Key Practice Points
Addressing the emotional needs of children and parents is as important as wound care.
If the history is inconsistent with the wounds, physical abuse of the child should be considered.
Examination of the child should begin at a site away from the wound so that the child can become accustomed to the examiner.
Physical restraints are more commonly used in the preverbal child. A gentle, empathetic approach can help avoid the need for restraints in older children.
Use of topical anesthetics and a gentle approach reduces the need for oral or intravenous sedation.
Topical anesthetics can be safely applied by parents.
Absorbable suture materials have the same cosmetic outcome as nonabsorbable sutures for superficial skin closure of the scalp, face, and hand. Absorbable sutures eliminate the need for a return visit for suture removal.
Because young children cannot accurately report loss of function in hand injuries, simple observation and special techniques are necessary to detect tendon and nerve injuries.
Fingertip amputations can heal with regeneration alone without surgical intervention.
Uncomplicated puncture wounds of the foot do not need prophylactic antibiotics.
Lidocaine 4% cream applied to a superficial skin abscess with an occlusive dressing can cause spontaneous drainage.
A dressing can be secured with Coban (3M, St. Paul, Minn.) to help prevent a young child from removing it.
Children commonly present to emergency departments (EDs) with lacerations, representing approximately 30% to 40% of all injuries seen in a pediatric ED. Estimates of the annual rate of lacerations are 50 to 60 per 1000 children. Lacerations often involve younger children who lack the experience, common sense, and motor coordination of older children. Boys are involved twice as often as girls. Lacerations frequently result from falls from stairways, bicycles, and furniture. In children, lacerations occur most often on the head (60% of the time), followed by the upper and lower extremities. Overall, lacerations are a common type of pediatric injury requiring functional and cosmetic evaluation by a physician.
General Approach and Calming Techniques
Assessing the Child
Lacerations in pediatric patients represent not only a technical challenge for the provider, but also an emotional challenge for the clinician, the child, and the parent or caregiver. Thus, it is important to take time to explain the procedure, the approach, and the possible discomforts to the child and the parents. Time spent up front preparing the child for the procedure is gained back in the end.
Assuming that there are no life-threatening or limb-threatening injuries, the clinician first should obtain the history while gaining the child’s confidence. The clinician should not undress the child or examine the wound immediately. A rapport should be established by talking directly to the child using age-appropriate terms. The clinician can involve toddlers by asking them how they got their “boo-boo,” but one should not expect to obtain an adequate history from the child alone; the specifics are better obtained from the parent. Children 4 years old and older frequently can provide some of the history, which allows them a sense of control. Information recommended for wound care documentation can be found in Chapter 2 , Box 2-1 .
Distraction can be effective at any age, such as asking about toys, cartoon characters, friends, siblings, or favorite colors or activities at an age-appropriate level. Table5-1 summarizes the developmental abilities and distraction techniques for children of different ages. Toys, interactive books, bubbles, videos, music, and sparkle wands can all be used to engage a child and divert their attention from the procedure at hand. Mental imagery is most effectively used with children who are 4 years old and older. Children younger than 4 years of age are distracted best by visual and auditory stimulation such as songs, books, or toys, as well as personal comfort items such as pacifiers, blankets, and stuffed animals. The outcome frequently relates to the verbal abilities of the individual child. Often a parent can be an ally and help distract the child if he or she is permitted and wants to be at the bedside. A general understanding of developmental milestones is invaluable in enabling the physician to interact appropriately with children.
|Age (yr)||Development Issues||Fears||Techniques||Distraction/Comfort Items|
|School age (5-10)|
|Adolescent (10-19)||Video games|
Child life specialists have been used successfully in inpatient settings for distraction during painful procedures. More and more pediatric EDs are employing child life specialists. These professionals can provide all of the following support to staff before and during procedures: coaching children through coping techniques such as deep breathing, imagery, or story telling; distraction with bubbles, toys, and games; and parent and child preparation before procedures. Studies have found that child life specialists have a positive effect in reducing fears and improving satisfaction in children requiring repair for facial lacerations and angiocatheter placement. A general ED with as few as 15,000 pediatric visits annually can financially support the presence of a child life specialist.
As in all trauma situations, the history should focus on the events of the injury and the potential for injury to other areas of the body. If the history is not consistent with the injury pattern, then the possibility of intentional injury is raised. Physical abuse should be considered when the history and the injury are not consistent with one another, or when the event cannot be explained by the developmental age of the patient (e.g., a 6-month-old climbing onto and falling from a counter). There are some specific injury patterns that should raise suspicion of abuse, including burns in an immersion pattern, linear marks or lacerations consistent with a belt or hanger, or an unusual injury location not usually prone to injury. A social services referral is necessary for any case in which abuse is suspected.
Special attention should be paid to the immunization status. Simply asking the parent if the child’s shots are up to date most often elicits a positive response whether or not this is actually true. It is better to inquire about the number of “shots” and the age when the last one was given. Children should receive a total of 5 doses of diptheria/tetanus/pertussis (DTaP) at pediatrician visits at 2, 4, 6, and 15 to 18 months and at 4 to 6 years of age. Forroutine tetanus prophylaxis in children 6 years old or less who have not completed their primary immunization series, DTaP should be used instead of single-antigen tetanus toxoid (Td). The final booster for children should be around 11 years of age. Inthe event a child is completely unimmunized and parents refuse administration of tetanus prophylaxis, involvement of your local risk management department and local/state department of immunization may be necessary to facilitate appropriate treatment for the minor patient. Unfortunately, there are no alternatives to immunization for the prevention of tetanus because administration of antibiotics is “neither practical nor useful in managing wounds.” An in-depth discussion of tetanus prophylaxis is presented in Chapter 21 .
Assessing the Wound
Next, the wound is assessed. Allowing the child to remain with the parent for as long as possible facilitates the examination. The physician can gain the child’s confidence by telling him or her that initially the physician is just going to “look.” However, it is important to avoid a “promise not to touch,” thus misleading the child about your plans for an examination. The physician should continue to involve the parent in the evaluation process so that the child knows that the physician is there to help. Generally, kindness and patience should be accompanied by a thorough and directed approach. The examination should begin away from the injury, especially in a toddler or younger child. If the injury is on the hand or face, the physician should start by playing gently with a foot. This provides the child time to become comfortable with the exam and to develop confidence that the physician is not going to hurt him or her. After this development of trust, the provider can slowly advance to the site of the injury. Direct probing of the wound is painful and should not be done until after anesthesia is achieved. In cases in which hemostasis is necessary, pressure should be applied; this often can be done safely by the parent.
Parents can be of great help in calming and distracting their children, so they should be offered the opportunity to participate to the degree that their level of comfort allows. When asked, more than 80% of parents indicate that they would like to stay with their children through invasive procedures such as IV placement or laceration repair in EDs, and 90% of physicians and nurses support this parental presence. Some parents, however, cannot tolerate being present during the invasive treatment of their children, and these parents should also be given the option of going to the waiting area, if close by.
Restraint for Wound Care
Physical restraints ( Fig. 5-1 ) should be considered in a preverbal child if imagery and verbal calming techniques are ineffective. Limited language and limited ability to comprehend the situation make it difficult for preverbal children to cooperate with caregivers. Velcro restraint boards (Papoose Boards [Olympic Medical, San Carlos, Calif.]) are usually well tolerated, especially if used in conjunction with pharmacologic anxiolysis such as oral midazolam. It is our experience that, once in place on a board, an infant or toddler frequently becomes less agitated after infiltration is performed. Parents understand the need for restraints to protect the child from harming himself or herself and generally think that the child is comfortable in restraint and would be willing to have a Papoose Board used in a future visit.
Regardless of the method used, the caregiver always must take the time to explain the need for restraints to the parents. Restraints protect the child and caregiver during the procedure and ensure the best result. Their use is not without complication, however. Restraints limit the child’s protective reflexes should he or she vomit. Excessive crying increases gastric pressure, and, together with a full stomach, the possibility of emesis increases. Suction should be readily available, and the child should be turned to a lateral decubitus position while in the papoose if emesis occurs.
Pediatric Patient Sedation
Despite caregivers’ best efforts, occasionally there are children who are not able to cooperate. When the child’s inability to cooperate interferes with the physician’s ability to perform an adequate repair, or poses a danger to the caregivers or to the child himself or herself, the physician can consider the use of pharmacologic sedation. The type, location, and complexity of the laceration, and the emotional state of the child, help to determine the type of sedative to use. In small, simple lacerations, the risk of sedation may outweigh the benefits. In our experience, by using the previously described techniques and a topical anesthetic such as LET (lidocaine 4%, epinephrine 0.1%, and tetracaine 0.5% solution or gel), rather than an injected anesthetic, we are able to repair most small lacerations, including facial lacerations, without the use of sedatives.
For repair of a laceration, the physician usually induces moderate sedation, where the child retains protective reflexes, maintains his or her own airway, and is able to respond to a directed command. All sedation techniques can inadvertently evolve into deep sedation, which is a more depressed state of consciousness in which the child is not easily aroused and cannot maintain protective reflexes or an open airway, or even into general anesthesia, which is a drug-induced complete loss of consciousness with impaired ventilatory function. Titrating the sedative dose to the desired level of sedation may help prevent the evolution of consciousness into deep sedation; however, practitioners must be prepared to intervene during any airway emergency. In the office or ED, conscious sedation should be limited to children with American Society of Anesthesiologists (ASA) classifications I and II (class I is a normally healthy patient; class II is a patient with mild systemic disease). Additionally, the time of the last meal must be considered when deciding whether or not to sedate a child. ASA and American Academy of Pediatrics guidelines for fasting are 2 hours for clear liquids, 4 hours for breast milk, and 6 hours for formula, cow’s milk, and food. However, there is controversy regarding the applicability of these guidelines in the ED setting. The American College of Emergency Physicians Clinical Policy concerning sedation of pediatric patients in the ED specifically states that “procedural sedation may be safely administered to pediatric patients in the ED who have had recent oral intake.” Overall, as with any area in medicine in which there are conflicting recommendations, the relative risk of providing sedation must be weighed against the risk of delaying the procedure.
The room where sedation is performed must have equipment available for airway and cardiovascular interventions for children of all ages and sizes. The physician must have the ability to handle a sudden change in the child’s status. Whenever sedatives are used, there should be one practitioner present whose sole job is to monitor the patient and to assist in any resuscitative measures that become necessary. Continuous monitoring of pulse oximetry, pulse, and intermittent documentation of respiratory rate and blood pressure are necessary in all of these patients. The monitoring of any child who has received a sedative continues until discharge criteria are met. Discharge criteria include an ability to converse at an age-appropriate level, maintenance of a clear airway, stable cardiovascular function, and the ability to sit unaided. Regardless of the agent used, parents should be informed of the type of sedative to be used and the potential side effects. Consent should be documented in accordance with hospital, local, and state requirements.
Medications for Sedation
For pain control during moderate sedation, fentanyl is an excellent choice ( Table 5-2 ). It is a synthetic opioid agonist that is 100 times more potent than morphine. It is commonly used in combination with a sedative (e.g., midazolam) for conscious sedation. The benefits of this agent are rapid onset of pain control, short duration, and predictability. Fentanyl must be used with caution, especially when combined with another sedative agent, because of an increased risk of respiratory depression. If administered intravenously, it should be titrated in 1 μg/kg increments with a maximal dose of 5 μg/kg over 1 hour. Higher doses administered rapidly can induce chest wall rigidity with impaired ventilation.