In our study, we evaluated how wound/laceration care/management is performed in our PED. Moreover, we analysed the differences in laceration repair between clinicians and fellows of various specialties working in PED.
Wound/laceration management and care are usually a big challenge for doctors with regard to what treatment tactics to use. For this purpose, certain methodologies are being developed and used to enable physicians and fellows to choose and follow the appropriate wound evaluation and management technique. Despite the large proportion of patients with minor trauma referring to our hospital, our PED still does not have a unified and accepted wound care SOP. As a result, young physicians and residents working in PED have to follow word-of-mouth or their own personal knowledge and not always use correct or study/evidence-based practices.
We observed no difference in length of the wound being treated by surgical specialties or EM doctors/fellows. Interestingly, we noted that paediatricians and GP fellows managed smaller and shorter wounds. This could be the reason why they chose no-needle techniques more often. Also, EM physicians treated older children than paediatric doctors/fellows and GP fellows. Our personal observation leads to hypothesis that paediatricians and GPs have higher clinical experience in caring for smaller children and communicating with them, thus, were more involved in their care in PED. However, this does not reflect the situation regarding all clinical cases/diseases referring to PED.
-Wound management and anaesthesia
In our study, most of the cases of paediatric wounds were small, superficial with a slight risk of complications. According to the results of questionnaires, most of the wounds were small and usually not deep. Non-invasive wound management techniques could usually have been sufficient for such wounds. However, we have noticed that almost half of all wounds were sutured. We observed that older children were chosen suturing (7.3 [4.67 - 9.96] years), however, younger children received non-invasive treatment methods (4.57 [2.46 – 6] years). Interestingly, anaesthesia was not used in six suturing cases and the age of these patients was about 7.5 [5.63 – 9.13] years old. Typically, anaesthesia is not given when the wound is left to self-heal or treated by non-invasive techniques (gluing or stripping). The fact that a significant number of the wounds during suturing procedure were not anesthetized (8.7%, n=6) raises a concern. Painful experiences/procedures during primary care/emergency or hospital visits lead to increased anxiety or fear associated with medical care. Moreover, it can contribute to disturbed sleep, mood swings or post-traumatic stress disorder . Even in the presence of needle fear or to avoid injection, the literature indicates needle-free local anaesthesia (e.g., lidocaine, tetracaine and adrenaline gel) may be used . In our study, topical anaesthesia was applied to only about one in ten patients using a lidocaine spray or EMLA gel (alone or combined with another anaesthesia method). In addition, younger patients were more likely to receive topical anaesthesia for wound care (4.13 [3.58 – 5.17] years). According to the study performed by Kristin Olsen et al., EMLA gel is effective for about 30-60 minutes. This topical anaesthetic can be applied to healthy skin and access directly into the wound should be avoided . Lidocaine spray is more suitable for mucous membranes . Thus, it can be safely used in any age and must be applied to avoid increased anxiety and pain which can worsen procedural outcomes. We noticed that EM physicians or fellows chose local anaesthesia in more than 1/3 of their wound repair cases, surgical specialists used this type of anaesthesia in half of their cases. We observed that most commonly infiltration with lidocaine solution was performed, which is reported in the literature as one of the most reliable types of anaesthesia because of its quick and sufficient action . The medium age of patients who received local injectable anaesthesia was 7.68 [5-10] years old. In our study general intravenous anaesthesia was extremely rare, and other studies described it as an option . This method was given for patients who were approximately 4.47 [3.58 – 5.17] years old. It is offered to apply this method for younger and more scared children . We also noticed that some specialists combined two methods of anaesthesia. We can only speculate that this could be due to the failure of one anaesthesia method selected. Interestingly, our study demonstrated that GP and paediatricians used anaesthesia-free methods more than other specialties. It could be related to wound characteristics per se as GP and paediatricians/fellows were more likely to treat smaller wounds. However, lack of experience in suturing or lidocaine injections can be the biggest stimulus to select needle-free approaches.
The data regarding wound cleaning/irrigation are controversial. Some of the studies suggest tap water as a safe irrigation solution with no increased infection risk [15,16]. Several investigators found no difference between various antiseptic solutions but indicated that Chlorhexidine 0.02% or Hydrogen peroxide 3% (HP) causes cell damage and thus worsens wound healing [15,16]. Surprisingly, we detected that these two solutions were chosen most frequently for wound cleaning. EM physicians and fellows preferred ChG and HP alone or in combination in most of the cases. Other specialty physicians and fellows chose ChG in 45.2% and HP in 6.1% of the cases (in 19.6% of the cases both irrigation solutions were used). Other solutions as tap water or NaCl were less preferred. It is quit an interesting observation as our study excluded animal bites or heavily contaminated wounds.
-Techniques of wound repair
After analysis, we realised that all wounds received primary wound closure or were left to heal by itself. Majority of the wounds were treated non-surgically with tissue adhesives or tape, and only 47% (69/148) were sutured. According to different data, sutures are recommended for larger wounds and in the case of strong skin tension due to the risk of separation of the wound edges. Although, it is associated with higher risk of infection caused by needle trauma and the type of suture within the wound . Tape and tissue adhesive can be used for minor trauma with minimal skin tension. Studies show that tissue adhesives have significantly shorter time of wound treatment compared with suturing [17–19]. However, they also have certain disadvantages, such as the ability of wound separation or require special learning skills. Our study revealed that paediatricians/paediatric fellows and GP fellows preferred Steri-strips™ and tissue adhesive. Meanwhile, surgical specialties chose suturing in most of the cases. EM physicians/fellows performed both methods almost equally. There are many circumstances that could have led to these results. One of the reasons could be education and experience related to primary wound diagnostics and treatment selection. As our PED working teams are mixed (paediatrician, EM physician, paediatric-, EM- and GP fellows) methods can relate to individual choice, previous experience and study curriculum. Our paediatricians do not have that much experience in suturing as this was and still is not covered in their curriculum, so these physicians prefer non-invasive methods to invasive. Recently, updates in paediatric residency curriculum has been made with regards to trauma care and wound management leading to improved knowledge, skills and experience in paediatric fellows. Emergency fellowship is a new residency program in which residents are taught to treat minor trauma by suturing and using tissue adhesive or Steri-strips™. They have enough knowledge to decide which method should be used in a specific situation.
The probability of infection of small wounds or lacerations is less than 6.3% . However, the choice of antibiotic prescription depends on the wound itself and the mechanism of the injury. Patients with chronic comorbidities or immune deficiencies are expected to receive systemic antibiotics after wound treatment. When a wound is infected, contaminated, or contains foreign bodies, and when it is an animal bite, antibiotics should be prescribed . Antimicrobial agents that act on gram+ microorganisms can sometimes be selected even with minimal trauma. These could be first-generation cephalosporins or macrolides in the case of allergy to penicillin. Amoxicillin-clavulanic acid can be used for animal bites . In our study, 4 children received systemic antibiotics (3 of them - amoxicillin and 1 cefadroxil). None of them had any comorbidities which could have any influence to wound healing (e.g. immunodeficiency, coagulation system disorders, etc.). Wounds were not contaminated. Even with only four cases, antibacterial treatment should be chosen wisely as overtreatment leads to increased antimicrobial resistance .
Different guidelines recommended to remove sutures after 7 to 14 days from scalp, after 5 days from face area, after 3 days from eyelids and neck and after 8 to 10 days from extremities . We documented that physicians and fellows’ recommendations were not cohesive and did not adhere to any international recommendations of wound after-care. Stitches from head area were recommended to be removed after 7 to 10 days, from face area after 5-7 days and from extremities after approximately 5-10 days. This again confirmed our aim to implement unified wound management and care guidelines.