39 Common Injuries

Dawn Lee Garzon, Sara D. Degolier, Constance B. Brehm

Injuries are major pediatric health problems that are best managed with treatment as well as prevention strategies. A child with an injury might respond best to (1) a simple home treatment by the parent, caregiver, or supervising adult; (2) intervention by the provider in the primary care setting; (3) referral to a medical specialist or inpatient facility; or (4) a combination of these. Addressing the potential for injury before it has occurred is a key factor of injury management. Health care professionals have a responsibility to educate families to prevent injuries from occurring.

Due to the importance of injury prevention, the term “accident” has been replaced by the term “unintentional injury.” “Unintentional injury” implies that the resulting injury was predictable and preventable, whereas “accident” does not (Hagan et al, 2008). For children older than 1 year of age, injuries (defined as unintentional injury, violence, and suicide) cause more deaths than the next five causes combined (National Center for Health Statistics, 2010). Unintentional injury is also the leading cause of pediatric hospitalization and disability, resulting in more than 9 million emergency department visits each year and more than $17 billion in health care expenditures (Borse et al, 2008).

Prevention of unintentional injuries involves anticipatory guidance to help parents provide a safe environment and necessary supervision. Strategies to prevent injuries in children and adolescents focus on understanding and modifying risk factors, developing community-wide program approaches, and promoting health policy legislative agendas that focus on injury prevention. When implementing prevention strategies, it is important to consider that injury occurrence and severity vary depending on several factors including age, race, gender, and socioeconomic status.

Principles of Injury Control

In the past, there was an underlying assumption that children were simply “accident prone” because of their highly active and impulsive nature. Earlier prevention efforts often focused on these childhood characteristics. Emphasizing accident proneness is now considered a counterproductive strategy. Injury control and prevention guidance strategies focus on “the development and age of the child, the environment in which the safety concern or injury takes place, and the circumstances surrounding the event” (Hagan et al, 2008, p 178). This new approach evaluates injury and safety more closely, focusing not just on the injury itself, but all associated factors including, but not limited to, culture and economics. Information gathered from these three domains helps to customize education for families and communities and create safe environments for children.

The most effective injury prevention education focuses on specific, usable information to decrease injury risk rather than broad, nonspecific recommendations. For example, teaching children and parents how to purchase and size a bicycle helmet is more effective than telling children, “always use a bike helmet.” Anticipatory guidance provided by health providers at well-child visits should be geared to the developmental stage of the child. Written materials, audiovisual presentations, peer counseling, and one-to-one interaction with a health professional are all effective teaching and learning strategies. However, safety information should be provided in moderate doses, with reinforcement or repetition at subsequent visits. This strategy helps ensure that the prevention education points are well received and used by caregivers, patients, and their families.

For infants, preschoolers, and school-age children, active adult supervision is key because young children are not able to identify risk, are developmentally impulsive, and cannot consistently remember safety rules. Active supervision involves proximity (close enough to intervene should risk occur), consistency (adult does not stop supervising to engage in other activities like cooking or cleaning), and freedom from distraction or impairment (the adult is not distracted by a book or phone call, for example, and is not under the influence of alcohol or prescription or recreational drugs that cause impairment).

Passive injury prevention is the implementation of safety measures that do not require caregivers to constantly change their behavior to make the environment safer for their children. This prevention strategy is the most effective intervention and includes modification of everyday items in the child’s environment. Examples include the use of child-resistant caps on medicines and cleaning products, and safety designs in toys. Other safety implementations include environmental modification such as the use of smoke and carbon monoxide detectors, safe roadway design to reduce traffic volume and speed in residential neighborhoods, window locks, and firearm safety locks. Providers can advocate for local and national prevention strategies and support such programs as the Safe Kids USA campaign. They can also play a key role by supporting injury prevention legislation or initiatives. Public and consumer awareness is crucial for successful prevention programs.

Although most children with serious injuries are seen first in emergency departments (ED), primary care providers have a professional obligation to remain current in basic life support techniques. Competence in performing emergency cardiopulmonary resuscitation and emergency intervention for choking (whether it be for infants, children, or adults) should be a requirement of all licensed health professionals employed in clinical practice settings. Likewise, all parents and caregivers should be encouraged to enroll in a basic pediatric life support program, especially parents and caregivers of infants and children at risk for cardiopulmonary arrest.

Approach to Trauma

Three main components essential in the management of an injured child include history, mechanism of the injury, and a thorough physical examination. If the injury is life-threatening, or there has been any deterioration in the child’s condition, a trauma severity assessment must immediately be performed. Primary assessment of the injured child should occur within the first 5 minutes of initial contact and includes the assessment of the airway, breathing, circulation, evaluation of vital signs, obtaining a brief history (allergies, medications, past medical history, and events surrounding the injury), and rapid assessment of essential organ status. Cardiopulmonary resuscitation must be initiated if indicated. Once the patient is stabilized, a secondary assessment should include complete physical examination and laboratory and radiographic studies as indicated. Assessment of the patient’s vital signs, physical exam, and laboratory tests should be repeated as indicated based on the injury and initial study results. The definitive care phase includes stabilization of local injuries and preparation of the patient and family for transport to the ED if necessary (Table 39-1).

TABLE 39-1 Classification and Disposition of Trauma by Severity

The practitioner should always consider non-accidental trauma (child abuse) when a child presents with an injury, especially when the history of the injury given by the caregiver fails to adequately explain the child’s injury (Hisea and Sirotnak, 2009).

Common Pediatric Injuries

Trauma to the Skin and Soft Tissue

Abrasions

Puncture Wounds

Description

Puncture wounds result from varying levels of the skin and underlying tissue penetration. These wounds are typically classified as superficial or deep. Because of the potential for serious infection, puncture wounds must be carefully evaluated and treated if indicated. The location and depth of the wound and the presence of a foreign object are key risk factors for the subsequent development of infection. For example, deep penetrating injuries to the forefoot with a dirty object, especially if they involve the plantar fascia, have a higher risk of infection than wounds to the arch or heel area. The forefoot has less overlying soft tissue than other plantar surfaces and is the major weight-bearing area of the foot; therefore, cartilage and bone can be involved. The metatarsophalangeal joint region is also at high risk for infection due to the same principles. Puncture wounds through the soles of tennis shoes can transfer bacteria into the tissue, where minimal drainage is possible, placing the child at higher risk for a secondary infection.

Epidemiology

Puncture wounds are common pediatric injuries and may occur at any age. Glass, wood splinters, toothpicks, needles, nails, metal, staples, and thumbtacks are common sources of injury. Bites also produce puncture wounds and are especially infection-prone.

Although the majority of puncture wounds heal without problems, a sizable minority of these injuries are complicated by infections that may lead to cellulitis, fasciitis, septic arthritis, or soft-tissue abscesses. Staphylococcus aureus and beta-hemolytic streptococci are normal flora of the skin and are common causative agents in secondary infections from puncture wounds. Pseudomonas aeruginosa colonizes on the rubber soles of tennis shoes and is a common pathogen for plantar puncture wounds when the puncture occurs through the sole of a tennis shoe and into the foot. Osteomyelitis can occur if the puncture wound penetrates a bone or joint. The most common pathogens that cause osteomyelitis secondary to a puncture wound are P. aeruginosa in nondiabetic patients, and S. aureus in diabetic patients (Baddour, 2009). Cat and dog bites can cause wound infection from Pasteurella multocida.

Clinical Findings

The assessment of a child with a minor wound includes first excluding more serious and sometimes occult injuries.

Physical Examination

To ensure a thorough examination, a good light source is necessary when assessing and treating a puncture wound. Note circulation, movement, and sensation of the area next to the injury. Determine the amount of involvement of underlying tissue or bone structures. For plantar puncture wounds, have the child lie prone with the feet positioned at the head of the examining table and the knees slightly flexed to assist in proper examination positioning (Buttaravoli, 2007). Assess the wound for length and depth, presence of debris or penetrating object, and signs of infection.

Examination findings consistent with cellulitis include:

Examination findings consistent with osteomyelitis-osteochondritis include:

Examination findings consistent with pyarthrosis (septic arthritis) include:

• Pain, swelling, warmth, and erythema over the affected joint

• Decreased range of motion and weight bearing of the affected joint

Diagnostic Studies

• Plain film radiograph should be ordered if any of the following are true:

A retained foreign object is suspected.

There is tremendous amount of pain at the puncture site with localized tenderness or questionable mass underneath the skin surface (Baddour, 2009).

There was penetration of a joint space, bone or growth cartilage, or the plantar fascia of the foot.

The puncture site has signs of infection and is from a nail injury.

• Most metal and glass foreign bodies can be seen on a plain radiograph. However, if the foreign object is not radiopaque or if the x-ray is negative despite suspicion of foreign object in the wound, computed tomography (CT), ultrasound, and magnetic resonance imaging (MRI) are useful diagnostic tools (Buttaravoli, 2007).

• Bone scans are sensitive, but not specific for osteomyelitis. Radiographs are specific, but findings for osteomyelitis are noted late. Clinical examination and laboratory studies and imaging should be considered early in the diagnosis of osteomyelitis (Polousky and Eilert, 2009).

• A complete blood count (CBC) and blood culture may be needed. An elevation in the white blood cell count might indicate infection.

• An erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are nonspecific inflammatory markers and are helpful in the diagnosis and management of bony inflammation and infection.

• A wound culture is indicated prior to starting antibiotics if the wound appears infected.

Differential Diagnosis

The circumstance surrounding the penetrating injury and the presenting symptoms are the best indicators of whether the injury represents a superficial wound that will heal uneventfully or develop infectious complications.

Management

Buttaravoli (2007) suggests the following practical and straightforward approach to the management of puncture wounds:

• Irrigate with copious amounts of normal saline for puncture wounds caused by small, clean, slender nonrusty objects (e.g., thumbtack or needle) after confirmation of complete removal of the intact object, and when signs of infection are absent.

• Larger puncture wounds require profuse irrigation. Wound debridement may also be necessary. A No. 10 scalpel may be used to gently shave off the cornified epithelium surrounding the puncture wound to aid in the removal of debris that collected around the point of entry of the puncture wound. If debris is found in the wound, gently slide the plastic sheath of an over-the-needle catheter down the wound track and move the catheter sheath in and out while irrigating with copious amounts of normal saline until debris no longer flows from the wound. A local anesthetic agent may be necessary for debridement and irrigation procedures.

• Obtain imaging studies as indicated for proper management of the puncture wound. If imaging studies demonstrate that the foreign object has invaded bone, growth cartilage, or a joint space, refer the child immediately to an orthopedic surgeon. Always suspect a retained foreign object if the puncture wound is infected, the infection is not responding to antibiotic therapy, or if pain or aching of the injured site is still present weeks after the injury. In order to prevent a catastrophic outcome, wounds that are deep or highly contaminated should be referred to an orthopedic surgeon so that debridement can take place in an operating room (Buttaravoli, 2007).

• Following careful wound cleansing, the wound can be covered with a simple bandage. Deeper wounds that require more extensive exploration should have a small sterile wick of iodoform gauze placed in the wound tract in order to keep the edges open, thus aiding in granulation tissue growth and wound healing. Remove the gauze 2 to 3 days after placement (Selbst and Attia, 2010).

• Children with simple, uncomplicated puncture wounds do not need antibiotics; however, if there are signs of infection, the puncture is the result of a cat bite, or if the wound is deep or contained debris, antibiotics should be part of the treatment plan. Appropriate antibiotics for puncture wounds include amoxicillin clavulanate or cephalexin. Clindamycin should be used when children are allergic to penicillins. Plantar puncture wounds require ciprofloxacin. If methicillin-resistant Staphylococcus aureus (MRSA) is cultured from the wound or pus is present at the puncture site, then trimethoprim-sulfamethoxazole (TMP-SMX) or clindamycin is recommended until sensitivities are known. All antibiotics should be prescribed for 7 to 14 days depending on severity of infection (Baddour, 2009).

• Schedule a recheck appointment within 48 hours. If pain, erythema, and swelling have not improved or symptoms have worsened within the first 48 hours of outpatient treatment, hospitalization and intravenous antibiotics are indicated (Baddour, 2009).

• Treatment for severe infections secondary to puncture wounds such as septic arthritis and osteomyelitis includes surgical debridement and parenteral antibiotics (Hosalkar et al, 2007).

• Tetanus prophylaxis is indicated if it has been more than 5 years since the last tetanus vaccine or if the date of the last tetanus vaccine is unknown. Consider passive immunization with tetanus immune globulin (TIG) or initiation/continuation of a primary tetanus series (DTaP, Tdap, or Td as appropriate) for children who may have never been immunized or are behind in their vaccinations (see Chapter 23).

Ingrown Toenails and Nail Hematoma

Description

Onychocryptosis (ingrown toenail) and nail hematomas are common occurrences in pediatrics. Ingrown toenails are caused by several factors including abnormal position of the toenail on the nailbed, tight and improperly fitting shoes, trauma to the nail, and improper toenail trimming. The lateral nail edges of the toenail impinge on the adjacent skin tissue causing erythema and edema. This constant impingement causes granulation tissue to build up at the site of the impingement and presses the toenail into the nail base and corner edge of the adjacent skin structure, which causes pain and potentially infection (Jacome et al, 2008).

Subungual hematomas are blood accumulations under the intact nail. Nail injuries that involve lacerations or a fracture of the distal phalanx should be referred to an orthopedist. Uncomplicated nail hematomas can be drained (nail trephination) by primary care providers. Tuft fractures (distal phalanx) are commonly associated with fingertip crush injuries and are often able to be managed in the primary care setting with orthopedic consult if needed.

Management

• Ingrown toenail

Pack cotton under the nail edge to elevate the nail, and educate the patient to repack the cotton daily to prevent infection.

Epsom salt mixed with warm-water foot soaks for 20 minutes, three times a day. Keep the foot or affected toenail clean and dry. Encourage frequent elevation of the affected toe as well as minimal activity to aid in healing.

Educate about the importance of clipping nails straight across with extension of toenail just over the edge of the nailbed. Properly fitting shoes are also important.

Systemic antibiotics are rarely needed and should be reserved for severe cases.

For persistent ingrown toenails with or without infection, consider a referral to a podiatrist for partial or complete toenail removal.

• Subungual hematoma

Determine whether a digital or regional nerve block is needed (proper training is required).

Attempt to lift the nail to examine for the presence of significant nailbed injuries.

Irrigate nail surface with saline solution, then clean with chlorhexidine or isopropyl alcohol.

Make one or more holes in the area of the nail hematoma with either a portable heat cautery device or the end of an untwisted heated-to-red paperclip (heated to melt the nail). Ensure the holes are large enough to drain the hematoma. Remove the cautery device immediately after creating a hole to ensure that the underlying tissue is not cauterized subsequently blocking the drainage of fluid.

Antibiotics generally are not needed.

Home care includes educating patient and parent to monitor for signs of infection (increased redness, swelling, pain, or purulent drainage) and to return for further care if infection is suspected. Instruct soaking of affected nailbed three times per day with antibacterial soap until the drainage has stopped and the underlying skin has healed.

An aluminum splint can be used to immobilize a Tuft fracture for 2 to 3 weeks.

Lacerations

Description

Lacerations are second only to contusions as the most common soft-tissue injury managed in the ED, resulting in approximately 112 million visits annually (Garcia-Gubern et al, 2010). Lacerations are deep cuts to the skin caused by a wide variety of mechanisms and are most common on the face, scalp, and hands. Lacerations often require more complicated treatment than other minor wounds because they can be associated with occult injuries to the deeper tissues and require careful exploration.

Shear, tension, and compression injuries are the three most common types of lacerations (Sullivan, 2009). Shear injuries are caused by sharp objects that tend to cause minimal, if any, damage to the tissues surrounding the injury. The biggest danger of shear injuries is the potential for damage to nerve, tendon, and vascular structures that may require more complicated repair that should only be attempted in the ED or operating room by a skilled surgeon. Shear injuries heal quickly and have the lowest potential for wound infection.

Tension lacerations are caused from stresses on the skin, usually secondary to the force of a blunt object at less than a 90-degree angle. The skin tears due to the stress and causes an irregularly shaped edge to the injury. These types of lacerations are accompanied by damage to surrounding tissues. A classic example is when a child falls and bumps his or her head on the dull edge of a piece of furniture, causing the skin to break open in the appearance of a laceration.

Compression lacerations are caused by a crush injury, usually involving blunt force of an object at a 90-degree angle. This type of laceration usually has irregular, often stellate wound edges. Compression injuries can cause significant injury to adjacent tissues and have the highest incidence of wound infections.

Epidemiology

Lacerations are caused by various forms of trauma and are a very common reason for pediatric health care visits.

Differential Diagnosis

The history and physical examination provide the diagnosis.

Management

Providers may repair the wound using sutures, staples, glue, or tape, as indicated. Minor lacerations to the scalp, arms, and legs are commonly managed by primary care providers. Significant wounds to the face, hands, or genital areas should be referred to a specialist, such as an orthopedic surgeon that specializes in hand repair, or a plastic surgeon for plastic and reconstructive surgery (particularly for the face).

The steps in wound management are summarized as follows (Selbst and Attia, 2010):

1. Decision to close the wound. Compared with adults, children are less likely to get wound infections. In fact, the infection rate from sutured lacerations in children is 2%. Most wounds may be closed using a primary wound closure (i.e., bringing the edges of the skin together, known as “approximation”) as soon after the injury as possible to speed healing, prevent infection, and improve the cosmetic result. Delayed closure increases the risk of infection. Some researchers suggest a “golden period” for wound closure of 6 hours. However, wounds considered low risk for infection, such as a clean knife wound to an extremity, can be closed even 12 to 24 hours after the injury. Other guidelines to consider in wound closure include the following:

• Most facial wounds may be closed up to 24 hours after initial injury in order to provide the child with the most optimal cosmetic outcomes. Depending on the severity of the laceration or potential for infection (such as a dog bite), repair and management may be best performed in the operating room.

• Risk of infection is inversely related to the blood flow to the body part where the laceration is present. The lower the blood flow, the higher the infection risk. For example, a hand or foot laceration is far more likely to become infected than a scalp laceration because the extremities of the body have lower blood perfusion than the head and scalp.

• Contaminated wounds, crush wounds, and lacerations in children who are immunocompromised are at high risk for infection and should be closed within 6 hours of injury.

• Animal, human, or barnyard animal bites should be left open for healing by secondary intention, which is a process of healing by granulation and reepithelialization. The potential of scar formation increases with this method, but the benefits of improved healing and decreased infection outweigh the cosmetic negative.

• Delayed primary closure consists of closing of a wound 3 to 5 days after initial injury when the risk of infection has decreased. This type of closure is recommended for selected heavily contaminated wounds and those associated with extensive damage, such as high-velocity missile injuries, crush injuries, and explosion injuries. Initial management of such an injury should include wound cleansing, debridement, and a sterile dressing. Close follow-up is recommended in order to check for infection and for wound closure (Selbst and Attia, 2010).

2. Anesthesia. Appropriate use of local anesthetic and conscious sedation is essential for successful repair of lacerations in children. Proper wound care includes wound exploration and careful cleansing, both painful procedures made worse by fear and anxiety. Infiltration of the wound with local anesthetic, such as 1% lidocaine with or without epinephrine (depending on location of laceration) can also help control bleeding. LET (lidocaine, epinephrine, tetracaine), LAT (lidocaine, adrenaline, tetracaine), and TAC (tetracaine, adrenaline, cocaine) are topical solutions placed on minor wounds 20 to 30 minutes prior to cleansing or repair procedures to help with pain management and to control bleeding. Topical solutions such as these cannot be used on eyes, ears, nose, fingers, genitals, or toes. Texts are available that address procedures in primary care that include excellent information on local anesthetic and wound closure. Attendance at workshops that focus on wound management is also helpful.

3. Hair. Hair near the wound usually creates minimal difficulty during repair and generally does not need to be removed. In any case, hair should not be shaved because to do so can damage hair follicles and increase the risk of infection. Instead, the hair should be clipped with scissors when necessary. Alternatively, petroleum jelly can be used to keep unwanted scalp hair away from the wound while suturing. Eyebrow hair should not be removed because this may lead to abnormal or slow regrowth.

4. Wound cleansing. Chlorhexidine or povidone-iodine surgical scrub preparations may be used to clean the skin surrounding the wound but are not recommended for use in the wound itself. Other agents not recommended for wound cleansing include hydrogen peroxide and alcohol. These agents may be irritating to tissues, causing slow healing times, and may increase infection by damaging white blood cells. The preferred method of wound cleansing is irrigation to reduce bacterial contamination and prevent subsequent infection. Normal saline or tap water is a safe and cost-effective choice for irrigation (Garcia-Gubern et al, 2010). A good rule of thumb for volume needed for saline irrigation is to use 50 to 100 mL of normal saline per centimeter of the wound or laceration. More solution may be needed if the wound is unusually large or contaminated. A large irrigating syringe (20 to 50 mL) is needed to provide enough force to cleanse the wound. A splash guard attached to the syringe is recommended to reduce splatter during irrigation. Scrubbing the wound should be reserved only for particularly “dirty” wounds when irrigation does not remove contaminants completely. Forceps may also be required to remove foreign debris from the wound when saline irrigation is unsuccessful. It is important to remove all foreign debris to decrease infection risk and prevent tattooing of the skin.

5. Exploration of the wound. The wound must be explored for presence of foreign bodies, deep tissue layer damage, injury to nerve or blood vessel, or joint involvement. It is imperative that the depth of the wound be determined. Wound probing is done with a cotton-tipped swab, a hemostat, or a needle holder. Deep lacerations should be referred to an ED for layered closure. If tendon injury is suspected or if bone is exposed, referral to an orthopedist is the standard of care.

6. Wound debridement. Gentle removal of unattached loose tissues may be done with sterile instruments. Debridement is advantageous because it helps to remove contaminant from the wound and creates more approximated wound edges. The approximation of wound edges allows for easier wound repair and cosmetic acceptability after the wound is healed for the patient. Although it is helpful to excise necrotic skin, excessive trimming of irregular lacerations should not be attempted. Excessive removal of tissue can create a defect that is difficult to close or that may increase tension at the wound margin, making scarring more likely.

7. Wound closure. Several methods are available for wound closure.

• Traditional stitches (or sutures) are often used to close lacerations. This involves “sewing” the skin together with a needle and surgical thread. This procedure usually requires an injection of anesthetic and a bandage applied to the wound afterward. Simple, uncomplicated lacerations to the scalp, trunk, arms, or legs may be closed with sutures (called primary closure). Choice of suture material and type of stitch used is dependent on the wound itself. In general, an absorbable suture material is used for closure of structures deeper than the epidermis and nonabsorbable sutures are used to close the outermost layer of a laceration. Deep sutures promote more efficient healing of the wound by relieving skin tension and decreasing dead space.

• Staples can be used for the scalp, trunk, and extremities (not including the hands and feet) and provide a more rapid closure time than with sutures. Laceration repair with staples is associated with a lower infection rate but can be more painful to remove and also not as cosmetically appealing after the wound has healed. Staples should not be used if MRI or CT is going to be necessary.

• Surgical tape such as Steri-Strips is used for small superficial wounds. Surgical tape cannot be used on wounds in moist areas or in areas of tension such as flexor or extensor surfaces. Surgical tape should also be avoided in wounds on small children, who will most likely remove the tape prematurely.

• Topical skin adhesive, also known as skin glue, is used for simple lacerations. The adhesive is applied on top of the skin while the edges of the wound are held together. Usually two or three applications of the adhesive are applied to ensure adequate closure. Adhesive in the wound or between wound margins should be avoided. Skin glue takes less time to apply than stitches and forms a strong, flexible bond over the top of the wound. A bandage is not required for cover after tissue repair with skin glue. The topical skin adhesive sloughs off the wound as it heals, usually in 5 to 10 days and does not require a return visit to the physician for suture removal. Infection risk is minimal due to antimicrobial properties of the adhesive. Minimal scarring is associated with this method of laceration repair. Table 39-2 compares wound closure techniques.

8. Dressing. A simple repaired laceration may be covered with an adhesive bandage. For more complex repaired injuries, dress the wound with nonadherent gauze for the first layer followed by a second layer of plain gauze if needed and secured in place with adhesive tape or elasticized gauze (tubular net bandage).

9. Immunization. Give tetanus booster or tetanus immunoglobulin as indicated.

10. Antibiotic controversy. Antibiotic prophylaxis of clean wounds is not indicated. Its use in contaminated wounds may be helpful, but careful wound cleaning with extensive irrigation followed by prompt wound closure (when indicated) are the most effective safeguards in preventing infection.

11. Suture and staple removal. Remove sutures or staples depending on their location (a useful guide can be found in Table 39-3).

TABLE 39-2 Advantages and Disadvantages of Common Wound Closure Techniques

Technique	Advantages	Disadvantages
Suture	Time honoredMeticulous closureGreatest tensile strengthLowest dehiscence rate	Requires removalRequires anesthesiaGreatest tissue reactivityHighest costSlowest applicationHighest risk of needlestick
Staples	Rapid applicationLow tissue reactivityLow costLow risk of needlestick	Less meticulous closureMay interfere with imaging techniques
Tissue adhesive	Rapid applicationPatient comfortResistant to bacterial growthNo need for removalLow costLow or no risk of needlestick	Lower tensile strength than suturesDehiscence over high-tension areasNot useful on hands
Surgical tape	Least reactiveLowest infection rateRapid applicationPatient comfortLow costNo risk of needlestick	Frequently falls offLower tensile strength than suturesHighest rate of dehiscenceRequires use of toxic adjuncts to adhere to skinCannot be used in areas with hairCannot get wet

From Sullivan DM: Soft tissue injury and wound repair. In Strange GR, Ahrens W, Schafermeyer R, et al, editors: Pediatric emergency medicine, ed 3, New York, 2009, McGraw-Hill, p 335.

TABLE 39-3 Suture and Staple Removal Guide

Location of Sutures	Length of Time Before Removal
Facial	3-5 days
Scalp	7-10 days
Upper extremity	7-10 days
Trunk	10 days
Lower extremity	8-10 days
Over a joint	10-14 days

Burns

Description

A burn injury to one or more layers of the skin and underlying tissues causes varying degrees of damage. Burns are classified by depth of injury, percent of body surface area involved, location of the burn, and association with other injuries. Although traditional classification of the depth of burns as first, second, third, or fourth degree are still in use, the designations of superficial, partial thickness (superficial or deep partial thickness), and full thickness are more commonly used based on recommendations from many experts (Tsarouhas and Agosto, 2008).

• Superficial, or first-degree, burns involve only the epidermis. The skin is erythematous, inflamed, and painful, but there are no blisters. Superficial burns typically heal in 3 to 7 days, have little risk of scarring, and require only symptomatic treatment. A common example of a superficial burn is a sunburn.

• Partial-thickness, or second-degree, burns involve the epidermis and the dermis to a variable degree. Superficial partial-thickness burns involve less than 50% of the dermis, and deep partial thickness burns involve more than 50% of the dermis (Tsarouhas and Agosto, 2008). The dermal appendages are always preserved and provide a source for regeneration.

Superficial partial-thickness burns are red, very painful, mottled, moist, and blistered. These burns usually heal in 7 to 14 days, and scarring may occur.

Deep partial-thickness burns appear pale and yellow. These burns are less painful and weepy than superficial partial thickness burns. Deep partial-thickness burns take longer to heal (3 weeks) and scarring is more likely to occur.

• Full-thickness or third-degree burns are major thermal injuries in which the epidermis and dermis are completely destroyed. The skin appears whitish (a waxy white appearance) or leathery. The surface is dry and nontender to palpation. Fluid losses can be profound with this degree of burn. Full-thickness burns usually require skin grafting, are associated with permanent scarring, and take several weeks to heal.

• Full-thickness burns with extension into deep tissues, also known as fourth-degree burns, involve destruction and/or extensive injury of muscle, fascia, nerves, tendons, vessels, and bone. They typically require surgical intervention and skin grafting.

Burns involving large surfaces of the body generally vary as to their degree of depth. Burn wounds are dynamic, and the effect of dermal ischemia (affected by infection, exposure, and dehydration) may not be readily apparent at first. Their depth can also change from day to day. The percentage of body surface area (BSA) and the part(s) of the body affected are also key factors to determine treatment, disposition, and prognosis (Table 39-4). Multiple methods have been devised to estimate the BSA affected. For example, the area covered by a child’s palm (from wrist crease to finger crease), also called the “rule of the palm,” is considered to represent 1% of total BSA and may be used for estimating the extent of small burns covering less than 10% of BSA (Antoon and Donovan, 2007). Free software to calculate BSA in pediatric burn victims is available at http://www.sagediagram.com/.

TABLE 39-4 Estimation of Surface Area Burned Based on Age^∗

Determining the need for admission to a hospital or burn center involves many factors including burn depth, percentage of body surface area injured, and mechanism of the burn injury. Other factors that influence hospital or burn center admission include risk of infection, pain control, functional and cosmetic outcomes, and social considerations. Children with burn injuries who meet the following criteria should be admitted to a children’s hospital or a burn center (Reddy and Parke Maier, 2009; Tsarouhas and Agosto, 2008):

Children with any sign of airway compromise should immediately be placed on 100% oxygen and sent to the hospital for further care and management. Airway complications and inhalation injuries should be suspected if there is loss of consciousness, presence of facial burns, burns over nasal passages or oral cavity, hoarseness, change in voice, or presence of cough or wheezing (Antoon and Donovan, 2007).

Epidemiology

Although the incidence of pediatric burn injuries has declined with the help of legislative action and public education, burn injuries continue to be a major source of morbidity and mortality for children (Tsarouhas and Agosto, 2008). Nearly 34% of all fatal injuries in children younger than 16 years are due to burns (Antoon and Donovan, 2007). In 2006, 553 children younger than age 20 died from burns, and 133,000 children were treated in EDs for nonfatal burns in 2007 (Quinlan et al, 2010). Modern technology such as the use of microwaves has increased the exposure of children to potentially injurious thermal energy in their environment. Common modes of injury include scalding, flash injuries from ignition of volatile substances, and electrical and flame injuries. The house fire is by far the most lethal cause of burns in children and typically results in thermal and concomitant inhalation injury.

Overall, scald-related burns account for 85% of total injuries and occur most commonly in children younger than 5 years of age, with a peak between 9 and 33 months of age (Antoon and Donovan, 2007; Quinlan et al, 2010). Scald injuries are usually caused from accidental tipping of a container holding hot liquid that spills on a child. Burn injuries sustained from hot liquid can be deeper and more severe with less contact time in children than in adults (Reddy and Parke Maier, 2009).

The intentional inflicting of burns to a child is unfortunately a common form of abuse. Every burn injury in a child should be evaluated for a potential etiology of abuse or neglect. Intentionally inflicted burn injuries often leave a characteristic pattern.

Clinical Findings

Physical Examination

The physical examination should begin by conducting a primary assessment of the airways. The most common cause of death during the first hour after a burn injury is respiratory impairment. Inhalation injury produces upper airway edema that can proceed with alarming speed to complete airway obstruction. Inhalation injury should be suspected if there is hoarseness, wheezing, cough, rales, singed nasal hairs, carbonized sputum, cyanosis, or altered mental status. Inhalation injury may also be associated with facial or neck burns. In such cases immediate emergency intervention (paramedics and immediate transport to the ED) is warranted. Once the patient is stable, a thorough physical examination requires the following determinations:

Diagnostic Studies

• A CBC is indicated to establish baseline levels. The hematocrit is often elevated secondary to fluid loss. Initial elevation of the white blood cell count is most always secondary to an acute phase reaction, but later may be an indicator of infection.

• A basic metabolic panel may reveal elevated potassium due to cell breakdown. Blood urea nitrogen (BUN) and creatinine are used to assess renal function and tissue perfusion.

• A urinalysis, particularly the specific gravity, helps determine hydration status, and presence of myoglobin may suggest acute tubular necrosis secondary to muscle tissue destruction and breakdown.

• Baseline clotting studies and typing and crossmatching may be indicated if there is associated trauma or if surgical intervention, such as grafting, is considered.

• Pulse oximetry, arterial blood gases, carboxyhemoglobin (for inhalation or suspected inhalation injury), and chest radiographs are indicated if there is airway involvement or vascular instability.

• Cardiac monitoring may be needed for electrical burn injury and as indicated.

• Culturing of critical burn wounds may need to be done weekly or more frequently if infection develops.

Chapter 17 discusses intentional burn injuries resulting from child abuse. Scalded skin syndrome caused by staphylococcal infection can cause skin exfoliation, but the clinical presentation clearly differentiates it from an accidental burn injury. Management is similar to that used for burn management.