For the first time, we’re also featuring EBMedicine‘s latest Pediatric Emergency Medicine Practice review on LITFL. Just like our sneak peeks at each issue of Emergency Medicine Practice for ‘big people’ this is going to become a monthly diversion. First up we’ve got:
Agrawal P, Brown CA (2010). Management Of Wounds In The Pediatric Emergency Department. Pediatric Emergency Medicine Practice, 12(9). [Abstract and subscription link]
What’s covered in the review?
The review looks at the assessment and management of injury-related wounds in children presenting to the emergency department:
- epidemiology and physiology
- prehospital and emergency department evaluation
- treatment — primary versus secondary intention, different closure methods, wound cleaning and irrigation, when to involve a specialist, antibiotics and other issues
Kids are always finding novel and interesting ways to cut and scrape themselves, so this is a subject well worth brushing up on. The review has a couple of useful flowcharts highlighting the important considerations for both wound closure and analgesia/ anxiolysis options in pediatric wound management.
Top tips from this month’s review
As usual I’ve got a collection of my favourite tips and ‘take home’ messages from this month’s very comprehensive review:
- Remember your wound physiology — re-epithelialisation occurs on average at a rate of 1 mm per day from the wound margins. There are 3 classically described phases of wound healing:
- inflammatory or substrate phase — usually the first 48 hours or so, depending on the size of the wound and degree of contamination.
- proliferative phase — angiogenesis and new connective tissue formation over 2-4 days.
- remodelling phase — cross-linking of collagen and a decrease in vascularity occurring over up to 6-9 months. Final tissue strength is usually about 75% of that of the preinjury tissue.
- Remember to take a history! How did the injury occur? How was the wound treated before prehospital? How old is the wound? Are there comorbidities that will impair healing (e.g. diabetes, chronic corticosteroid use)?
- Two things to always consider and never miss — non-accidental injury (NAI) and the presence of a foreign body.
Infection, irrigation and primary vs secondary closure
- The overall infection rate is about 3.5% following wound closure. A lot of variables modify this: old age (!), diabetes, wide wounds, use of adrenaline during wound closure, foreign bodies and trauma to skin adjacent to the wound. Head and neck wounds are less likely to get infected.
- Over 30 years of research has still not really pinned down how young a wound should be for primary closure. Somewhere between 6 and 18 hours is advocated by most authorities — longer delays are OK for neat clean wounds in vascular areas like the scalp, only short delays are tolerated for ragged wounds in more tenuous areas like the shin.
- You don’t have to be Einstein to work out that classical delayed primary closure (initial cleaning and debridement, followed by further cleaning, debridement and closure at 3-4 days) isn’t often a great option for children with delayed wound presentations. Remember that in most cases secondary closure of wounds <2 cm long results in good outcomes.
- The evidence for topical antimicrobial solutions isn’t great, but chlorhexidine-alcohol solutions are probably the best option, rather than povidone-iodine.
- Irrigation is a mainstay of wound care — I still use saline, but the folks at Cochrane suggest that tap water may be just as good. Don’t use toxic irrigants like peroxide or iodine.
- Irrigation pressure and volume recommendations come from animal models — the more fluid the better, and use a 19G needle with a ’35 to 65 mL’ syringe to achieve >25 psi pressure.
Analgesia, anxiolysis and anesthesia
- Anxiolysis and analgesia are overwhelmingly important in children — remember non-pharmacologic methods like distraction and hypnosis. Oral midazolam may be sufficient for simple repairs, but more more delicate work may require deep sedation.
- Remember how to make infiltration with local anesthetic less painful — warm the solution, enter through the wound not intact skin, inject slowly, use a small needle and buffer with bicarbonate (1 cc of NaHCO3 with 10 cc of lignocaine).
- Topical anesthetic solutions have been shown to be as effective as intradermal lignocaine in some studies.
Wound closure, adhesives and sutures
- Choice of wound closure method isa balancing act between 3 groups of factors — provider factors (cost, time, etc.), wound factors (depth, location, tension) and patient factors (e.g. age, anxiety, comorbidities).
- Use tissue adhesives whenever possible (knowing when is no doubt of the ‘art’ of medicine). Octylcyanoacrylate is probably the best option. Adhesives are quicker, cause less pain and save money. Overall, rates of wound dehiscence are slightly higher (risk difference 0.04). Don’t glue yourself to the patient!
- Use synthetic monofilament sutures (less infection than natural fibres or multifilament sutures) — however, the literature largely sits on the fence when it comes to comparing absorbable and non-absorbable sutures in terms of outcomes such as cosmesis, dehiscence and infection.
- What about suture size? Smaller sutures are used on delicate areas to reduce tension (e.g. face). But larger defects with more tissue loss will require larger sutures due to the greater tension. Check out the handy table in the review listing suggested suture sizes and durations for different wound locations.
- The literature doesn’t support one type of suturing technique over another. Simple interrupted sutures are most commonly used, but knowing how to do vertical and horizontal mattress sutures is worthwhile for wounds under tension, those with ongoing bleeding or to encourage eversion of the wound edges.
- Bites — except for uncomplicated dog bites to the head/ neck region, treat with amoxicillin/ clavulinic acid (infection risk: cats >> humans > dogs). Don’t forget to consider rabies prophylaxis, and if he bite was from a human consider the possibility of blood-borne viruses or NAI (especially if >3cm between the canines!)
- How to reduce scarring? What about creams and topical vitamin E? No supporting evidence for any of them (except the use of honey as a dressing) — the best way to decrease scarring is not to get injured in the first place…
- The evidence base for antibiotic prophylaxis is a dark and murky place to be — if a high risk wound or patient consider flucloxacillin or cephalexin, and consider adding an anti-pseudomnal for puncture wounds. Topical antibiotics are also an option, but cleaning, irrigation and debridement are far more important.
- Don’t forget about tetanus prophylaxis — especially in younger children who may not have had 3 doses of vaccine yet.
- Consider involving a specialist to review a child’s wound for the following:
- cosmetic concerns (don’t be offended by parental requests!)
- ears, eyes or soft palate involved
- suspected NAI
- genital injuries (unless minor)
- deep wounds
- nail-bed injuries and bites on the hand
- neurovascular, tendon or potential joint space involvement
- general anesthesia is required
Read the review for a fuller discussion of these highlights and a whole lot more!