The aim of wound care is to reduce pain, prevent wound infection, promote healing and minimise scar formation.
A successful treatment strategy consists of reducing the child's fear, optimal pain relief and a careful inspection of the wound.
Timely and adequate analgesic medication, as well as stopping bleeding by applying pressure to the wound with a clean dressing for 5-10 minutes, will prepare the child for the wound care procedure.
It is preferable to close the wound painlessly with tissue adhesive or wound-closure strips; in small wounds the results are as good as those achieved with suturing.
Surgical debridement is required for badly contaminated lacerations.
If the application of pressure to the wound for 5-10 minutes does not stop bleeding, ligation or electrocoagulation of the bleeding vessel is likely to be needed.
Antimicrobials are only rarely indicated in fresh wounds, but the patient's cover against tetanus must always be verified if the wound is contaminated.
First aid
Apply pressure to the bleeding wound for 5-10 minutes using a clean dressing, provide pain relief and, at the same time, find out how the wound was acquired from the child and/or the person accompanying the child.
Suitable also for children with allergic disorders, asthma or renal impairment
Must not be given to children with hepatic impairment
The dose is 20 mg/kg orally three times daily. The dose exceeds that recommended by the manufacturer and hence the prescription should be furnished with the locally relevant indication of exceptional dosage instructions (in Finland marked with "sic!").
In adolescents, there are preliminary experiences of inhalable methoxyflurane even though it does not have an official indication for children's or adolescents' pain management or managing their painful procedures.
History and assessment
When did the wound occur?
A wound cannot be considered as fresh after 6-24 hours, depending on the degree of contamination present.
Non-contaminated wounds of the trunk and limbs should be closed within 12 hours and wounds of the head and face within 24 hours.
What was the trauma mechanism?
The possibility of other injuries must be borne in mind if the wound was caused by contusion, incision or puncture (stab).
The possibility of a foreign body?
Sand, wood splinters and fibres from clothing may penetrate deep into the wound.
Functioning?
The possible loss of sensation, functioning of the tendons, motor function and circulation must all be carefully assessed.
Systemic disease?
Are there any pre-existing conditions that may influence wound care and the healing process (e.g. diabetes, coagulation defects)?
Medication?
Potential interactions with analgesics or possible allergy/hypersensitivity
When was the last time the child had something to eat or drink? This information should be recorded in the referral letter to specialist care to aid the planning of possible general anaesthesia.
Marked inconsistencies between the story and physical findings?
The inspection of the wound must not cause unnecessary pain or fear in the child.
Analgesic medication should be given well in advance and, if possible, the child should be examined in the lap of the parent or the person accompanying the child.
Try to reduce the child's fear.
Talk to the child and explain what you are doing using simple words.
Position yourself at the child's eye level.
Remain calm and composed.
Create a feeling of safety before touching the child.
Examine a non-affected site first (e.g. the contralateral limb) to familiarise the child with your touch.
When examining the wound, note its location, size, appearance, possibility of contamination and consider whether, in addition to the skin, the deeper structures may have been damaged.
Examine and test systematically for the possibility of associate injuries (nerves, tendons, blood vessels and muscles - in puncture wounds to the body, remember the possibility of injury to the internal organs).
Preparation
Consider the type of anaesthesia required at the wound site.
Topical anaesthesia (EMLA® cream or similar) works well if the product is allowed to absorb into the area for at least 30 minutes.
Block anaesthesia and local anaesthesia also provide good pain relief, but as these agents need to be injected with a needle the associated fear and pain often prevent their use in children under the age of 10 years.
The wound should be cleaned with tap water Water for Wound Cleansing. Physiological saline may sting less than water. Pressure irrigation using a syringe may be necessary in order to optimise the cleaning of the wound.
An incised wound with smooth edges can be closed with tissue adhesives or wound-closure strips without preparation. Surgical debridement is required if the wound has jagged edges, is very contaminated or contains dead tissue.
It is almost always possible to close a non-contaminated clean-cut wound with tissue adhesive or butterfly strips, up to 6 to12 hours after the occurrence of the wound.
Wounds most suited for closure with a tissue adhesive or butterfly strips are non-contaminated small cuts with smooth edges at sites where the wound is not exposed to a great deal of stretching.
When using a tissue adhesive, appose the wound edges and apply the adhesive over the skin - not into the wound!
Wear gloves. It is easier to cut off the end of a glove finger than your own fingertip should you become inadvertently adhered to the patient. The small piece of rubber from the glove will detach itself when the adhesive peels off in time.
There is no need for dressings as the adhesive itself provides sufficient cover. The adhesive will peel off within a few weeks.
Wounds suitable for closure with wound-closure strips (e.g. Steristrip® ) are fresh incised wounds with smooth edges as well as gaping and jagged wounds that occurred over 6 hours previously.
Wound-closure strips must be as long as possible and are not suitable for hairy body areas.
The strips are applied across the wound whilst the wound edges are gently pressed together.
A dressing should be placed over the strips and the wound kept dry and clean for a few days.
If an older wound with jagged edges is closed with wound-closure strips the parents must be informed about the risk of wound infection. The routine use of antimicrobials is not recommended, but surgical debridement is important to minimise the risk of infection.
Adequate alleviation of pain and fear is essential before suturing is started.
The most recommended sutures for the facial area in under school age children are quickly absorbed monofilament sutures, size 6-0 or 5-0. Stronger nonabsorbable monofilament sutures are used in the trunk and limbs. A skin needle with a cutting point should always be used.
The sutures must not pull at the wound edges since this will cause pain and impair blood circulation to the wound and is likely to cause more severe scarring.
A clean dressing should be placed over the sutures for 24 hours. The wound should be kept dry and clean for a few days.
Non-absorbable sutures should be removed after about 5 days from the face, after 5-7 days from a hand and after 7-10 days from elsewhere.
Wounds involving the cheeks and lips may be accompanied by tooth injuries. Sutures are not often needed on the buccal mucosa as the wound will heal quickly even without them. A wound that penetrates the entire lip must be closed layer by layer, and the careful repair of the lipstick area is of particular importance.
Patients with wounds to the eyelids should be sent to a hospital for an ophthalmological evaluation, unless the wound is only superficial.
A superficial traumatic amputation of a fingertip, less than 1 × 1 cm, is treated with a non-adherent dressing impregnated with soft paraffin (tulle gras).
A fingertip that has become partially detached from the rest of the finger at the base of the nail is reattached with adhesive tape placed around the fingertip or with a couple of lateral sutures. A soft paraffin dressing (tulle gras) is then placed over the wound, and the finger is splinted to its neighbouring finger for support. The fingertip may atrophy somewhat but will, however, be more functional than an amputation stump.
In hand wounds, it is important that circulation to the hand is checked as well as the functioning of the nerves and tendons. In crush injuries, an x-ray is often indicated to exclude coexistent bone injuries.
Wound closure with skin staples
Removable skin staples may be used in place of sutures. They are quick and easy to put in place and, moreover, their removal is often less painful than that of sutures.
However, skin staples can only be removed with an instrument developed solely for this purpose. Staples should remain in situ for the same length of time as sutures.
Staples are not recommended for cosmetically important areas.
Bite wounds
Bite wounds are not closed but the wound should be cleaned with water and covered with a dressing. Loose monofilament sutures may be used to bring the wound edges slightly closer if considered necessary. Wound-closure strips may be used if the bite wound is on the face.
A patient with an extensive and ugly bite wound should be sent for specialist evaluation and management without delay.
Infection will develop in about one fifth of dog bites, in half of cat bites and one quarter of human bites. A bite wound to the limbs and face may be accompanied by a fracture. See also Bite Wounds.
The wound is rechecked after a few days and gently closed with sutures or wound-closure strips, if required for cosmetic reasons and no marked inflammation is present.
Abrasions (grazes) in children
A skin abrasion is cleaned with water Water for Wound Cleansing, physiological saline or a disinfectant. If necessary, clearly necrosed tissue should be surgically removed.
Dirt and soil should be meticulously removed; local anaesthesia and a brush may be used if indicated. Tattooing caused by trapped dirt or foreign material is very difficult to remove after the wound has healed.
After cleaning, the abrasion is covered with a soft paraffin or silicone dressing.
A dry dressing placed on top of the soft paraffin dressing is secured in place either with surgical tapes or a gauze bandage wrapped around the affected limb.
If indicated, the dressings are changed daily and the wound cleaned (rinsed or bathed with water). If the abrasion was not very contaminated, the dressings may stay in situ for a few days.
Should the wound show signs of infection, oral antimicrobials may be prescribed.
References
Jakeman M, Oxley JA, Owczarczak-Garstecka SC et al. Pet dog bites in children: management and prevention. BMJ Paediatr Open 2020;4(1):e000726. [PubMed]
Bhaumik S, Kirubakaran R, Chaudhuri S. Primary closure versus delayed or no closure for traumatic wounds due to mammalian bite. Cochrane Database Syst Rev 2019;(12):CD011822. [PubMed]