Lacerations

Disclaimer These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.  Read the full PCH Emergency Department disclaimer.

Aim 

To guide PCH ED staff with the assessment and management of lacerations in children.

Background

• Minor wounds and lacerations are common injuries in children
• Goals of treatment include:
  • restoring function and structural integrity
  • prevention of infection
  • cosmetically acceptable healing
  • minimising distress to the child and parents during wound repair.

Assessment 

History

To determine the best management for the child’s wound the following information should be considered:

• Mechanism of Injury – will assist in determining the degree of devitalised tissue in the surrounding area
  
  • Shearing - sharp cuts, high velocity missiles
  • Tension - flap lacerations, avulsion injuries
  • Compression - direct blow causing both laceration and haematoma
• Patient factors - identify risk factors that may delay healing or cause infection / complications
  
  • General health e.g. diabetes, malnutrition, shock, anaemia, renal failure, tendency to form keloid scars
  • Medication e.g. steroids and immunosuppressive drugs
  • Tetanus status - refer to Tetanus prone wounds.
• Environment - where the wound occurred will determine likely contamination
• Age of wound

Examination

Assess wound

Extent of wound	Size, shape, site, structure and sensation
Deep structures	Tendons, nerves, bones - check distal function, check for fractures - X-ray if indicated
Blood supply	Flaps may be dusky, be mindful of damage to end arteries
Contamination	Dirt, foreign bodies - may require X-ray or ultrasound

Tetanus prone wounds

Tetanus can follow apparently trivial, even unnoticed wounds. However, some wounds tend to favour the growth of tetanus organisms: refer to Tetanus prone wounds.

Management 

Wounds requiring surgical review

Signs of vascular injury or compromise Wounds requiring exploration and possible repair of deeper structures Extremely large wounds – e.g. face > 3cm laceration Extensive repair in sensitive areas e.g. perineum, medial canthus eye Compound fractures Highly contaminated wounds which require thorough debridement Uncooperative patient unable to be adequately sedated by conscious sedation Wounds requiring optimal cosmetic repair

Specific wounds
Lip Requires exact approximation of the Vermillion border. May require plastics referral.
Tongue and Intraoral Most of these lacerations in children will heal without suturing. Exceptions are free edge of tongue involved or involving facial nerve and salivary ducts.
Eyelids May require referral to Ophthalmology, especially if fat exposed, deep involving muscles or medial lacerations affecting tear duct structures  – refer to Eye trauma.
Bites Common injuries prone to infection. All require prophylactic Antibiotics Human Bites Often involved in high impact mechanisms i.e. fist fights or sports injuries  resulting in tissue crush and devitalisation. Should not be closed unless thoroughly irrigated and debrided.  Animal Bites Most common dog bite, then cat Requires meticulous wound preparation Rabies prophylaxis not required for bites in Australia, but beware patients presenting from Asian destinations.
Foreign Body X-ray if foreign body (FB) is radio-opaque for identifying position Ultrasound may be necessary for determining presence of radiolucent FB Wound exploration is essential, this often requires local anaesthetic (nerve block  useful for difficult to inject areas) or general anaesthesia Deep foot FB to be referred to orthopaedics.
Contaminated Thorough irrigation with 0.9% saline and debridement is essential – may require antiseptic liquid (Chlorhexidine 0.05% or 1% Providine-Iodine) Delayed primary closure for 4-5 days may be useful in grossly contaminated wounds.

Procedure

• Minimise distress to the child and parent during the procedure with appropriate analgesia, local anaesthesia and/or sedation
• Obtain necessary resources for treatment. If in doubt, consult with a senior medical officer or nurse.

Local Anaesthetic

• Infiltration with local anaesthetic (e.g. 1% lignocaine)
• ALA or Laceraine
• Regional nerve blocks – refer to appropriate guideline

Analgesia and sedation

• Refer to Analgesia and appropriate sedation guideline (Nitrous Oxide or Ketamine)

Cleaning and irrigation

• Irrigate with 0.9% saline using a large bore needle and syringe to remove obvious foreign material.
• Antiseptics may damage tissue defences and potentially impede healing. Exception – contaminated wounds may benefit from Chlorhexidine 0.05% or Povidone-iodine irrigation. 

Debridement

• Can reduce wound infections by removing debris, bacteria and devitalised tissues
• May make a jagged wound into a long wound requiring too much tension and wider scar
• Hair can be trimmed around lacerations but avoid shaving large patches
• Never shave eyebrows

Wound repair options	Suitable wound	Comments
Wound tapes (Steristrips™ or Skinlinks™)	Suitable for simple linear lacerations with minimal tension. Not useful on wet (oozing) areas or lacerations with surrounding abrasions.	Prepare intact adjacent skin with tincture of benzoin to aid adhesion, but avoid contaminating wound with it (causes severe pain). Use Leukosan ™ Skinlink as per directions.
Tissue adhesive (e.g. Dermabond)	Suitable for simple superficial lacerations (less than 3cm) especially on the face.	Skin Glue Dermabond.
Suturing	Suitable for clean uninfected wounds where the depth will lead to excess scarring if the edges are not properly opposed. Typically this is when the laceration extends through the dermis. Absorbable (chromic) sutures are suitable for deep structures.	In general use interrupted sutures. Nylon monofilament preferable to silk to reduce suture marks. To avoid the need for removal absorbable (chromic) sutures maybe appropriate if the wound is not under tension, particularly in the frightened and uncooperative child.
Staples	Suitable alternative for linear lacerations through the dermis that have straight edges on the scalp, trunk, arms and legs.  Staples will create artefacts on CT scans if imaging is required.	Can be more painful and cosmetically may cause more scarring. Can be placed more rapidly than sutures. Place staples approximately 0.5 – 1cm apart.

Post repair wound care

• Dressing 
  
  • Wound and dressing guide
• Antibiotics
  • Not a substitute for meticulous irrigation and debridement. If indicated initiate early 
• Elevation 
• Immobilisation
• Tetanus
  • Ensure booster is given for Tetanus prone wounds +/‐ tetanus immunoglobulin in non-immunised patients.
• Sun exposure
  • Healing wounds are more sensitive to the sun. Sun protection maybe required for at least two years post injury.
• Removal of sutures
  • 3-5 days face
  • 7 days scalp, upper limb, anterior trunk
  • 10-14 days lower limb and back
• Removal of staples
  • One week (provide staple remover to parents for GP to remove)
• Tissue adhesive
  • Remains for 1-2 weeks
  • Does not require removal 
• Leukosan™ Skinlink™
  • Remain for up to 10 days 
  • Does not require removal
  • If Skinlink™ begins to curl, the edges may be trimmed with scissors
  • Limited bathing
  • Always pat dry if exposed to moisture
  • Do not scrub
• Wound tapes
  • Do not remain in place for long periods
  • Keep dry for 24 hours
  • Limit bathing
  • Always pat dry if exposed to moisture

Bibliography

1. Grabb and Smith's Plastic Surgery By Thorne Lippincott Williams and Wilkins  2013
2. Textbook of Pediatric Emergency Medicine. 6th ed. Fleisher GR, Ludwig S. Philadelphia: Lippincott Williams & Wilkins, 2010.
3. Textbook of Paediatric Emergency Medicine 2nd Edition Cameron Elesevier 2012
4. Nelson Textbook of Pediatrics: 20th Edition Robert M. Kliegman, Bonita M.D. Stanton, Joseph St. Geme, Nina F Schor Publisher: Elsevier 

Endorsed by:	Executive Director, Medical Services	Date:	Oct 2021
		Review date:	Oct 2022

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