Wound Care Introduction

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Wound Care Introduction

A wound is a break in the skin (the outer layer of skin is called the epidermis). Wounds are usually

caused by cuts or scrapes. Different kinds of wounds may be treated differently from one another,

depending upon how they happened and how serious they are.

Healing is a response to the injury that sets into motion a sequence of events. With the exception of bone,

all tissues heal with some scarring. The object of proper care is to minimize the possibility of infection and

scarring.

There are basically 4 phases to the healing process:

y Inflammatory phase: The inflammatory phase begins with the injury itself. Here you have bleeding,

immediate narrowing of the blood vessels, clot formation, and release of various chemical substances

into the wound that will begin the healing process. Specialized cells clear the wound of debris over the

course of several days.

y Proliferative phase: Next is the proliferative phase in which a matrix or latticework of cells forms. On

this matrix, new skin cells and blood vessels will form. It is the new small blood vessels (known

as capillaries) that give a healing wound its pink or purple-red appearance. These new blood vessels

will supply the rebuilding cells with oxygen and nutrients to sustain the growth of the new cells and

support the production of proteins (primarily collagen). The collagen acts as the framework upon which

the new tissues build. Collagen is the dominant substance in the final scar.

y Remodeling phase: This begins after 2-3 weeks. The framework (collagen) becomes more organized

making the tissue stronger. The blood vesseldensity becomes less, and the wound begins to lose its

pinkish color. Over the course of 6 months, the area increases in strength, eventually reaching 70% of the strength of uninjured skin.

y Epithelialization: This is the process of laying down new skin, or epithelial, cells. The skin forms a

protective barrier between the outer environment and the body. Its primary purpose is to protect

against excessive water loss andbacteria. Reconstruction of this layer begins within a few hours of the

injury and is complete within 24-48 hours in a clean, sutured (stitched) wound. Open wounds may take

7-10 days because the inflammatory process is prolonged, which contributes to scarring. Scarring

occurs when the injury extends beyond the deep layer of the skin (into the dermis).

Wound Care Signs and Symptoms

y Scrapes and abrasions are superficial (on the surface). The deeper skin layers are intact, and bleeding

is more of a slow ooze. They are usually caused by friction or rubbing against an abrasive surface.

y Lacerations (cuts) go through all layers of the skin and into the fat or deeper tissues. Bleeding may be

more brisk or severe. Severe blows by a blunt object, falls against a hard surface, or contact with a

sharp object are the most common causes of lacerations.



y Puncture wounds are generally caused by a sharp pointed object entering the skin. Most common

examples are stepping on anail, getting stuck with a needle or a tack, or being stabbed with a knife.

Bleeding is usually minimal, and the wound may be barely noticeable.

y Human bites and animal bites can be puncture wounds, lacerations, or a combination of both. These

wounds are always contaminated by saliva and require extra care.

Home Care

Scrapes and abrasions often do not require any more care than washing the area 4 times daily for the

first 48 hours and keeping the area covered with a sterile bandage. Deeper wounds and bites will require

medical attention.

y Stop the bleeding: If bleeding will not stop, apply a clean bandage to the area and press down on it for

10 minutes.

y Clean the wound: Water under pressure is the best way to clean a wound. Either a

briskly running faucet or a hand-held shower nozzle is the best way to wash a wound. The woundshould be washed for 10-15 minutes. Make sure you remove all dirt and debris. Do not scrub deep

wounds or bites, just wash them out.

y Check when you last had a tetanus shot.

Prognosis

Most wounds heal just fine if given proper care.

y Overall, the infection rate is 6.5%. Redness around the wound, a red line extending toward the body

from the wound, or yellowish drainage from the wound are signs of infection and require immediate re-

evaluation by a doctor.

y Keeping the sutures clean and avoiding the formation of a scab over them aid in a good cosmetic

result. A dilute peroxide solution or plain water may be used. It is all right to wash a sutured wound

after 48 hours, but it should not be soaked.

y Antibiotics are not necessary in most cases.

Prevention

y Take care when using sharp objects such as knives, scissors, saws, and trimmers.

y Wear shoes or boots on your feet.

y Use helmets when riding a bicycle.



y Use helmets, kneepads, wrist protectors, and elbow pads when using in-line skates.

y Avoid picking up broken pieces of glass and handling razor blades.

y Neonatal and Pediatric Wound Care: Best Practicesy f or our Sm allest Patientsy Glossaryy Acute pain ± see nociceptive pain; Pain that begins quickly but lasts a short or definitive time.

y Adult skin ± quality is age-related: decreased dermal thickness & epidermal regeneration.

y Autolysis - disintegration or liquefaction of tissue or of cells by the body¶s own mechanism, such asleukocytes and enzymes.

y Childhood - starts at 1 year of age and extends until teenage years of 13.

y Chronic pain -A persistent state of pain that lasts for an extended period of time.

y Collagen ± major structural protein found in the dermis and is secreted by dermal cells; main protein of connective tissue;

y makes up to 25%-35% of the whole body¶s protein content.

y Cyclic acute pain -Periodic pain that recurs due to repeated treatments or interventions.

y Dermal ± related to skin or dermis; synonym is ³integumentary´.

y Dermal-Epidermal Junction ± the area that separates the epidermis from the dermis; also referred to as

the basementy membrane zone.

y Dermis ± inner layer of the skin that lies under the epidermis; contains blood vessels, lymph vessels, hair follicles, glands and

y nerves.

y Dermatitis ± dermatological condition, inflammation of the skin.

y Desiccate ± to dry out.

y Dressings ± Materials applied to a wound for protection, absorption and drainage:

y � Hydrogel dressing- glycerin, saline or water-based dressings

y � Gauze dressing -usually made of cotton or synthetic that is absorptive and permeable to water, water vapor, and oxygen.

y The gauze may be impregnated with sodium chloride, petrolatum, antiseptics, or other agents.

y � Hydrocolloid dressing - formulations of elastomeric, adhesive, and gelling agents. Semi-occlusive and

impermeable toy fluids and bacteria.

y � Polyurethane film dressing- semi-permeable, transparent and non-absorptive, polymer-based adhesivedressing.

y � Foam dressing- cellulose or polyurethane dressing that may be impregnated or coated with other materialand has some

y absorptive properties. May have adhesive or soft silicon borders or be non-bordered.

y � Composite dressing-a non-adherent contact layer covered with an absorbent material and water-proof backing.

y � Alginate dressing ± highly absorbent, biodegradable dressing derived from seaweed

y � Hydrofiber dressing-highly absorbent, with gelling properties derived from carboxymethylcellulose.

y � Contact layer ± applied next to the wound bed to protect from trauma; some have absorptive propertiesand are coated

y

with soft silicone.y � Soft Silicon dressing- unique material that does not adhere to the wound because it does not contain

traditional

y adhesive; Available in many forms, such as a contact layer, absorptive foams, or impregnated dressings.

y Edema ± presence of abnormally large amounts of fluid in the interstitial space.

y Elastin ± protein found in the dermis; provides the skin¶s elastic recoil.

y Epidermis ± outermost layer of the skin.

y Epidermolysis bullosa (EB) ± genetic disorder characterized by skin and mucosal blistering. Three types:simplex, junctional,

y and dystrophic.



y Epithelial migration ± the movement of epithelial cells across the wound bed in the resurfacing or repair process.

y Epithelial stripping ± (skin stripping) the remove of the epidermis by mechanical means; denude.

y Epithelialization - regeneration of the epidermis across a wound surface.

y Exudate ± any fluid that has been extruded from a tissue or its capillaries, such as fluid, cells, or cellular debris, which has

y escaped from blood vessels and has been deposited in tissue surfaces.

y Extravasation ± leakage of a vesicant from the vein into surrounding soft tissue.

y Fetal skin ± gelatinous and extremely thin skin; produces scarless healing of wounds due to special dermalproteins (hyaluronan,

y collagen, transforming growth factor beta).

y Fibroblast- a cell that is responsible for building collagen and granulation tissue.

y Fissure ±a groove or deep furrow in the skin.

y Friction ± the force of two surfaces moving across one another, such as the mechanical force exerted whenskin is dragged

y across a coarse surface.

y Full-term skin - full development (36-40 weeks gestational period): is relatively same as post-term skin.

y Granulation tissue ± pink to red, moist tissue that contains new blood vessels, collagen, fibroblasts, andinflammatory cells that

y fills an open, previously deep wound when it begins to heal.

y Growth f actors - proteins that stimulate the deposition of collagen and matrix formation in a wound; calledcytokines, stimulate

y cell-activity.

y Inf ant - 30 days to 1 year of age.

y Inf ant skin - thinner skin & nails, collagen and elastin more rapidly produced than in adults.

y Inf ection ± the presence and growth of a microorganism that produces tissue damage.

y Keratinocytes ± cells in the skin that synthesize keratin; (the outer layer of cells) forms the epidermalbarrier.

y Maceration ± over-hydration or softening of the stratum corneum.

y NPUAP ± National Pressure Ulcer Advisory Board, www.npuap.org.

y Neonate/Newborn - the time from delivery to 30 days delivery.

y Neonatal skin - immature stratum corneum, far fewer cell layers, and increased permeability, especially first2 weeks;

y fibroblasts present in greater numbers than in adults.y Neuropathic pain - Pain that originates from nervous system damage or malfunctioning nerve fibers;

burning or electric

y shock-like.

y Nociceptive pain - Pain arising from stimulation of pain receptors; a normal pain response to injury or tissuedamage; acute pain

y Noncyclic pain -Single episode pain, usually acute pain.

y Occiput ± the back part of the skull.

y Pain - An unpleasant sensory or emotional experience associated with actual or potential tissue damage.

y Pediatric ± concerning the treatment of children.

y Peristomal - the skin surrounding a stoma.

y Pressure ulcer - is a localized injury to the skin and or underlying tissue, usually over a bony prominencethat is a result of

y pressure, or pressure in combination with shear and friction.y Pre-term skin (premature) - before term or full development (before the normal 36-40 weeks gestational

period; epidermis is

y thin and a weak protective barrier.

y Procedural pain ± pain that occurs due to a procedure and usually stops after procedure completed.

y Rete ridges or pegs - fingerlike projections in the epidermis that interlock with upward projections of papillary dermis; helps

y anchor the epidermis to the dermis

y Sepsis ± the spread of an infection from its initial site to the blood stream.



y Shear ± the mechanical force that is parallel rather than perpendicular to the surface area of the body;trauma caused by tissue

y layers sliding against each other, results in disruption or angulation of blood vessels.

y Skin Tear - result of friction alone or shearing and friction forces that separate the epidermis from the dermisor that separate

y both the epidermis and dermis from underlying structures.

y Stratum Corneum ± the outermost horny layer of the epidermis.

y Subcutaneous tissue - superficial fascia, forms beneath the dermis; also referred to as hypodermis.

y Syndactylism ± a fusion of two or more digits.

y Toddler/Childhood skin - fast epidermal turnover time, granulation tissue forms more quickly than in adults

y Wound bed ± uppermost viable tissue layer of the wound; may be covered with slough or eschar.

Minor injuries in children are extremely common.The combination of a developing physical ability,lack of recognition of dangerous situations and awillingness to robustly explore their environmentmeans that children are more likely than adults toinjure themselves.The most common types of wounds that children sustainare soft tissue bruising, abrasions, lacerations and puncturewounds (including human and animal bites). Managementgoals of these wounds are to avoid infection, minimisediscomfort, facilitate healing and minimise scar formation.Meticulous attention to wound care and repair shouldensure the best possible outcome and functional result.In children this will often require sedation in addition toadequate local anaesthesia and analgesia.

Wound assessmentThe care of the patient as a whole should be the firstmanagement priority. The airway, breathing and circulation

should be assessed and treated as appropriate. A thoroughsecondary survey may then be undertaken; if serious injuriesare detected, immediate intervention may be required.Wounds can be classified into various types includingabrasions, lacerations, avulsions, punctures, and bites.Regardless of the type of wound, there are basic steps inthe initial evaluation and management of skin wounds thatall clinicians should be familiar with (Table 1).

HistoryWhile haemostasis is being achieved, a thorough historyshould be taken to include the following:� time of injury� mechanism of trauma (cut, crush, fall, bite, burn)including details of inflicting object

� likelihood of foreign body� motor function and sensation distal to the affected area� health status of the patient especially with regard tochronic illness that may impact wound healing� current medications (important for both druginteractions with antibiotics that may be prescribed andfor medications that may interfere with wound healing)� history of allergies, and� immunisation history.In wounds that require general anaesthesia or sedation,a history of when the child last ate or drank is important.



Nonaccidental injury should be considered, especially whenthe history and injury are inconsistent.Ronan O¶SullivanMBBCh, BAO, FRCSI, FCEM, isFellow in Paediatric EmergencyMedicine, EmergencyDepartment, Royal Children¶s

Hospital, Melbourne, Victoria.Ed OakleyMBBS, FACEM, is a paediatricemergency physician,Emergency Department, RoyalChildren¶s Hospital, Melbourne,Victoria.Mike Starr MBBS, FRACP, is apaediatrician, infectiousdiseases physician, andPaediatric EmergencyConsultant, EmergencyDepartment, Royal Children¶sHospital, Melbourne, Victoria.

[email protected] Minor injuries in children are extremely common in the general practice setting.OBJECTIVEThis article describes a systematic approach to the assessment and treatment of wounds in children.DISCUSSION Wound management goals are to avoid infection, minimise discomfort, facilitate healing and minimise scar formation.The care of the patient as a whole should be the first management priority. Successful examination requires gainingthe child¶s trust, relieving pain early, and using a flexible and creative examination technique. Superficial abrasionsand lacerations can be safely cleaned with good quality water, and all foreign material removed. Deeper wounds withsuspected damage to nerves, tendons or circulation need formal exploration under general anaesthetic. Good localanaesthesia can be produced by topical preparations, and many wounds can be closed with tissue adhesives with anexcellent cosmetic result. All children with injuries should be checked for adequate tetanus cover for prophylaxis.

Wound repair inchildrenTHEMEMinor injuries in children are extremely common.

The combination of a developing physical ability,lack of recognition of dangerous situations and awillingness to robustly explore their environment

means that children are more likely than adults toinjure themselves.The most common types of wounds that children sustainare soft tissue bruising, abrasions, lacerations and puncturewounds (including human and animal bites). Managementgoals of these wounds are to avoid infection, minimisediscomfort, facilitate healing and minimise scar formation.Meticulous attention to wound care and repair shouldensure the best possible outcome and functional result.In children this will often require sedation in addition toadequate local anaesthesia and analgesia.



Wound assessmentThe care of the patient as a whole should be the firstmanagement priority. The airway, breathing and circulationshould be assessed and treated as appropriate. A thoroughsecondary survey may then be undertaken; if serious injuriesare detected, immediate intervention may be required.Wounds can be classified into various types including

abrasions, lacerations, avulsions, punctures, and bites.Regardless of the type of wound, there are basic steps inthe initial evaluation and management of skin wounds thatall clinicians should be familiar with (Table 1).

HistoryWhile haemostasis is being achieved, a thorough historyshould be taken to include the following:� time of injury� mechanism of trauma (cut, crush, fall, bite, burn)including details of inflicting object� likelihood of foreign body� motor function and sensation distal to the affected area� health status of the patient especially with regard tochronic illness that may impact wound healing

� current medications (important for both druginteractions with antibiotics that may be prescribed andfor medications that may interfere with wound healing)� history of allergies, and� immunisation history.In wounds that require general anaesthesia or sedation,a history of when the child last ate or drank is important.Nonaccidental injury should be considered, especially whenthe history and injury are inconsistent. WoundsReprinted f rom Australian Family Physician Vol. 35, No. 7, July 2006 477

ExaminationAssessing wounds in children can be challenging. Thecooperation achieved and the comprehension level of the child influence wound examination and therefore the

information gained. A calm, unhurried, friendly approachwith assistance from parents will maximise the chances of cooperation. Useful strategies include:� bobbing down to the child¶s eye level� leaving the child in a parent¶s arms� gaining trust by talking to the child, as well as to theparents, and explaining what is happening in a manner appropriate for the child¶s age� dealing with pain early by using analgesics, splintingand distraction.It is important to minimise the amount of additional pain byhandling limbs slowly and sensitively, soaking dressings off wounds, and avoiding unnecessary movement.Observe the wound, looking for the site, shape and size,the presence of a tissue flap, and possible contaminationby dirt or other foreign material. Decide what deeper structures may be involved and specifically test for each.In children, testing the integrity of nerves and tendonsneeds to be done creatively and flexibly, using simpleinstructions relayed through parents. This may involve theuse of mimicry, toys and playing. Assess the circulationlocally and distally to the wound. While conducting theexamination, make an assessment of the likelihood of thechild being cooperative during a procedure and the type of analgesia and sedation that may be necessary.



Unfortunately, even despite good preparation andtechnique, not all examinations will be successful. If thewound is deep or there is any doubt as to the integrity of nerves, tendons or circulation, the wound must be formallyexplored, a procedure best done in hospital under sedationor general anaesthesia.

Investigation

If the presence of a foreign body is expected, radiologicalinvestigation is advised. In wounds caused by glass, all butsuperficial wounds should be investigated with plain, softtissue X-ray to exclude a glass foreign body. Ultrasound canalso be useful to both confirm the presence of a foreignbody and to provide a guide to its depth and location inthe wound. Plain X-rays may also be indicated for injurieswhere underlying fracture is possible (eg. crush injury tothe finger).

Wound treatmentAfter assessment of the wound and the child in general, atreatment strategy can be devised. This should include:� whether the child needs analgesia and sedation� how the wound will be anaesthetised

� how the wound will be closed, and� whether any other treatment such as splinting,tetanus vaccination or antibiotics is needed.Clearly, the expertise of the doctor and other treating staff,the availability of drugs and equipment and the wishes of theparents and the child will influence treatment.

Pain managementAnalgesia and sedationA number of therapeutic options are possible.1,2 Select theappropriate agent depending on the wound, the degree of pain, the experience of the staff, and the procedure thatis likely to be performed. A summary of options is listedin Table 2 . Some agents such as morphine provide bothanalgesia and sedation. Be generous with the provision of analgesia and allow time for it to work, as poor pain control

is one of the major causes of procedural failure in children.Local anaesthesiaLocal anaesthesia options are listed in Table 2 . Topicalanaesthesia is painless, easy to apply and has a similar efficacy to infiltrated lignocaine.3 EMLA (an eutectic mixtureof lignocaine and prilocaine) is a cream usually applied tointact skin, however, it appears to be safe and effective for simple extremity lacerations even though it is not licensedfor this use.4,5

Regional nerve blocks, such as digital, ulna or femoral nerve blocks, are very effective in children. Anumber of reference books are available that provide theanatomical knowledge and practical instruction necessaryto perform them.2

Cleaning woundsAll dirt and foreign material in the wound must be locatedand removed before closure. Superficial wounds may besafely cleaned with good quality tap water.6 Preparationssuch as aqueous chlorhexidine are painful to apply andof doubtful benefit. Irrigation with saline under pressure(using a 19 gauge needle on a 10±20 mL syringe) is a goodway of dislodging and removing foreign material. Abrasionsshould be covered with a nonstick dressing and securedwith tape or a bandage.

Table 1.Overall wound management



� Haemostasis� History of wound mechanism and patient health (including tetanusimmunisation history)� Thorough wound cleansing, removal of debris� Debridement of devitalised tissue� Closure of wound (if indicated)THEME Wound repair in children478 Reprinted f rom Australian Family Physician Vol. 35, No. 7, July 2006

Wound closureSmall superficial wounds with opposed edges do notrequire closure and can be managed with dressings alone.Other wounds may be closed with tissue adhesives,adhesive strips, sutures or a combination of these.

Tissue adhesivesTissue adhesives are most successful on wounds thatare less than 3 cm long, have clean straight edges, do notrequire deep sutures, and are not under tension when theedges are opposed. They do not require local anaesthesiaand are quick and easy to apply. The cosmetic result for a wound closed with tissue adhesives is the same as for wound closure achieved with sutures, staples or adhesivestrips.7 There is a small increase in the incidence of wound

dehiscence with tissue adhesives compared with sutures,but all other wound complications appear to be the samefor both wound closure methods.7

Any area of the skin may be glued, however, gluing inthe vicinity of the eye requires extreme care to preventany glue dripping into the eye or onto the eyelashes. If gluing the scalp, remove any hair from the wound but donot shave or cut the surrounding hair. Before gluing, thewound must be dry and not bleeding.To apply tissue adhesive, position the child so thewound is uppermost to minimise the glue running.Ensure the operator is wearing gloves; this is not only for hygiene reasons, but to ensure that it is the glove, not theoperator, that is stuck to the child if adhesive inadvertentlyruns on to the operator¶s fingers. The hand can thenbe removed from the glove, and the glove fingers cutclose to the child¶s skin and left to spontaneously detach.The edges of the wound are brought together withthe edges slightly everted and a thin layer of adhesiveapplied on each side of the wound; the wound is thenbridged by applying a layer from side-to-side. Take carenot to get adhesive in the wound. The child and parentsshould be informed that the adhesive will feel warmas it polymerises.The wound should be kept clean and dry, but a dressingis usually not required as the wound is covered by theadhesive. The adhesive does not require removal andcomes off spontaneously in 1±2 weeks.

Adhesive strips

Adhesive strips are adequate for closing simple woundsthat require opposition of slightly separated skin edges onnonhairy areas of the body. They are particularly useful for aligning small flaps of skin back over a wound. They do notremain in place for long periods and should not be usedif there is skin movement or tension across the wound.Make the strips as long as possible and separate themwith sufficient space between each to allow drainage of fluid from the wound. Dress the wound and ask the parentto keep it dry for 72 hours.

Sutures



The techniques of suture placement vary with the size,shape and position of the wound. Detailed descriptionof these techniques can be found in reference bookson emergency medicine.8,9 Adequate analgesia andanaesthesia of the wound is essential before commencingsuturing; this is often more difficult and time consumingthan the suturing itself.

Scalp wounds can often be closed by the nonsurgicaltechniques already described. However, deep wounds willoften need to be sutured in two layers to prevent a cavityforming in the tissues.Forehead wounds should have minimal debridementand the eyebrow should not be shaved. Modern absorbablesutures should be used in small children.Wounds on the chin are often much deeper than theyfirst appear and are prone to scarring. Deep sutures areoften necessary to prevent tension on the skin sutures.Eyelid lacerations involving the lid margin or tarsal platerequire accurate opposition and repair, and children with

Table 2. Pain management in children with minor injuriesAnalgesia and sedationOptions include:

� paracetamol 20 mg/kg orally as an initial dose (ongoing doses shouldbe 15 mg/kg)� codeine 0.5 mg/kg orally� paracetamol/codeine mixtures (at doses given for paracetamol above)orally� morphine 0.05±0.1 mg/kg intravenously� midazolam 0.5 mg/kg orally� nitrous oxide/oxygen mixture inhaled, concentration of nitrous oxideup to 70%12

� supplement pharmacological agents with distraction and guidedimageryLocal anaesthesiaTopical anaesthetics� lignocaine gel� EMLA (eutectic mixture of 2.5% lignocaine and 2.5% prilocaine)

Infiltrated local anaesthetics� 1% lignocaine; maximum dose 5 mg/kg (0.5 mL/kg)� 1% lignocaine plus adrenaline; maximum dose 7 mg/kg (0.7 mL/kg)Regional nerve block� 1% lignocaine; maximum dose 5 mg/kg (0.5 mL/kg)� 0.5% bupivacaine; maximum dose 2 mg/kg (0.4 mL/kg)Wound repair in children THEMEReprinted f rom Australian Family Physician Vol. 35, No. 7, July 2006 479

such injuries are best referred to an ophthalmologist or plastic surgeon. Other simple lacerations can be glued or sutured under low tension with fine absorbable sutures.Wounds around the mouth need careful consideration.If the wound crosses the vermilion border, very accurateapproximation of the edges is necessary to achieve agood cosmetic result. In young children, this is often best

achieved under general anaesthesia. Wounds that passcompletely through the lip need to be closed in layers.Lacerations of the inner lip rarely need any intervention.Children with lacerations of the gum margin (eg. deglovinginjury) need to be referred for debridement and repair under general anaesthesia.Wounds of the palate and tongue heal exceptionallywell with little or no intervention. They do not requiresuturing unless they are gaping widely, extending throughthe free side margin of the tongue or continuing to bleed.



Fingertip wounds with or without skin loss are verycommon. Areas of skin loss up to 1 cm are treated withtulle dressings and heal with good return of sensation.Children with any greater degree of tissue loss should bereferred for plastic surgical opinion.Partial amputation or crush injuries of the fingers or toes need to have the integrity of the nail bed assessed. If

this is damaged, referring the child for plastic surgery repair is warranted. Fracture of the distal phalanx implies damageto the nail bed, therefore an X-ray may be warranted. If thenail bed is intact, the wound may be closed using adhesivestrips or sutures.Hand wounds need to be carefully examined, asdeeper structures are often involved. Lacerations throughthe dermis risk tendon injury. If any such structures aredamaged or there is any doubt, refer for plastic surgicalopinion. Neurological function should be tested beforelocal anaesthetic infiltration.

Antibiotics and immunisationFor most lacerations, antibiotics are not indicated for prophylaxis against infection, but wound cleaning anddecontamination are most important. Antibiotics shouldbe prescribed for specific circumstances such as animalor human bites, and wounds with extensive contaminationor tissue damage. Recommended antibiotics for animalor human bites are amoxicillin/clavulanic acid (22.5 mgamoxicillin component per kg up to a maximum of 875 mg)12 hourly orally for 5 days. Procaine penicillin (50 mg/kgup to a maximum of 1.5 g) intramuscularly may be addedif there is likely to be a delay in commencing oralantibiotic medication.10

All children should be checked for adequate tetanuscover for prophylaxis. The recommendations of the NationalHealth and Medical Research Council should be followed indetermining the need for additional vaccinations (Table 3).11

Conflict of interest: none declared.

Ref erences1. Algren JT, Algren CL. Sedation and analgesia for minor paediatric procedures.

Pediatr Emerg Care 1996;12:435±41.2. McKenzie I, Gaukroger PB, Ragg P, Brown TCK. Manual of acute painmanagement in children. New York: Churchill Livingston, 1997.

3. Ferguson C. Topical anaesthetic versus lidocaine infiltration to allowskin closure in children. Available at www.bestbets.org/cgi-bin/bets.pl?record=00381 [Accessed March 2006].

4. Zempsky WT, Karasic RB. EMLA versus TAC for topical anaesthesia of extremity wounds in children. Ann Emerg Med 1997;30:163±6.5. Bush S. Topical anaesthesia use in the management of children¶s lacerations,

a postal survey. J Accid Emerg Med 2000;17:310±1.6. Thompson S. Tap water is an adequate cleansant for minor wounds.Available at www.bestbets.org/cgi-bin/bets.pl?record=00024 [Accessed

March 2006].7. Farion K, Osmond MH, Hartling L, et al. Tissue adhesives for traumaticlacerations in children and adults. Cochrane Database Syst Rev

2001;(4):CD003326.8. Lipton JD. Soft tissue injury and wound repair. In: Strange GR, AhrensWR, Lelyveld S, et al, editors. Pediatric emergency medicine: a comprehensive

study guide. 2nd ed. New York: McGraw Hill, 2002;164±84.9. Oakley E. Wound management. In: Cameron P, Jelinek G, Everitt I, et al,editors. Textbook of paediatric emergency medicine. Sydney: ChurchillLivingstone Elsevier, 2006;89±102.10. Therapeutic guidelines: antibiotic. Version 12. Melbourne: TherapeuticGuidelines, 2003.

11. The Australian Immunisation Handbook. 8th ed. Canberra: AustralianGovernment Department of Health and Ageing, 2003. Available atimmunise.health.gov.au/handbook.htm [Accessed March 2006].



12. Luhmann JD, Kennedy RM, Porter FL, et al. A randomised clinical trialof continuous flow nitrous oxide and midazolam for sedation of youngchildren during laceration repair. Ann Emerg Med 2001;37:20±7.

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Wound Care Introduction