Pediatric Cut Injury (Laceration): Treatment and Management

1. Initial Assessment

• Location and depth: Note proximity to nerves, vessels, tendons, or joints.
• Wound characteristics: Length, shape (linear vs. stellate vs. flap), degree of contamination, presence of foreign body.
• Neurovascular status: Test sensation (two-point discrimination), capillary refill, and motor function distal to the wound.
• Tetanus immunisation status: Always ask about vaccination history.
• Time since injury: Wounds older than 6-12 hours (or 24 hours on the face) carry higher infection risk and may need delayed primary closure.

2. Anesthesia (Pediatric Considerations)

Topical Anesthesia

• EMLA cream (lidocaine 2.5% + prilocaine 2.5%): Apply at least 1 hour before procedure under occlusive dressing. Age/weight-dependent dosing is required (Table 28-1 in Family Medicine 9e).
• Caution in children < 3 months: prilocaine breakdown product orthotoluidine can cause methemoglobinemia at systemic doses of prilocaine ~8 mg/kg. Also avoid in G6PD deficiency.
• Other options: 30% lidocaine cream (45 min under occlusive patch), liposomal tetracaine/lidocaine.
• LET gel (lidocaine 4%, epinephrine 0.1%, tetracaine 0.5%) is widely used for pediatric facial lacerations.

Local Infiltration

• Lidocaine 1% is the most commonly used agent.
• Maximum dose: 4.5 mg/kg without epinephrine (max 300 mg in adults); 7 mg/kg with epinephrine.
• Inject slowly with a fine-gauge needle (25-30G) to minimize pain; buffering lidocaine with sodium bicarbonate reduces injection sting.
• Epinephrine should NOT be used in end-artery areas (fingers, toes, nose, ears, penis) until further evidence is available - Family Medicine 9e, p. 749.

Digital Block

• For finger/toe lacerations: infiltrate 1-2 mL of 1% lidocaine without epinephrine at the 2, 4, 8, and 10 o'clock positions around the digit.
• Allow 5-30 minutes for full distal anesthesia.

3. Wound Preparation

Hemorrhage Control

• Apply direct pressure for 5-10 minutes. Avoid blind clamping.

Wound Exploration and Foreign Body Check

• Only after anesthesia: fully inspect the wound, explore for foreign bodies (glass, gravel, organic material).
• Radiograph the wound if radio-opaque foreign body (glass ≥2 mm, metal) is suspected.

Irrigation (Most Important Step)

• Copious irrigation with normal saline using a 19-gauge angiocatheter and 20-30 mL syringe provides ~8 psi pressure - sufficient to mechanically reduce bacterial load.
• Volume: typically 100-200 mL for a 2-3 cm wound; more for contaminated wounds.
• Wound irrigation is the single most effective measure to reduce infection risk - Tintinalli's 9e.
• Avoid povidone-iodine directly in wound (cytotoxic to tissue); it can be used on surrounding skin.

Debridement

• Remove all devitalized (necrotic/contaminated) tissue.
• Good anesthesia is critical before debridement.
• Wounds requiring significant debridement should have this documented - Family Medicine 9e, p. 749.

4. Wound Closure

Choosing the Closure Method

Tissue Adhesive (Cyanoacrylate Glue) - Key for Pediatric Use

• 2-octylcyanoacrylate (OCA) is preferred over butylcyanoacrylate - more flexible, lower dehiscence rate.
• Tensile strength equivalent to 5-0 sutures.
• Full strength achieved within 2.5 minutes.
• Do NOT use on: moist areas, hairy skin, mucous membranes, actively bleeding wounds, joints, bite wounds, dirty lacerations.
• Patients may shower immediately with OCA; butyl-cyanoacrylate should be kept dry for 48 hours.
• Avoid antibiotic ointments and petrolatum - they dissolve cyanoacrylate adhesives - Family Medicine 9e, p. 755.
• Evidence: Wound closure of superficial lacerations with tissue adhesives is quicker and less painful than suturing, with similar outcomes on appropriate wounds (SOR: A).

Suture Technique

• Interrupted sutures: Most common. Evert skin edges slightly for best cosmesis. Enter skin 2-3 mm from the edge, perpendicular to skin plane.
• Subcutaneous/deep sutures: Used to close dead space and reduce tension on skin sutures. Use absorbable suture (e.g. Vicryl 3-0 or 4-0). Inverted buried knot technique.
• Running/continuous sutures: Faster but higher risk of dehiscence; used in lower-risk wounds.
• Half-buried horizontal mattress: Ideal for closing flaps or stellate lacerations - preserves flap vascularity.
• Scalp: Staples are practical and provide hemostasis; hair apposition technique is non-invasive alternative.

Suture Size by Location (General Guide)

Wound Closure Timing

• Primary closure: Within 6-12 hours of injury (up to 24 hours for clean facial wounds).
• Delayed primary closure: For contaminated wounds, bite wounds, or wounds >12-24 hours old - pack open, close at 3-5 days if clean.
• Secondary intention: For infected wounds or wounds with significant tissue loss.

5. Tetanus Prophylaxis

6. Antibiotics

• Not routinely indicated for clean lacerations.
• Consider antibiotics for:
  • Bite wounds (animal or human) - amoxicillin-clavulanate is first-line
  • Heavily contaminated wounds
  • Immunocompromised patients
  • Wounds involving joints, tendons, or bones
  • Puncture wounds in high-risk locations (e.g., foot through shoe)
• For skin coverage: amoxicillin-clavulanate, or co-trimoxazole if MRSA is a concern.

7. Wound Dressings and Aftercare

• Apply a non-adherent dressing for the first 24-48 hours to protect the repair.
• Keep wound dry for 24-48 hours after closure.
• After 48 hours, gentle washing with soap and water is permitted.
• Antibiotic ointment (e.g., bacitracin or mupirocin) can be applied once or twice daily on sutured wounds - but NOT on cyanoacrylate-closed wounds.
• Apply sunscreen to healing wounds to reduce post-inflammatory hyperpigmentation.

Suture Removal Timing

8. Special Pediatric Considerations

• Sedation: For young or uncooperative children, procedural sedation (e.g., intranasal dexmedetomidine, oral midazolam, or ketamine IV/IM) may be needed before repair.
• Child abuse: Always consider non-accidental injury when the mechanism is inconsistent with the injury pattern, or when multiple injuries are found at different healing stages. Mandatory reporting may be required.
• Facial lacerations: Use fine sutures (5-0 or 6-0), tissue adhesive if appropriate. Cosmetic outcome is paramount. Involve plastics early for complex facial wounds.
• Growth cartilage and epiphyseal involvement: Any wound near a joint or growth plate in a child requires imaging.
• Scalp wounds: Bleed profusely due to high vascularity. Direct pressure and expedient closure (staples or sutures) is effective. Always palpate for underlying skull fracture.
• Wound infection signs to watch for: Increased pain, warmth, erythema beyond 1-2 cm from wound edge, purulent discharge, fever - return immediately if any are noted.

9. When to Refer / Admit

• Suspected tendon, nerve, or vascular injury requiring operative repair
• Deep wounds involving joints or bones
• Facial lacerations requiring plastic surgery (complex, over eyelid, lip vermilion, nasal ala)
• Wounds with significant tissue loss or requiring skin grafting
• Suspected non-accidental trauma
• Signs of systemic infection (fever, spreading cellulitis)

• Textbook of Family Medicine, 9th ed., pp. 749-755 (Chapter 28: Wound Care and Laceration Repair)
• Tintinalli's Emergency Medicine: A Comprehensive Study Guide, Ch. 40-41 (Wound Preparation; Wound Closure)
• Rosen's Emergency Medicine, pp. 2593+ (Table 118.2-118.3: Tetanus Prophylaxis)
• The Harriet Lane Handbook, 23rd ed. (Pediatric Emergency Procedures)