Wound Management

Kelly 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 wound management.
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.

AUTHOR DISCLOSURE Drs Black, Cico, and

Caglar have disclosed no nancial
relationships relevant to this article. This
commentary does not contain a discussion of
an unapproved/investigative use of
a commercial product/device.

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

Vol. 36 No. 5
Downloaded from http://pedsinreview.aappublications.org/ at Gazi University on May 1, 2015

MAY 2015

207

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 physicians 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, 41 million
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 etiologybased categories in the medical literature: injury-related
wounds, bites, and burns. Injury-related wounds include lacerations, avulsions, and punctures. This review examines

208

injury-related wounds and bites; chronic wounds are outside 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 hemorrhage, 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 the child with 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 disorder. However, studies are rarely needed in routine wound care.
Radiographs may be helpful if the clinician has concerns
about retained glass or metal. Ultrasonography can be particularly helpful to evaluate for a radiolucent foreign body or to
assist in removal of a foreign body during the procedure.

WOUND CLOSURE
Primary
Primary closure of a wound involves denitive repair at the
time of presentation. Generally, trainees are taught sterile

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

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 becoming increasingly rare in the medical setting, is associated
with higher rates of infection compared to the more commonly 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 the most common home
treatment of lacerations and wounds. High-pressure irrigation (>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 solutions have not been denitively shown to be advantageous in
decreasing rates of infection compared with saline and tapwater irrigation. (11)

than those who underwent suture repair. Concern for

scarring is high for many families, but conservative management of small, uncomplicated lacerations should remain
a treatment option in appropriate situations.
Closure by secondary intention should also be used when
wound infection is a concern. Wounds that are grossly
contaminated, have signs of infection, present late for
medical attention, or are at high risk for infection based
on wound or patient factors should be allowed to heal by
secondary intention. Primary closure should not be performed. Risk factors for infection are listed in Table 1.

Delayed
Delayed primary wound closure involves intentional delay
in primary wound closure. Although described in the medical literature dating back to 1919, delayed primary closure is
underused currently. This approach is useful for highly
contaminated wounds. The clinician debrides and thoroughly irrigates the wound; applies a nonocclusive bulky
dressing; and reevaluates, debrides and irrigates the wound
3 to 4 days later. Primary closure is attempted when there is
no obvious evidence of infection on reevaluation. This
method is also useful for wounds that may require the
expertise of a specialist such as a plastic surgeon who is
not immediately available or if the child needs sedation but
has recently eaten. Wounds can be irrigated, debrided if
necessary, and covered with a wet-to-dry dressing, and the
child may return the following day. When comparing early
versus delayed closure, surgical studies do not show a
signicant difference in infection rates. (14) Shepard performed an observational study of infection rates in high-risk
wounds treated with delayed primary closure and found an
infection rate of 3%. (15)

TABLE 1.

Risk Factors for Wound Infection or

Poor Wound Healing

Secondary
Wound 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 (<2 cm) conservatively
allowed to heal by secondary intention and those treated
with sutures or tissue adhesive. (1113) Although outcomes
were similar in both study groups, the group treated conservatively experienced less discomfort and shorter visits

Patient Factors

Immunocompromised
Peripheral arterial disease
Diabetes mellitus
Malnutrition
Corticosteroid use
Obesity

Wound Factors

Increased age of wound at time of

presentation
Animal bites, particularly in decreased
vascular areas (extremities, trunk)
Deep puncture wounds that are difcult to
irrigate effectively
Excessive wound tension with suture
placement

Vol. 36 No. 5
Downloaded from http://pedsinreview.aappublications.org/ at Gazi University on May 1, 2015

MAY 2015

209

ANESTHESIA
Anesthesia can be applied topically to open wounds. Lidocaine, 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 solution without use of needles, it can decrease anxiety and
increase cooperation of pediatric patients while still providing 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 360 minutes
if used with epinephrine. However, lidocaine with epinephrine 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),
but when used in combination with epinephrine, the maximal
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 standard for regional blocks such as femoral nerve blocks and
seems to increase the effectiveness of the block compared to
traditional injection techniques. (17,25)

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 outcomes 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 to moisture 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 application. (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 petroleum 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 adhesives also have inherent antimicrobial properties, particularly against Gram-positive organisms, (32) which may be an
advantage in the pediatric population.

Surgical Staples
CLOSURE METHODS
Surgical Tapes
Surgical tapes are a fast, simple, relatively pain-free, and inexpensive method of wound closure. They do not require outpatient physician follow-up for removal. They do not provide
signicant hemostasis nor do they adhere to areas of the body
with hair, 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.

Even 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 appropriate in many areas of the body. (33)

Hair Apposition Technique

Tissue Adhesives
Relatively painless, rapid application makes tissue adhesives,
also known as cyanoacrylate adhesives, ideal for pediatric

210

The 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

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

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 mindful 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)

Sutures
Sutures are the gold standard of wound closure, offering the
most meticulous skin closure with good strength, particularly 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, sutures 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 wound may 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, and may 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 approximation. This suturing technique is relatively easy to learn
and master, 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 approximately 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 polylament. Natural sutures cause more skin reactivity than synthetic 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 Lacerations
The 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 without changing landmarks around the lip. (47) However, in
younger or more anxious children, this type of block may not
be easily achieved and deeper anesthesia may be necessary.

Vol. 36 No. 5
Downloaded from http://pedsinreview.aappublications.org/ at Gazi University on May 1, 2015

MAY 2015

211

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 polylament

absorbable (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

When repairing a lip laceration, the rst stitch must 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 Lacerations

Most 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 polyglatin or chromic gut.

Ear Lacerations
Trauma 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 auricular hematoma. If present, it must be evacuated to allow for

212

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 incision measuring 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 4
4 gauze pads on the posterior aspect of the
auricle, 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 Injuries
Injuries to the ngertip and nail are common. The nail itself
plays an important role in normal hand function by protecting the ngertip, providing counterforce to assist with picking 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

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

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 by making 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 phalangeal physis in children. (49) Proper treatment requires
removal of the nail plate, irrigation, debridement, administration of antibiotics, reduction of the fracture, and nailbed
repair and would likely benet from orthopedic consultation. Complications can include osteomyelitis, growth
arrest, and nail deformity.

Bite Wounds
Bite 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 bite wounds 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 occasional mixed anaerobes. Although Pasteurella multocida
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 Corynebacterium 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 transmission 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 Wounds
Puncture wounds, with or without a retained foreign body,
are a common presentation to the emergency department,
urgent care center, or physicians ofce, although most individuals 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 contamination or necrotic tissue can be managed without prophylactic
antibiotic coverage. The wound should be evaluated by caregivers

Vol. 36 No. 5
Downloaded from http://pedsinreview.aappublications.org/ at Gazi University on May 1, 2015

MAY 2015

213

TABLE 3.

Common Wound-related Antibiotics

ANTIBIOTIC

DOSING

COMMON USE

Amoxicillin-clavulanate

90 mg/kg divided BID

Bites, intraoral wounds, grossly contaminated

wounds, 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-allergic

patients

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

810 mg/kg/day of trimethoprim divided

every 12 hours

Hand bites (cat, human), penicillin-allergic

patients

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 management 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 bacteria 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 history 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

214

supported in a 2013 Cochrane review. (55) Child life specialists 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
(0.4 mg/kg to a maximum dose of 10 mg) or orally (0.5 mg/kg
to a maximum dose of 15 mg) with good effect. For longer or
more complicated repairs (eg, vermillion border, facial, layered 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). Clean wounds merit 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 immunoglobulin in any high-risk wound sustained by patients who
have had fewer than three immunizations.

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

TABLE 4.

Tetanus Prophylaxis in Routine Wound Management

HISTORY OF TETANUS
TOXOID (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 <10 years since last tetanuscontaining vaccine dose

Yes if >10 years since last tetanuscontaining vaccine dose

No

No if <5 years since last tetanuscontaining vaccine dose.

Yes if >5 years since last tetanuscontaining vaccine dose.

No

No

No

DTaPdiphtheria and tetanus toxoids with pertussis; Tdaptetanus toxoid, reduced diphtheria toxoid, and acellular pertussis, adsorbed; Tdtetanus and
diphtheria 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 from
missiles, crushing, burns, and frostbite.
Note: DTAP is used for children <7 years of age. Tdap is preferred to Td for underimmunized children 7 years of age or older who have not received Tdap
previously.
Adapted from the Red Book: 2012 Report of the Committee on Infectious Diseases, p. 709

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 outcome. 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 are not warranted and do not improve overall outcome.
However, despite good wound care, some infections still occur.
Host and wound characteristics should be considered
(Table 1). Patients who are immunosuppressed (eg, chemotherapy, 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 puncture wounds from cat bites,
and should always be prescribed prophylactic antibiotics to
cover likely organisms, typically a b-lactamase inhibitor antibiotic (ie, amoxicillin-clavulanate). (57) Table 3 lists commonly
used wound-related antibiotics, indications, and dosing.

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

comparing early postoperative bathing (<12 hours) to delayed
bathing (>48 hours). (59) Typically, sunblock products are
recommended for 6 to 12 months after wound healing.

Summary
Diagnostic studies are rarely needed in the management of
a child with a simple laceration or wound.
On the basis of strong evidence from clinical studies, the use of
nonsterile gloves and tap water for laceration repair does not
increase infection rates. (711)
On the basis of some evidence and consensus, wounds that have
a late presentation, are grossly contaminated, or are at high risk for
infection should be allowed to heal by secondary intention. (1113)
Important history and physical examination ndings pertaining
to wounds should be obtained.
On the basis of several studies and consensus, topical anesthetics
can decrease anxiety and increase cooperation of pediatric
patients while still providing adequate analgesia. (1619)
Different closure methods and suture types must be considered based
on the type and location of wound to be repaired. (1115,26,27,47)
On the basis of strong evidence, dog and cat bite wounds should
be adequately cleaned and antibiotics prescribed empirically to
decrease the risk of wound infection. (5255)

WOUND CARE

Consensus recommendations support that tetanus immunization

status should be reviewed for all wounds. (57)

After repair, wound care and appropriate discharge instructions are important for good cosmetic outcomes. Patients
should be advised to monitor closely for signs of infection.
Wounds repaired with 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

Host and wound characteristics can affect wound healing and

outcomes.

References for this article are at http://pedsinreview.aappublications.org/content/36/5/207.full.

Vol. 36 No. 5
Downloaded from http://pedsinreview.aappublications.org/ at Gazi University on May 1, 2015

MAY 2015

215

PIR Quiz
1. Increased risk of infection after laceration repair is associated with which of the following?
A.
B.
C.
D.
E.

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

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

A.
B.
C.
D.
E.

A
A
A
A
A

chin laceration that occurred 3 hours ago in a healthy 2-year-old girl.

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

Dog bite.
Elbow laceration.
Forehead laceration.
Lip laceration.
Puncture wound.

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

A.
B.
C.
D.
E.

2-year-old boy with a forehead laceration after tripping onto a tile oor.
3-year-old boy with a lip laceration after falling and striking his lip on a table.
5-year old girl with a scalp laceration after running into the edge of a door.
10-year-old girl with a leg laceration obtained from the pedal of her bicycle.
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 stepping
on a nail that pierced through his shoe while working on his family farm. The patients
shoes and wound appear grossly contaminated with horse manure. The patient has
received ve prior diphtheria and tetanus toxoids with pertussis (DTap) immunizations and
a tetanus toxoid, reduce diphtheria toxoid, and acellular pertussis, adsorbed (Tdap)
immunization at age 11 years. In addition to cleaning the wound, which management is
most 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.

216

REQUIREMENTS: Learners
can take Pediatrics in
Review quizzes and claim
credit online only at:
http://pedsinreview.org.
To successfully complete
2015 Pediatrics in Review
articles for AMA PRA
Category 1 CreditTM,
learners must
demonstrate a minimum
performance level of 60%
or higher on this
assessment, which
measures achievement of
the educational purpose
and/or objectives of this
activity. If you score less
than 60% on the
assessment, you will be
given additional
opportunities to answer
questions until an overall
60% or greater score is
achieved.
This journal-based CME
activity is available
through Dec. 31, 2017,
however, credit will be
recorded in the year in
which the learner
completes the quiz.

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

Wound Management
Kelly D. Black, Stephen John Cico and Derya Caglar
Pediatrics in Review 2015;36;207
DOI: 10.1542/pir.36-5-207

Updated Information &

Services

including high resolution figures, can be found at:

http://pedsinreview.aappublications.org/content/36/5/207

References

This article cites 51 articles, 6 of which you can access for free at:
http://pedsinreview.aappublications.org/content/36/5/207#BIBL

Permissions & Licensing

Information about reproducing this article in parts (figures, tables) or

in its entirety can be found online at:
http://pedsinreview.aappublications.org/site/misc/Permissions.xhtml

Reprints

Information about ordering reprints can be found online:

http://pedsinreview.aappublications.org/site/misc/reprints.xhtml

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

Wound Management
Kelly D. Black, Stephen John Cico and Derya Caglar
Pediatrics in Review 2015;36;207
DOI: 10.1542/pir.36-5-207

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pedsinreview.aappublications.org/content/36/5/207

Pediatrics in Review is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1979. Pediatrics in Review is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2015 by the American Academy of
Pediatrics. All rights reserved. Print ISSN: 0191-9601.

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