Key Feature 4: Identify wounds at high risk of infection (ex: puncture wounds, some bites, some contaminated wounds), and do not close them.
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, Treatment
Key Feature 5: When repairing lacerations in children, ensure appropriate analgesia (ex: topical anesthesia) and/or sedation (ex: procedural sedation) to avoid physical restraints.
Skill: Clinical Reasoning
Key Feature 6: When repairing a laceration, allow for and take adequate time to use techniques that will achieve good cosmetic results (ex: layer closure, revision if necessary, use of regional rather than local anesthesia).
Skill: Clinical Reasoning
A few days ago, a kiddo came into the children's ED with scalp lacerations from an eagle attack! He was in a lot of pain, but the reassurance of having his parents next to him appeared to be a major analgesic. We also injected the area surrounding the laceration with local anesthesia. We then proceeded to irrigate the wound (there was no visible debris and so only moderate quantities of fluid and pressure was needed, and in this healthy child without risk increased risk factors for infection, we did not need to use sterile solution). There was no devitalised tissue so debridement was not needed. Once clean and frozen, with his parents holding both of his hands, my attending and I put his scalp back together with staples.
What wounds are at increased risk of infection, and what type of closure is warranted? According to the UpToDate article, "Minor wound preparation and irrigation" (2018), "The decision of whether to perform primary closure, allow a wound to heal by secondary intention, or perform a tertiary (ie, delayed primary) closure is dependent upon the age of the injury as well as the mechanism and degree of contamination. Absolute contraindications to wound closure are signs of inflammation (redness, warmth, swelling, pain). In the absence of these findings, the decision to close a wound must be made based upon clinical judgment."
Basically, primary closure is indicated unless a reason is found that puts the patient at increased risk of wound infection. Such factors include factors on history (mechanism of injury increasing risk of wound contamination, time from injury, patient risk factors [ex: advanced age, diabetes mellitus, renal impairment, poor nutrition, smoking, obesity, chronic steroid use]) or physical exam (location on body, degree of contamination, presence or possibility of foreign body). This patient with the eagle lacerations did not have risk factors on history or physical exam that suggested primary closure was contraindicated, and so we closed the lacerations to control bleeding and improve cosmesis.
Again, stay tuned for my future procedure posts on wound management, in which I will go through in more detail the reasons to opt for different wound closures more specifically, as well as technique to best promote healing and cosmesis. While it takes time to develop the skills of wound repair, and while it takes extra time during the procedure to ensure best results, as a cardiac surgeon once told me when he was operating, "Slow is smooth and smooth is fast." In other words, if you slow things down and work more deliberately, things tend to go smoother and ironically faster. There is less need for revising previous repairs, and the outcome tends to be much better.
The child with the eagle lacerations had two very supportive parents, and he was old enough to be able to understand how important it was to stay still despite pain while we injected the local anesthesia so we could do a good job cleaning and fixing his scalp wounds. He was a brave boy. Not all children and not all adult even will be able to be so "mind over matter." Once a minor wound is frozen, generally speaking, most patients will be able to tolerate the process of irrigation, debridement as needed, and wound closure. I will go through freezing options and how to administer them in a future procedural post. In some settings, local anesthesia may not suffice, and procedural sedation with the assistance of an anesthesiologist may be warranted to be able to properly provide wound care.