the dermis and

epidermis, allowing good wound edge eversion and approx-

imation. This suturing technique is relatively easy to learn

andmaster, the process is fast, and the sutures produce good

cosmetic outcomes. Running sutures are a variation on

simple sutures where the suture material is not cut.

Accordingly, these sutures are faster to place than simple

interrupted sutures. However, if a knot loosens or suture

breaks, the entire wound may dehisce. Mattress sutures can

help take tension off the wound edges by dispersing the

forces with additional bites of the skin. They can be used for

wounds that gape open or are under high tension. (33)

Suture material can be absorbable or nonabsorbable.

Examples of absorbable products are plain catgut, chromic

catgut, and polyglactin sutures. These are used for deep

sutures because they eventually are absorbed by the body

and do not need to be removed. The rst two are natural

monolaments and begin to lose their strength in approx-

imately 1 week; the synthetic polylament suture retains its

strength for 1 to 2 months.

Fast-absorbing gut sutures can be used for skin closure

on areas of the body that heal quickly (highly vascular areas

such as the face) and are under low tension. These sutures

are thinner than other natural absorbing sutures and begin

to lose tensile strength in 3 to 5 days. This makes them ideal

for pediatric patients with small linear facial wounds in

terms of timing of absorption and the lack of need for suture

removal. There seems to be no difference in long-term

scarring for lacerations repaired with absorbable versus

nonabsorbable sutures. (44)

Nonabsorbing sutures include nylon, polypropylene, silk,

and linen sutures. These retain their tensile strength for

months and require removal after the wound is healed. The

former two are synthetic and the latter two are natural polyla-

ment. Natural sutures cause more skin reactivity than syn-

thetic sutures, and polylament sutures are more prone to

increased rates of wound infection. (45,46) Suture type,

appropriate location, and time to removal are listed in Table 2.

SPECIAL SITUATIONS

Lip LacerationsThe approach to repair of lip lacerations depends on the

complexity of the wound and structures involved. The lip

consists of several layers: the skin, the vermilion border, and

the oral mucosa. The key to proper repair of a lip laceration

is precise alignment of the vermilion border because even

small deviations in this line can have major cosmetic

effects. (47)

Sensation to the upper lip is supplied by the infraorbital

nerve, while sensation to the lower lip is supplied by the

mental nerve. Regional anesthesia is ideal for repairing lip

lacerations because it provides appropriate anesthesia with-

out changing landmarks around the lip. (47) However, in

younger ormore anxious children, this type of blockmay not

be easily achieved and deeper anesthesia may be necessary.


When repairing a lip laceration, the rst stitchmust align

exactly the edges of the vermilion border. Such alignment

may require several attempts, and the clinician should not

be afraid to place and remove sutures as needed until both

he or she and the family feel condent that cosmetic closure

has been achieved. Through-and-through lacerations should

be closed in layers with absorbable sutures, starting with

the mucosal layer, followed by the muscle layer and the

orbicularis oris, using absorbable sutures. For complicated

and deep lacerations, particularly involving the musculature,

consultation with plastic surgery may be warranted.

Mucosal lip lacerations often do not need to be sutured,

but they do need a full evaluation for foreign bodies, such as

tooth fragments. When closure is necessary for particularly

large lacerations or aps, absorbable sutures should be used.

Tongue and Intraoral LacerationsMost tongue and intraoral lacerations heal rapidly without

repair and do not warrant primary closure. Primary repair is

recommended for intraoral lesions that have a ap, may trap

food particles, and are more than 2 cm in length. Primary

repair of tongue lacerations should be considered for those

involving the tongue border, a large ap or gap in the tongue,

and muscle or all the way through the tongue; those that are

more than 1 cm in length or accompanied by profuse

bleeding; or those that may cause impaired speech (anterior

split in tongue). Tongue and intraoral wounds should be

repaired with absorbable 3-0 or 4-0 sutures, such as poly-

glatin or chromic gut.

Ear LacerationsTrauma to the ear can cause the formation of an auricular

hematoma, which can lead to an external ear deformity

(cauliower ear). This type of injury results from damage to

the underlying cartilage and is especially common among

wrestlers and boxers. The clinician should examine every

patient with an ear laceration for the presence of an auric-

ular hematoma. If present, it must be evacuated to allow for

proper healing of the structures of the ear. Treatment is with

needle aspiration or incision and drainage. A large-bore

needle is inserted at the point of maximal uctuance to

aspirate the hematoma. A scalpel with a #15 blade is used for

incision and drainage, with the incisionmeasuring less than

5 mm at the point of maximal uctuation. The hematoma is

drained, followed by copious irrigation. Regardless of the

chosen technique, a pressure dressing should be applied to

prevent reformation of a second hematoma. After placing

several 44 gauze pads on the posterior aspect of theauricle, multiple layers of soft gauze are placed on the

anterior aspect of the auricle. An elastic dressing is placed

around the head and tied to provide rm constant pressure.

The dressing should remain in place until the patient is

reassessed, preferably within 24 hours. (48)

Ear lacerations should be carefully examined for depth.

Supercial lacerations can easily be repaired in the ofce

setting, but the clinician should thoroughly examine any

deeper lacerations for cartilage involvement. If cartilage is

exposed, the patient may need subspecialist evaluation for

optimum cosmetic closure. Cartilage injuries often are

treated with a prophylactic course of antibiotics to prevent

superinfection.

Nailbed InjuriesInjuries to the ngertip and nail are common. The nail itself

plays an important role in normal hand function by protect-

ing the ngertip, providing counterforce to assist with pick-

ing up small objects, contributing to the tactile sensation of

the ngertip, and helping to regulate nger circulation.

Without careful repair of a nailbed laceration, nail deformity

is likely to occur, which can lead to long-term cosmetic and

functional disability. Subungual hematomas, which are

caused by bleeding under the nail plate, can occur after

a crush injury to the ngertip. Traditional approaches have

required removal of the nail, suture repair of any laceration,

and replacement of the nail (or substitute if the nail is

missing) into the eponychial fold. However, studies have

TABLE 2. Suture Type, Appropriate Location, and Time to Removal

LOCATION SUTURE TYPE SUTURE SIZE DURATION OF SUTURES

Face Monolament, fast-absorbing (fast-absorbing gut), or nonabsorbing(nylon, polypropylene)

5.0 or 6.0 45 days

Subcutaneous (deep) Monolament absorbable (plain or chromic catgut) or polylamentabsorbable (polyglactin)

4.0 or 5.0 N/A

Trunk Nonabsorbing (nylon, polypropylene) 4.0 or 5.0 710 days

Extremities Nonabsorbing (nylon, polypropylene) 4.0 or 5.0 1014 days


shown that patients have equivalent outcomes when injuries

to the nailbed are managed with trephination alone or

trephination with nail removal and laceration repair. (49)

Trephination is performed bymaking a hole at the base of the

nail or in the center of the subungual hematoma, often via

cautery. A 2008 study found that nailbed repair performed

using a tissue adhesive was signicantly faster than suture

repair and provided similar cosmetic and functional results,

even several months after the original injury. (50)

Nailbed injuries can often be associated with fractures

and warrant special attention. Displaced fractures of the

distal phalangeal physis with overlying nailbed laceration

are considered open fractures. In some cases, the germinal

matrix can become trapped within the fracture site. This

complication should be suspected with any proximal nail

avulsion that involves widening of the dorsal distal phalan-

geal physis in children. (49) Proper treatment requires

removal of the nail plate, irrigation, debridement, admin-

istration of antibiotics, reduction of the fracture, and nailbed

repair and would likely benet from orthopedic consulta-

tion. Complications can include osteomyelitis, growth

arrest, and nail deformity.

Bite WoundsBite wounds are exceedingly common, affecting millions of

people throughout the world, with increased frequency in

young children. The vast majority of these bites are caused

by dogs and cats; dog bites account for more than two thirds

of all animal bites. In adults, they primarily affect the hands

and legs, but the face, neck, or head are frequently involved

in children because they are at the same height as a dogs

mouth. Cat bites account for only 3% to 15% of all animal

bites and usually affect the arms and face. (51) Human bites,

although less common, require special consideration in

management of wounds.

The risk of developing an infection and its severity are

both related to the type of animal, the location and size of the

bite, and the predominant organism in the saliva. Bites

involving the head and neck (particularly when they cause

skull fractures or damage to deeper structures in the neck

and chest) can frequently be accompanied by the rapid

development of severe infections, with bacteremia and

severe sequelae. The same is true of bites involving the

hands because of the complex structures beneath the skin.

The size of the wound is also critical; the risk of infection

increases substantially when wound size exceeds 3 cm. (52)

Although they are signicantly less frequent, cat bites are

more commonly complicated by infections, which occur in

30% to 80% of cases. Cats have sharper teeth that lead to

deeper inoculation of bacteria and subsequent soft-tissue

abscesses or septic arthritis. In contrast, dogs teeth are

broader and atter and cause lacerations that primarily

involve the supercial tissues, which are easier to disinfect.

For this reason, dog bites lead to infection in no more than

25% of cases. (53)

Regardless of their site, dog and cat bitewounds frequently

lead to polymicrobial infections due to aerobic and anaerobic

bacteria that primarily are animal oral ora but also from

the patients skin and environment. Top offenders include

Staphylococcus, Streptococcus, Pasteurella, Capnophytophaga,

and occasionalmixed anaerobes. AlthoughPasteurellamultocida

frequently is found in the mouths of dogs, this pathogen is

signicantly more common in infections associated with cat

bites because it is carried by 90% of cats. Bartonella henselae

is also typical of cats and kittens.

Human bites are the third leading cause of bites seen in

the emergency department (behind cats and dogs) and tend

to be polymicrobial, with anaerobes and aerobes represented

almost equally. Commonly isolated bacteria include Eikenella

corrodens and Staphylococcus, Streptococcus, and Corynebacte-

rium species. S aureus is isolated in up to 30% of infected

human bite wounds and is associated with some of the most

severe infections. In addition to the acute risk of localized

infection, human bites pose the potential for the transmis-

sion of systemic infections such as hepatitis B, which can be

life-threatening. The Infectious Diseases Society of America

clinical practice guidelines state that all human bite wounds

require antibiotic prophylaxis (Table 3), particularly when in

high-risk areas such as the hand (ie, clenched st).

The general management of bites is similar to that for

wounds of any origin. The site of the bite should be washed

thoroughly with water and any devitalized tissues debrided.

There is still no agreement as to whether clinically uninfected

wounds should be sutured immediately or left for 24 hours to

evaluate the possible development of infection. (53,54) The

need for tetanus and rabies prophylaxis should be reviewed

and antibiotics be prescribed empirically to decrease the risk

of wound infection (see Antibiotics section).

Puncture WoundsPuncture wounds, with or without a retained foreign body,

are a common presentation to the emergency department,

urgent care center, or physicians ofce, although most in-

dividuals who sustain a puncture wound never seek medical

care. Patients may treat the wound at home, and some may

develop an infection or realize that something is wrong when

they have increased drainage, redness, or swelling several days

later. Supercial puncture wounds without clinical contami-

nation or necrotic tissue can bemanagedwithout prophylactic

antibiotic coverage.Thewound shouldbe evaluatedby caregivers


every 6 hours for the rst 48 hours and antibiotics started

if any signs of infection develop.

If the puncture wound has a retained foreign body,

consideration must be given to removal of the object. If

the object, such as a needle, nail, or gravel, is supercial,

removal is simple. The same steps as described for man-

agement of a delayed or contaminated wound should be

performed while removing the object. Deeper objects may

require imaging, deeper sedation, or surgical consultation.

Puncture wounds to the foot warrant special consideration.

When the puncture occurs through footwear, a small piece of the

shoe can be pushed deep into the tissues of the foot and become

a nidus of infection. S aureus and b-hemolytic streptococci are

common causes of skin and soft-tissue infections and can

produce wound infections after puncture. Gram-negative bacte-

ria also have been recovered from infected sites. Pseudomonas

aeruginosa is commonly isolated in patients who suffered plantar

puncture while wearing tennis shoes, perhaps due to the moist

inner sole of the shoe, which provides an excellent environment

for bacterial growth. Prophylactic antibiotics are typically not

warranted, but the clinician must provide adequate coverage for

these organisms if the wound becomes infected.

SEDATION

Laceration repair is a very common indication for procedural

sedation in children younger than 2 years of age. Depending

on the patients developmental age, temperament, and his-

tory as well as the location and complexity of the wound,

sedation may simply involve anxiolysis or the child may

require deeper sedation. The clinician must consider both

the childs and parents levels of anxiety, circumstances in the

emergency department, and duration of repair when creating

an appropriate and effective treatment plan.

Nonpharmacologic methods of anxiolysis (ie, distraction,

hypnosis) have been found to be highly effective and are

supported in a 2013 Cochrane review. (55) Child life special-

ists are especially helpful due to their training as well as their

ability to focus on comforting and distracting the child rather

than the technical aspects of the procedure. Preprocedure

preparation and basic explanations of what will happen

during the repair is helpful in forming family and child

expectations and can decrease the need for medications.

For relatively short procedures in anxious children,

midazolam (either oral or intranasal) or nitrous oxide may

provide sufcient effect. Midazolam can be given intranasally

(0.4mg/kg to amaximumdose of 10mg) or orally (0.5mg/kg

to a maximum dose of 15 mg) with good effect. For longer or

more complicated repairs (eg, vermillion border, facial, lay-

ered closures), a deeper level of anesthesia (ie, ketamine or

propofol) should be considered to allow for adequate cosmetic

closure. All deeper levels of anesthesia should be provided by

clinicians trained and credentialed to provide anesthesia for

the pediatric patient with appropriate safety measures.

TETANUS

Tetanus immunization status should be reviewed with any

wound. Although any open wound is a potential source for

tetanus infection, those contaminated with dirt, soil, feces,

or saliva are at increased risk. Puncture wounds, crush

injuries, avulsions, burns, and necrotic tissues are particularly

conducive to tetanus infection and immunizations status is of

great importance. (56) The clinician must consider the need

for both vaccine and immunoglobulin administration based

on the type of wound and the patients immunization history

(Table 4). Cleanwoundsmerit tetanus toxoid administration if

the patient has had three or fewer immunizations or it has

been 10 years since the last tetanus-containing immunization.

The clinician should consider the need for tetanus immuno-

globulin in any high-risk wound sustained by patients who

have had fewer than three immunizations.

TABLE 3. Common Wound-related Antibiotics

ANTIBIOTIC DOSING COMMON USE

Amoxicillin-clavulanate 90 mg/kg divided BID Bites, intraoral wounds, grossly contaminatedwounds, wounds with devitalized tissue

Ciprooxacin 1020 mg/kg divided BID Puncture wounds through shoes(Pseudomonas), hand bites (cat, human),penicillin-allergic patients

Clindamycin 2040 mg/kg divided every 68 hours Hand bites (cat, human), penicillin-allergicpatients

Trimethoprim/sulfamethoxazole suspension(40/200 per 5 mL)

810 mg/kg/day of trimethoprim dividedevery 12 hours

Hand bites (cat, human), penicillin-allergicpatients


ANTIBIOTICS

The primary goals of wound management are to achieve rapid

healing with optimal function, avoid wound infection, assist in

hemostasis, and achieve an aesthetically pleasing cosmetic out-

come. This is best accomplished by preventing infection of the

wound during healing. Such care includes copious irrigation,

debridement of devitalized tissue, removal of foreign bodies, and

wound closure. In the vast majority of patients, prophylactic

antibiotics arenotwarrantedanddonot improveoverall outcome.

However, despite good wound care, some infections still occur.

Host and wound characteristics should be considered

(Table 1). Patients who are immunosuppressed (eg, chemo-

therapy, long-term corticosteroid use), have poor wound

healing or collagen vascular disease, or have malnutrition

are at higher risk for infection. Wounds that are substantially

contaminated or cannot be thoroughly cleaned can become

infected in a short period of time.Mammalian bites have high

rates of infection, particularly puncturewounds fromcat bites,

and should always be prescribed prophylactic antibiotics to

cover likely organisms, typically a b-lactamase inhibitor anti-

biotic (ie, amoxicillin-clavulanate). (57) Table 3 lists commonly

used wound-related antibiotics, indications, and dosing.

WOUND CARE

After repair, wound care and appropriate discharge instruc-

tions are important for good cosmetic outcomes. Patients

should be advised to monitor closely for signs of infection.

Wounds repairedwith tissue adhesives should be kept dry, and

antibiotic ointment should not be applied to avoid wound

dehiscence. A moist healing environment has been shown to

improve the rate of re-epithelization, reduce pain, and improve

cosmetic outcomes. (58) No difference has been found when

comparing early postoperative bathing (48 hours). (59) Typically, sunblock products are

recommended for 6 to 12 months after wound healing.

References for this article are at http://pedsinreview.aappublica-

tions.org/content/36/5/207.full.

TABLE 4. Tetanus Prophylaxis in Routine Wound Management

HISTORY OF TETANUSTOXOID (DOSES) CLEAN, MINOR WOUNDS ALL OTHER WOUNDS

DTAP, TDAP, OR TD TIG DTAP, TDAP, OR TD TIG

Fewer than 3 or unknown Yes No Yes Yes

3 or more No if 5 years since last tetanus-containing vaccine dose.

No

DTaPdiphtheria and tetanus toxoids with pertussis; Tdaptetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed; Tdtetanus anddiphtheria toxoids (adult type); TIGtetanus immune globulin.Other woundsSuch as, but not limited to, wounds contaminated with dirt, feces, soil, and saliva; puncture wounds; avulsions; and wounds resulting frommissiles, crushing, burns, and frostbite.Note: DTAP is used for children

PIR Quiz

1. Increased risk of infection after laceration repair is associated with which of the following?

A. No surgical mask.B. Nonsterile gloves.C. Powder-covered gloves.D. Tap-water wound irrigation.E. Wound repair between 6 and19 hours after injury.

2. Which of the following wounds should not be closed primarily?

A. A chin laceration that occurred 3 hours ago in a healthy 2-year-old girl.B. A knee laceration that occurred 2 days ago in a healthy 4-year-old boy.C. A thigh laceration that occurred 6 hours ago in a healthy 7-year-old girl.D. A nailbed injury that occurred 1 hour ago in a healthy 8-year-old boy.E. A scalp laceration that occurred 9 hours ago in a healthy 15-year-old girl.

3. Tissue adhesive is an appropriate repair method for which of the following?

A. Dog bite.B. Elbow laceration.C. Forehead laceration.D. Lip laceration.E. Puncture wound.

4. Antibiotic prophylaxis is indicated in which of the following patients?

A. 2-year-old boy with a forehead laceration after tripping onto a tile oor.B. 3-year-old boy with a lip laceration after falling and striking his lip on a table.C. 5-year old girl with a scalp laceration after running into the edge of a door.D. 10-year-old girl with a leg laceration obtained from the pedal of her bicycle.E. 12-year-old boy with a hand laceration after being bitten by a cat.

5. A 17-year-old adolescent presents with a 3-cm laceration on his foot 2 hours after steppingon a nail that pierced through his shoe while working on his family farm. The patientsshoes and wound appear grossly contaminated with horse manure. The patient hasreceived ve prior diphtheria and tetanus toxoids with pertussis (DTap) immunizations anda tetanus toxoid, reduce diphtheria toxoid, and acellular pertussis, adsorbed (Tdap)immunization at age 11 years. In addition to cleaning the wound, which management ismost appropriate for this patient?

A. Close the wound by secondary intention and provide antibiotics for prophylaxis.B. Close the wound by secondary intention, provide antibiotics for prophylaxis, and

give a tetanus immunization.C. Close the wound by secondary intention, provide antibiotics for prophylaxis, give

a tetanus immunization, and give tetanus immune globulin.D. Close the wound with sutures.E. Close the wound with sutures and provide antibiotics for prophylaxis.

REQUIREMENTS: Learnerscan take Pediatrics inReview quizzes and claimcredit online only at:http://pedsinreview.org.

To successfully complete2015 Pediatrics in Reviewarticles for AMA PRACategory 1 CreditTM,learners mustdemonstrate a minimumperformance level of 60%or higher on thisassessment, whichmeasures achievement ofthe educational purposeand/or objectives of thisactivity. If you score lessthan 60% on theassessment, you will begiven additionalopportunities to answerquestions until an overall60% or greater score isachieved.

This journal-based CMEactivity is availablethrough Dec. 31, 2017,however, credit will berecorded in the year inwhich the learnercompletes the quiz.


DOI: 10.1542/pir.36-5-2072015;36;207Pediatrics in Review

Kelly D. Black, Stephen John Cico and Derya CaglarWound Management

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