Abstract
This chapter reviews the basics of wound assessment, burn management, and the care of bites and stings from various species. It is intended to provide a guide to aid in the care of children in an outpatient acute or urgent care setting.
Keywords
animal bite, bite, bites, black widow, brown recluse, burn, cat, contaminant, contaminated, coral snake, crotalid, dog, foreign body, scald, snake, sting, wound, wounds
Wound Assessment
1
Why does wound assessment matter?
Traumatic wounds are a common presenting complaint to acute care centers. Nearly 12 million wounds are treated in U.S. emergency departments annually, with about one third of those in patients under the age of 18. Wound care accounts for approximately 10% of all procedures performed in emergency departments, with literally millions more wounds assessed yearly that do not require procedural intervention.
Each wound is different, necessitating individualized treatment based on clinical assessment. Without appropriate treatment, patients with acute wounds may suffer complications such as poor healing and infections.
2
How do we begin wound assessment?
In assessment of any patient in the acute care setting, patient resuscitation and stabilization always take precedence and should proceed according to pediatric advanced life support (PALS), advanced trauma life support (ATLS) protocols. Assuming the patient is stable and requires only management of minor wounds, assessment may progress. Careful history taking and examination are essential to appropriate assessment and treatment of wounds. Documentation should include the mechanism described by the family as well as a clear description of the wound and assessment of whether or not the wound is consistent with the mechanism described by the caregiver.
3
What types of wounds may be appropriately treated in the urgent care setting?
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Appropriate: Minor cuts, lacerations, and abrasions.
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Not Appropriate: Any penetrating, complex, or severe traumatic injury should be referred to an emergency department (ED) for definitive management after ensuring patient stability for transfer. Any wounds concerning for nonaccidental trauma should also be referred to the ED.
4
What are the goals of wound management?
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Establishing hemostasis
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Minimizing the risk of infection
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Optimizing cosmetic results
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Returning function to normal
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Minimizing pain
5
Are there different types of wounds?
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Abrasions: Caused by force applied in opposite directions that scrapes away layers of skin or underlying tissue.
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Lacerations: Wounds where there is a separation between tissues. Different types of force can generate different subtypes.
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Cuts: Caused by shearing forces in injuries such as knife wounds, which are often “cleaner” in appearance with sharp edges or margins.
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True lacerations: Caused by compressive or tensile forces and often have somewhat rough, jagged, or torn edges and may be associated with contusion.
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Puncture wounds: Penetrating injuries with a small surface opening and depth that cannot be directly visualized. Susceptible to infection because of the enclosed environment, caused by a combination of forces.
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Avulsions: Tissue is separated either completely or nearly so from its base. Caused by shearing and tensile forces.
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Burns: Result in wounds (will be discussed separately)
Wounds may be a combination of these types.
6
What details of the patient history are key to wound assessment?
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How did this happen and what has happened since?
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When did this happen?
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Where did this happen? (Any exposure to soil, natural bodies of water, or animals or insects that bite can cause wounds that are at increased risk of infection.)
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Immunization and immune status
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Does story make sense and fit with the presenting injury? (If it does not or there is any doubt, appropriate steps to investigate nonaccidental injury should be taken.)
7
What aspects of exam should be focused on?
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Examination using clean or sterile gloves and other protective measures such as mask and eye shield.
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Exam should be conducted in a well-lit area, and additional lamps may be necessary for best visualization of the injury.
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Measures to control bleeding should be taken and then exam repeated once bleeding is controlled to ensure blood does not obscure any findings.
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Note extent of injury, any visible contamination, and damage to nearby structures.
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Neurovascular status in the form of distal perfusion as well as motor and sensory function are important to note and document before the use of any anesthetics.
8
A 17-year-old male patient presents with a laceration of the left hand that occurred 2 days ago. He states that he wants it “sewn up” so that it will heal faster. Is this laceration too old to be sutured?
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There is no absolute time period for when a wound is too old for surgical repair.
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Studies have demonstrated that many wounds may be closed safely up to 24 hours after injury and this is used as a “golden period” for repair.
9
A 5-year-old male patient presents with a laceration to the scalp that is bleeding profusely. How can bleeding be controlled?
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Apply direct pressure gently but firmly over the wound.
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Elevate the wound if it is on an extremity.
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Suturing or stapling of highly vascular areas may be useful for persistent bleeding.
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Epinephrine, either locally injected into the surrounding soft tissue at a bleeding site or applied topically in a preparation such as LET (Lidocaine, Epinephrine and Tetrocaine) gel may help with hemostasis through vasoconstriction.
10
A 13-year-old female patient presents for treatment of a laceration on her foot. You decide it requires closure with sutures, but she refuses to allow this, stating she is afraid it will hurt. How can her pain be controlled?
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Pain control for minor injuries is often well achieved using local methods such as topical gels or injectable solutions.
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Generally these methods should be coincidentally given with epinephrine to decrease systemic effects and prolong localized exposure to the medication.
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Medications such as benzodiazepine given orally, intravenously (IV), intramuscularly (IM), or intranasally (IN) may be useful for anxiolysis as well, particularly prior to attempting wound repair.
11
Do all lacerations need to be repaired?
No. Remembering our goals of wound management, sometimes these are best served by leaving a wound to heal by secondary intent. Many wounds should not be repaired because they will heal well on their own, repair may significantly increase the risk of infection, or for other reasons. The first rule in medicine is do no harm, so repair should only be performed if necessary.
12
When are antibiotics indicated?
Antibiotics should be reserved for complicated wounds such as:
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Bites
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Open fractures
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Tendon or joint involvement
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Obvious infection or high risk for infection
13
A 7-year-old male patient presents after stepping on a nail in the backyard. Does he require tetanus immunization or immunoglobulin?
See Table 43.1 .
| Age (years) | Vaccination History | Clean, Minor Wounds | All Other Wounds |
|---|---|---|---|
| 0–6 | Unknown or not up-to-date on DTaP series based on age | DTaP | DTaP TIG |
| Up-to-date on DTaP series based on age | No indication | No indication | |
| 7–10 | Unknown or incomplete DTaP series | Tdap and recommend catch-up vaccination | Tdap and recommend catch-up vaccination TIG |
| Completed DTaP series AND <5 years since last dose | No indication | No indication | |
| Completed DTaP series AND ≥5 years since last dose | No indication | Td, but Tdap preferred if child is 10 years of age | |
| 11 years and older ( ∗ if pregnant, see footnote) | Unknown or <3 doses of tetanus toxoid containing vaccine | Tdap and recommend catch-up vaccination | Tdap and recommend catch-up vaccinationTIG |
| 3 or more doses of tetanus toxoid containing vaccine AND <5 years since last dose | No indication | No indication | |
| 3 or more doses of tetanus toxoid containing vaccine AND 5–10 years since last dose | No indication | Tdap preferred (if not yet received) or Td | |
| 3 or more doses of tetanus toxoid containing vaccine AND >10 years since last dose | Tdap preferred (if not yet received) or Td | Tdap preferred (if not yet received) or Td |
Burn Management
14
What burns can be managed in an urgent care setting?
Children younger than 5 years account for 18% of burns presenting to care in the United States. Of these, the majority are minor, covering <10% of the total body surface area, and the predominant type of injury is a scald. Minor superficial burns are appropriate for treatment in the acute or urgent care setting; however, those affecting larger areas, greater depths, or with other associated injuries should be referred to advanced care centers.
15
How are burns classified?
Burns are generally classified or grouped according to three characteristics: depth of affected tissue, percent of total body surface area affected, and cause of injury (thermal, chemical, electrical, etc.). These classifications are in turn used to determine the severity of a burn and aid in triage toward appropriate treatment ( Table 43.2 ).
| Superficial or First Degree | Partial Thickness or Second Degree | Full Thickness or Third Degree | |
|---|---|---|---|
| Tissue depth affected | Epidermis only | Epidermis and dermis | Epidermis, dermis and below |
| Sensation | Painful | Painful | Diminished |
| Appearance | Erythematous, hyperemic, intact skin | Blistered, disrupted skin | Skin layers destroyed, deep tissue exposed |
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