Expert Advice on Emergency Carexper

Lacerations in Children: Twelve Questions for the ER Doctor

by Mark A. Brandenburg, MD

 

Every year nearly one million children suffer lacerations (skin cuts) to the face that require stitches in the emergency room. And millions more children get them on other areas of the body. Fortunately most wounds, no matter where they are located, can be cleaned and repaired by a well-trained emergency physician. These are the most common questions I hear from parents of children being treated for lacerations.

 

When Can Skin Tape be Used Instead of Stitches?

Skin tape is occasionally used to close minor wounds and has the advantage of being relatively painless and simple to place and remove. However, if used alone on a deep wound skin tape might not give enough support to hold the edges together.

 

When Can Dissolvable Stitches be Used?

Sutures that dissolve on their own have the obvious advantage of not needing to be removed by the physician. They are most commonly used in deep wounds beneath the skin to give added support to the outside stitches. Although dissolvable sutures can be used on the outside of a wound, they can cause a mild skin reaction that might increase scar visibility.

 

When are Surgical Staples Used?

Staples may be used by your emergency physician to close a wound on the scalp or elsewhere if the wound is superficial. The advantage of surgical staples- they are quicker and easier to put in and to remove later. They should not be used on the face though because the skin edges won¹t be brought close enough together to give the best cosmetic outcome.

 

When Should Stitches be Taken Out?

The reason for stitches in the first place is to keep the wound closed while healing begins. This decreases the size of the scar and keeps bacteria out. Once a healing wound is strong enough to stay together by itself, the stitches can be taken out. We usually remove stitches from the face after about 5 days. This is earlier than from other parts of the body, because a facial laceration is less likely to open back up. Also, the longer a stitch stays in the skin the more likely a scar is to form where it pierced the skin. On the other hand, a wound in an area of high skin tension, such as an elbow or knee, requires at least 10 and sometimes 14 days of healing before stitches can be removed.

 

Should My Child be Sedated?

Toddlers in particular can be difficult to treat. Not only do they get very scared, they are strong enough to resist the physician and nurses who are tending to the wound. In some situations sedation can be the safest, quickest and most gentle way to go. Sedating drugs can be given by mouth, nose, and shot or through an IV. But, sedating a child does have risks. Although it rarely occurs if too much medication is given, a child could stop breathing and require resuscitative care by the emergency physician.

 

Can a Topical Anesthetic be Used?

Yes. An anesthetic cream can be used to superficially numb a cut. Still, it is usually necessary to inject a numbing drug into the wound just before suturing so the deeper tissue gets anesthetized. Remember to ask your doctor if a topical anesthetic is available.

 

When Is It Okay to Get the Wound Wet?

After being stitched it is probably best to keep a wound dry for the first 24 hours so the wound edges have a chance to begin healing. Gentle cleaning with soap and water is then okay as long as the healing cut is not submerged in water for more than a few minutes. At all other times the wound should remain clean and dry.

 

Can an Antibiotic Ointment be used On the Wound?

Yes. A topical antibiotic might decrease the risk of infection and speed up the healing process. Whether this is due to the antibiotic itself or the protective barrier of the ointment is debatable. The ointment can be applied to a wound whenever dressings are changed- usually once or twice a day for the first two days.

 

Should My Child be Prescribed an Oral Antibiotic?

Oral antibiotics are not necessary for most wounds if they are cleaned and repaired properly. Certain wounds however do require antibiotics because the risk of infection is so high. For instance, wounds caused by animal bites and those contaminated by dirt and other organic matter usually require antibiotics.

 

Will there be a Scar?

Although some scars fade away after many years, all lacerations will cause at least a faint scar. The visibility of a scar is partly determined by the care provided immediately after the injury. Adequate wound cleaning in the emergency room within the first six hours is important, as this will decrease the likelihood of an infection. If a wound infection does occur, the scar might be more visible.

Other factors that determine scar visibility are the location of the wound, its position, size and shape. A laceration in an area of high skin tension is more likely to have a visible scar later on because the skin edges can pull apart slightly during the healing process. The direction in which a laceration lies is also a factor. For instance, a horizontal scar on the forehead will probably fit right in with natural lines and wrinkles, while a vertical scar in the same area is likely to be more obvious years later.

 

Are All Emergency Physicians Equal?

No. Some emergency physicians are certified by the ABEM (American Board of Emergency Medicine) or ABOEM (American Board of Osteopathic Emergency Medicine), while some are certified in other fields such as family medicine, pediatrics or internal medicine. Some have no certification at all. To insure that your child will receive the best quality care in the emergency room, be sure the emergency physician is well trained and competent to make appropriate medical decisions. Keep in mind that some ER¹s, especially those in pediatric hospitals, are better equipped to handle lacerations in children, particularly when sedation is necessary. Your best bet is to identify the ER your pediatrician or family physician recommends before the need arises.

 

When is a Plastic Surgeon Necessary?

Some lacerations are especially complicated and require a surgical specialist. The decision to involve a plastic surgeon is not always easy. There are two primary reasons an emergency physician would request a plastic surgeon. First, a wound can be so deep, irregular and dirty that it requires special equipment only available in an operating room. Second, a deep wound can be located in a cosmetically important part of a child's body such as the ears, nose, lips or eyelids. Fortunately, wounds of this severity represent only a small fraction of lacerations in children.

 

Dr. Brandenburg is a full-time emergency physician at the Trauma Emergency Center of St. Francis Hospital in Tulsa, OK. He is author of the book, CHILD SAFE- A Practical Guide for Preventing Childhood Injuries (Crown Publishers).