Effective anesthesia is important to optimize conditions for wound closure, to prevent patient movement, morbidity, and to aid in hemostasis. Perform a thorough neurological examination of the affected region prior to anesthesia.
There are a number of anesthesia agents to choose from, each with a unique set of attributes. Appropriate use of an agent includes consideration of duration of action, potency, and safety. A common emerging practice is use of topical anesthetics in the pediatric patient to avoid unnecessary injections, with near-equivalent efficacy to locally injected anesthetic agents. Use of regional anesthetics is limited by their cardiovascular and systemic toxicity.
Topical anesthetics are useful in patients with small, uncomplicated wounds. Use of tetracaine, adrenaline, and cocaine (TAC) has fallen out of favor due to toxicity and abuse potential. Current preferred preparations are listed following.
LET (lidocaine 2%, epinephrine 1:1,000, and tetracaine 2%): Apply to wound, cover with an occlusive dressing, and wait 20 minutes for absorption and anesthesia. Duration of action is 20 minutes.
LMX-4 (4% liposomal lidocaine): 30 minutes to achieve anesthesia, 45 minutes duration.
EMLA (5% preparation of 2.5% lidocaine and 2.5% prilocaine): 1 hour to achieve anesthesia.
Inhalation anesthetic is used to provide general sedation of the patient to aid in procedure. Nitrous oxide is often used as the inhalant of choice, but use is uncommon in the emergency department.
Local anesthetic is injected, usually from within the wound margin, to infiltrate into the bordering tissue (Figure 31–1). A 25- to 30-gauge needle is preferred, with the smallest needle providing the least discomfort. The minimum volume needed to achieve adequate anesthesia should be used to prevent toxicity and to prevent distortion of the wound borders that may interfere with cosmesis. The pH of the anesthetic preparation causes a local burning sensation, which can be reduced by slow infiltration or by buffering with sodium bicarbonate (add 1 mL sodium bicarbonate to 9 mL lidocaine). Warming the anesthetic prior to administration can reduce pain. Epinephrine preparations will provide a longer duration of action and help constrict local capillaries, providing additional hemostasis. Local anesthesia durations and maximum doses are listed in Table 31–1.
Injection of local anesthetic. (Reproduced, with permission, from Dunphy JE, Way LW: Current Surgical Diagnosis & Treatment, 5th ed. Los Altos, CA: Lange Medical Publications, 1981. Copyright © McGraw-Hill Education LLC.)
Table 31–1.Local anesthesia duration and maximum dose. |Favorite Table|Download (.pdf) Table 31–1. Local anesthesia duration and maximum dose.
|Agent ||Duration of Action ||Maximum Dosage Guidelines |
|Lidocaine ||Medium (30-60 min) ||Without epinephrine 4.5 mg/kg; ≥ 300 mg |
|Lidocaine with epinephrine ||Long (120-360 min) ||With epinephrine: 7 mg/kg |
|Mepivacaine || |
Medium (45-90 min)
Long (120-360 min with epinephrine)
|5 mg/kg; ≥ 400 mg |
|Bupivacaine ||Long (120-240 min) ||Without epinephrine: 2.5 mg/kg; 175 mg |
|Bupivacaine with epinephrine ||Long (180-420 min) ||With epinephrine: ≥ 225 mg |
|Prilocaine ||Medium (30-90 min) || |
Body weight < 70 kg: 8 mg/kg; ≥ 500 mg
Body weight > 70 kg: 600 mg
|Ropivacaine ||Long (120-360 min) ||2-4 mg/kg; ≥ 200 mg |
|Procaine ||Short (15-60 min) ||7 mg/kg; not to exceed 350-600 mg |
|Chloroprocaine ||Short (15-30 min) || |
Without epinephrine: 11 mg/kg; ≥ 800 mg
With epinephrine: 14 mg/kg; ≥ 1000 mg
Regional anesthesia is sensory nerve blockade at a location proximal to the wound. This has the advantage of anesthetizing a larger area with less volume, does not typically distort anatomy, and may have a longer duration of action. Common regional anesthesia sites are digital blocks, extremity nerve blocks, infraorbital, and supraorbital nerve blocks.
This block requires infiltrating about 0.5 mL of lidocaine or bupivacaine into base of the digit in the area of each of the four nerve sheaths. There are two nerves on the dorsum and two on the palmar aspect of the digits. The duration to adequate anesthesia for lidocaine is approximately 10 minutes. Newer literature supports the use of epinephrine for digital blocks as needed.
This nerve block will anesthetize the lateral dorsum of the hand in the distribution of the radial nerve. Approximately 2 mL of lidocaine is instilled just proximal to the Lister tubercle, where the radial nerve emerges from beneath the brachioradialis (Figure 31–2).
Radial nerve block, in which 2 mL of anesthetic is injected just proximal to the Lister tubercle on the radial aspect of the forearm. (Reproduced, with permission, from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
This nerve block will anesthetize the lateral palmar aspect of the hand in the distribution of the median nerve. This is achieved by injecting 2 mL of lidocaine into the carpal tunnel between the tendons of the palmaris longus and flexor carpi radialis (Figure 31–3).
Median nerve block, in which 2 mL of anesthetic is injected into the carpal tunnel between the tendons of the palmaris longus and flexor carpi radialis. (Reproduced, with permission, from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
This nerve block will anesthetize the medial palmar surface of the hand in the distribution of the ulnar nerve. This is performed by injecting 2 mL of lidocaine just medial to the flexor carpi ulnaris tendon (Figure 31–4).
Ulnar nerve block, in which 2 mL of anesthetic is just medial to the flexor carpi ulnaris tendon. (Reproduced, with permission, from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
This nerve block will anesthetize the infraorbital branch of the maxillary nerve (V2) as it exits the infraorbital canal. This is located inferior to the eye on an imaginary line between the pupil and the ipsilateral canine. Infiltrate 1-2 mL of lidocaine to achieve anesthesia of this nerve distribution (Figure 31–5).
Infraorbital nerve block, in which intraoral or percutaneous injection around the palpable infraorbital foramina will result in anesthesia within the shaded area. (Adapted, with permission, from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
This nerve block will anesthetize the supraorbital branch of the ophthalmic nerve as it exits the supraorbital foramen. This is performed by palpating the notch of the supraorbital foramen on the superior orbital ridge, then injecting 1-2 mL of lidocaine to achieve anesthesia of this nerve distribution (Figure 31–6).
Supraorbital nerve block, in which anesthetic is injected superior to the orbital ridge at the supraorbital notch. The shaded area will be anesthetized on the ipsilateral side of injection. (Adapted, with permission, from Stone CK, Humphries RL: Current Diagnosis & Treatment Emergency Medicine, 7th ed. New York: McGraw-Hill, 2011. Copyright © McGraw-Hill Education LLC.)
Procedural sedation has proven safe and effective for pediatric wound care. Sedation creates an environment in which the provider can carefully examine and treat wounds. This limits the risk of further injury to the patient caused by anxiety or pain. (See Chapter 4.)
Of particular note are parental concerns regarding whether their child will suffer during the procedure. Parents may demand sedation without regard to whether the risks of sedation outweigh the perceived benefits of being “asleep” during the procedure. Parents should be advised when it may be more efficacious, timely, and safe to defer procedural sedation and utilize a child life specialist or staff member to divert the patient’s attention for a simpler and more straightforward wound assessment and management.
Cleaning of an acute wound is vital to prevent infection and complications. The objective of wound cleaning is to remove as much bacteria, contaminants, and devitalized tissue as possible. There is a spectrum of approaches from wound irrigation, to scrubbing, to complete excision of the initial wound that may be utilized to optimize a clean wound. In the emergency department, copious irrigation is the most common method.
Wounds in hairy areas pose a unique difficulty as the native hair can become embedded in the wound and act as a foreign body. This can prevent adequate healing and promote infection. A simple solution is to clip the hair short enough to prevent interference with the wound, but not to shave the hair. Shaving exposes the hair follicle and predisposes to more infection. Eyebrows and eyelashes are an exception. It is not recommended to remove these hairs as they have significant cosmetic effect and may cause disruption of anatomic alignment needed to properly approximate wound margins. In a small subset of patients, eyebrows may regrow irregularly after being removed.
Irrigation is the most important intervention to prevent infection and promote wound healing. Wound irrigation is the steady flow of solution across exposed tissue to wash away particulate matter, to hydrate, and enable effective visualization. There is continued debate regarding the need for pressured irrigation versus gentle irrigation to adequately clean wounds. It is generally accepted that pressures of 7-11 lb/in2 are needed to adequately remove bacteria and particulate matter.
A number of commercial devices are available that provide either constant pressurized flow or pulsatile flow, although no clinical difference has been identified. In the emergency department, a 50 mL syringe and a 19-gauge needle are shown to provide ideal pressure and stream for thorough irrigation. Bulb syringes as well as fluid bottles or bags that have holes poked in them have been shown to be ineffective for adequate wound cleansing.
Recent studies have compared the use of chlorinated tap water versus saline to irrigate wounds. Tap water is shown to an effective alternative to saline to irrigate acute wounds.
Do not mix alcohol, peroxide, or iodine with the irrigation solution as these products are bactericidal, but they also exhibit significant cytotoxicity and can delay wound healing. Diluted hydrogen peroxide is effective for removing dried blood and debris from the surrounding skin. Ionic soaps and detergents are also not recommended for wound cleansing as they are irritating and may increase risk of infection.
High-porosity sponges may be used on the wound surface to gently remove debris. Brushes may further damage the tissue and decrease infection resistance but are effective for removing imbedded foreign bodies that would interfere with normal wound healing.
Removal of contaminating foreign matter and devitalized tissue is important to promote wound healing. Devitalized tissue should be excised with a sterile scalpel to expose healthy tissue underneath. Irregularities of the wound margins may be revised to encourage adequate approximation of wound margins and prevent tenting of the wound edges. Debridement of the face and other areas of cosmetic significance should be deferred to a plastic surgeon.
After careful examination, anesthesia, and irrigation, a decision about closing the wound must be made. Closing the wound in the acute setting is referred to as primary closure and is the preferred method to reduce scarring, encourage healing, and promote a rapid return to functional state. If electing not to close the wound in the acute setting, closing 48-96 hours later is referred to as delayed primary closure.
Delayed primary closure may be preferred for heavily contaminated wounds, wounds requiring significant debridement, and bite wounds. This is performed by packing the wound with moist saline after initial cleansing, which allows the tissue to develop resistance to infection that it would otherwise not have with primary closure. The moist gauze should be changed three times daily, while inspecting for signs of infection. After the interval period, if no signs of infection are identified, the wound may be closed in the same fashion as primary closure.
Not all wounds should be primarily closed in the emergency department. Heavily contaminated wounds, such as feces or pus, have such a high risk of infection that they are destined to fail and will benefit from delayed closure. Wounds that fall outside of the recommended interval period (> 6 hours) should prompt consideration of delayed closure to minimize infection risk. Any active wound infection evident on the initial examination should not undergo primary closure.
Major tissue defects, such as gaping wounds requiring high suture tension, should be considered for healing by secondary intention. These wounds have a high risk of dehiscence and wound cavity development. They are often best managed by regular dressing changes and allowing granulation tissue to fill the wound. Do not close wounds that result in an empty void under the closure—these spaces predispose to infection and possible abscess formation. Retained foreign bodies are a contraindication to primary closure and need to be addressed first. Crush wounds are high risk for complications such as compartment syndrome, hematoma formation, and dehiscence. Consider allowing these wounds to heal by secondary intention.
Wounds less than 6 hours old may undergo primary closure unless otherwise contraindicated and have a high likelihood of satisfying results. Primary closure of wounds with intervals greater than 6 hours is at the discretion of the provider. Resistance to infection is directly related to adequacy of blood supply. If the location has sufficient blood supply, closure may be performed at a longer interval, although there is increased risk of infection which should be communicated with the patient and parents. Some patients may have decreased blood flow, such as diabetics; such wounds may be best managed with a shorter interval window for primary closure. Facial and scalp wounds may be considered for primary closure up to 24 hours after initial injury, owing to the region’s excellent blood supply.
Four methods are available for wound closure: sutures, adhesive wound tape, staples, and tissue wound tape. The modality to choose is determined by the location and characteristics of the wound. There is often no cosmetic difference among the available selections, and outcome depends largely on the patient’s individual healing. For simple low-tension linear lacerations, any of the four methods described may be utilized with equivalent cosmetic outcome. For irregular lacerations, areas with movement, or those with high tension, suture is the modality of choice. Staples are frequently used in situations of time restraint or with uncomplicated scalp lacerations. Tissue adhesive is commonly used in the pediatric patient for uncomplicated facial lacerations in regions of low tension.
Suture selection is generally dependent on the location of the injury and the degree of tension that the sutures will need to maintain. Smaller suture and needle sizes are used for facial wounds to minimize scarring, generally with 5-0 or 6-0 suture. Layered wound closures require a fine absorbable deep suture. Dermal and epidermal closures in locations elsewhere on the body are commonly managed with a 3-0 or 4-0 suture, with 3-0 preferred for areas of higher tensile strength requirement. Scarring related to the suture depends on size of the suture, the wound tension, and the duration that the suture remains in place. All suture materials will cause a local foreign body tissue reaction with variations based upon the type of material.
Decision regarding use of absorbable or nonabsorbable suture is determined on a case-by-case basis. For dermal and epidermal closures, absorbable or nonabsorbable may be used and choice is often determined by the patient’s preference, reliability of follow-up, and degree of tensile strength required. For a patient with poor reliability for follow-up, closure with absorbable suture may be preferred to prevent long-term consequences of prolonged suture duration and even retained suture. Common sutures are listed in Table 31–2.
Table 31–2.Common suture materials. |Favorite Table|Download (.pdf) Table 31–2. Common suture materials.
|Nonabsorbable Suture ||Filament ||Classification ||Duration of Tensile Strength |
|Silk ||Braided ||Biological ||Many months |
|Nylon (Ethilon, Dermalon) ||Monofilament ||Synthetic ||Many years |
|Polypropylene (Prolene, Surgipro) ||Monofilament ||Synthetic ||No degradation |
|Polyester (Ticron, Mersilene) ||Braided and monofilament ||Synthetic ||No degradation |
|Polybutester (Novafil) ||Monofilament ||Synthetic ||No degradation |
|Absorbable suture |
|Plain gut ||Monofilament ||Biological ||50% at 5 d |
|Chromic gut ||Monofilament ||Biological ||50% at 10 d |
|Poliglecaprone (Monocryl) ||Monofilament ||Synthetic ||60% for 1 wk |
|Polydioxanone (PDS) ||Monofilament ||Synthetic ||50% at 4 wk |
|Polyglactin (Vicryl) ||Braided ||Synthetic ||65% at 2 wk |
|Polyglyconate (Maxon) ||Monofilament ||Synthetic ||70% at 28 d |
|Polyglytone (Caprosyn) ||Monofilament ||Synthetic ||50% at 10 d |
Nonabsorbable sutures are commonly used for superficial closures, for tendon repair, and for regions of high tension. Most nonabsorbable suture will maintain tension for up to 60 days. The following materials are not used in deep sutures due to high tissue reactivity and foreign body response.
Silk. A naturally produced braided material that has been used throughout history for wound closure. Silk is notorious for its high tissue reactivity, the highest of all nonabsorbable suture, as well as its propensity to lose tension with time. The use of silk has largely been replaced by synthetic suture material in developed countries.
Nylon. A monofilament suture material with relatively low tissue reactivity. This suture is progressively degraded by hydrolysis over time, resulting in loss of tensile strength. It is notoriously stiff and does not maintain a knot as well as other suture materials.
Polypropylene. Available as monofilaments that provide long-term tensile strength without a loss of tension, and cause the least tissue reactivity of all sutures. It is commonly used in superficial wound closures.
Polyester. Available as monofilament and braided applications. It is the suture of choice for tendon repair, has minimal tissue reactivity, and does not undergo degradation or weakening with time.
Absorbable suture is often used for deep closure of dermal wounds and fascial layers. It causes a high degree of local tissue reactivity that contributes to its degradation. These suture materials maintain tensile strength for less than 60 days. Many varieties are available for use with the selection decision based on duration of tensile strength. Rapidly absorbing sutures such as fast-acting gut, polydioxanone, or poliglecaprone are effective options for laceration repairs in children who are not candidates for tissue adhesive. This often eliminates a return visit for suture removal.
Gut. Commonly created from bovine serosa, these sutures are degraded by proteolytic enzymes and have inconsistent tensile duration. Available as plain gut or chromic gut, they are selectively used in the emergency department. Plain gut holds tension for approximately 2 weeks with a high degree of tissue reactivity. Chromic gut is treated with chromium salts, offering more predictable absorption and loss of tensile strength with a duration of up to 4 weeks.
Synthetic. Available in multiple applications including polyglycolic acid, polyglactin, polydioxanone, poliglecaprone, polyglytone and polyglyconate. They produce minimal tissue reactivity and are often used for deep closures and vascular repairs. Polyglycolic acid and polyglactin retain approximately 50% of tensile strength at 10-14 days. Polydioxanone retains 50% of tensile strength at 4 weeks. Poliglecaprone retains 60% of tensile strength at 1 week. Polyglyconate retains 70% of tensile strength at 1 month.
Forgoing the use of suture for wound repair will provide the lowest risk of infection, as there is no foreign body reaction. Wound tapes are highly effective in closure of uncomplicated linear lacerations with low tension. They are also effective for epidermal approximation in wounds that have been closed with deep dermal sutures. Because of very low infection rates, wound tapes are very effective in contaminated wounds as well. The wound must be prepped clean and dry before placement of wound tapes to prevent early failure. Tincture of benzoin is effective in promoting tape adhesion and tension. Wound tapes allow for tension only in the most superficial layers of skin; thus deep dermal sutures may be required to maintain adequate approximation of the wound with the epidermal layer closed with tape.
The ease of use, speed, and good cosmetic outcome makes closing of wounds with staples an acceptable choice. There are a variety of commercially available staple applicators. Staples may be used in relatively simple lacerations without a significant deep component, as they close only the superficial layer of the skin. They are most commonly used in scalp lacerations as both application and removal are uncomplicated by hair. Infection rate and long-term scarring are similar to sutures. Staple removal is slightly more painful than removing suture. It is performed with a commercially available staple remover to evert the penetrating arms of the staple.
Cyanoacrylate tissue adhesive is a commonly used method of closing small uncomplicated wounds in pediatric patients, usually facial lacerations. Cyanoacrylate adhesive polymerizes to maintain approximation of wound edges, providing effective cosmesis and infection prevention while treatment is nearly painless. Adhesives are recommended for lacerations that are less than 5 cm in length, and less than 0.5 cm in width and that are easily approximated with minimal tension. They are not recommended in areas close to eyes, mucous membranes, or active infection. Adhesive application is performed by approximating wound edges and applying two layers of adhesive over the entire surface of the wound and extending 5-10 mm beyond the wound border. The wound is held in approximation for 45-60 seconds while the adhesive polymerizes and is followed by a second application. To prevent runoff into eyes or hair, cover eyes with gauze and apply petroleum jelly to nearby hair.
There are a number of suture techniques for wound closures. The goal is to optimize wound margin approximation and reduce the incidence of infection and scar formation. Most often in the emergency department, simple interrupted suture technique is sufficient to obtain optimal repair results. Running sutures may be performed in linear lacerations with low tension, especially during time constraint. Deep or gaping wounds may be closed with vertical and horizontal mattress sutures, respectively. Occasionally, the wound may require multiple layers of suture to close the wound defect, especially in patients with fascia involvement or tissue loss. The specific technique required will vary with patient and provider.
POSTMANAGEMENT WOUND CARE
The role of a wound dressing is to protect from contamination and forceful wound disruption, and to optimize the wound-healing environment. An occlusive dressing is a cost-effective means to prevent failure of the wound repair. It can be used to maintain moisture and ointments, and is simple and easy to change. A dressing consists of a simple adhesive bandage or a complex organization of gauze and antibacterial components. Dressing changes should be performed at least daily.
Studies have indicated no difference between antibacterial ointment and petrolatum ointment in the prevention of wound infections. Both ointments maintain moisture on the healing tissue, preventing it from drying and delaying healing. Ointments may help prevent and reduce scar formation. Maintaining a moist wound is preferred over the historical recommendation of keeping the wound clean and dry.
Very large wounds and those that overlie joints should be immobilized in a splint. A splint prevents dehiscence and wound disruption caused by the stretching and stress on the wound. Immobilization should be continued for at least 1 week to allow for sufficient wound healing to withstand separation by movement. Avoid prolonged splinting, which will contribute to joint stiffness.
Skin lacerations require an average of 7 days to achieve adequate tissue strength to prevent spontaneous dehiscence. General recommendations for suture duration depend on the location of suture due to variations in tissue tension, movement, and cosmetic concerns.
Sutures in the face should be removed after 3-5 days—longer increases the risk of scarring. Sutures or staples in the scalp and arms should be removed after 7-10 days. Sutures of the trunk, legs, hands, and feet should be removed after 10-14 days. Sutures on the palms and soles should be allowed 14-21 days before removal. Each wound should be assessed individually, and dependent on the progress of the wound, suture duration varies. Allow more time for wounds that do not appear to have healed well enough to maintain closure. Table 31–3 lists recommended duration of suture by location.
Table 31–3.Duration of suture by location. |Favorite Table|Download (.pdf) Table 31–3. Duration of suture by location.
|Location ||Duration of Suture (days) |
|Face and scalp ||3-5 |
|Arms ||7-10 |
|Trunk ||7-10 |
|Legs ||10-14 |
|Hands and feet ||10-14 |
|Palms and soles ||14-21 |
Development of a wound infection is a serious consideration in determining management of an acute wound. From decreasing inflammatory cell actions and tissue oxygenation to increasing inflammation, infection retards healing and worsens outcomes. For outpatient management, topical and enteral antibiotics are the mainstay of treatment.
Irrigation should take priority over antibiotics in the majority of wound management patients where it can be employed. Antibiotics should be employed as an adjunct. An average of 4.5-6.3% of wounds will become infected, but no evidence exists to support the widespread use of prophylactic antibiotics. Patients with comorbidities (AIDS, uncontrolled diabetes), specific type of wounds (crush and compression injuries), grossly contaminated wounds, deep structure involvement, bite wounds, and delayed presentation are candidates to receive antibiotics.
Choice of antibiotic should be tailored to the presumed organism(s). Most wound infections are due to staphylococcal and streptococcal species. Salt-water wounds have increased risk of Vibrio species, fresh water wounds have increased risk of Aeromonas, and soil-contaminated wounds are at risk of Clostridium species. Although community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) is a main cause of cutaneous infection, the overall carriage rates are low and should not impact antibiotic choice for the otherwise healthy patient.
Topical antibiotics have historically been used as basic wound management. However, there is a paucity of data to specifically recommend their use. It has been demonstrated that topical antibiotic administration in the emergency department may decrease the risk of wound infection in comparison with petroleum jelly. The optimum choice of topical antibiotic is unknown. Commonly used and over-the-counter topical ointments include bacitracin or a combination of bacitracin, neomycin, and polymyxin (triple antibiotic ointment). Neomycin is known to cause allergic dermatitis in patients. Ointments are not recommended after a wound has been closed with a tissue adhesive as they can cause early weakening of the polymerized film.
Tetanus is a potentially life-threatening disease resulting from wound infection by Clostridium tetani. In the United States, routine immunization for tetanus is common in children. Tetanus prophylaxis has become standard-of-care in routine wound management and should be considered for a wound with potential skin or mucosal loss of integrity. A three-part immunization series is recommended for adequate background coverage. If a patient has not had an immunization for tetanus in greater than 5 years, it should be updated while in the emergency department. Table 31–4 summarizes tetanus prophylaxis recommendations.
Age of the patient and vaccination status will determine the tetanus toxoid-containing booster. Patients aged 6 weeks to 6 years should be given the diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. For children aged 7-10 years, who are previously vaccinated, the tetanus and diphtheria toxoids (Td) vaccine is preferable. Patients aged 10-18 years, the tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis (Tdap) vaccine are recommended.
Tetanus immunoglobulin (TIG) is considered safe and standard of care for appropriate wounds. High-risk wounds that increase the risk of tetanus include those contaminated with dirt, feces, soil, saliva, and wounds associated with frostbite, crush or avulsion wounds. For infants younger than 6 months, it is appropriate to utilize the mother’s immunization status in addition to recommendations in Table 31–4 TIG use. Additionally, TIG should be considered in tetanus-prone wounds for patients with HIV infection regardless of immunization status.
Table 31–4.Summary of tetanus prophylaxis recommendations.
Rabies remains a serious problem in the United States and abroad. It is a nearly universal fatal viral infection caused by an RNA virus transmitted after inoculation into a wound from an infected reservoir. Proximity of inoculation site to the recipient’s brain will partially determine time to onset of disease, often weeks to months. Once symptoms of rabies have begun, rabies prophylaxis will no longer be beneficial.
More than 23,000 doses of rabies post-exposure prophylaxis (RPEP) are given annually in the United States. Management of a potential exposure is an essential element in proper wound care.
Animals considered high-risk include bats, raccoons, skunks, foxes, coyotes, and other carnivores.
Note: Bats are considered high-risk reservoirs and have been linked to many cases in the United States. In situations where it is possible that there was contact with a bat (sleeping areas, children present, mentally disabled patients), even without obvious evidence of a bite, it is recommended that RPEP be administered.
Animals considered low-risk include mice, rats, squirrels, rabbits, gerbils, other small rodents, birds, and reptiles. Domestic cats and dogs are less concerning because of high vaccination penetration in the United States.
Circumstances of Exposure
Unprovoked bite by a domestic animal is considered high-risk for rabies. Normal defensive behavior is conversely low-risk. It can be difficult to discriminate normal defensive behavior from rabid behavior.
Violation of skin integrity is considered potential for virus transmission. In addition to teeth breaking through the skin barrier, contamination of previously open wounds with animal saliva is considered higher risk.
Determine if Animal Is (or likely is) Rabid
Rabies vaccination status of the offending animal should be determined quickly. If the domestic animal has up-to-date vaccinations, the risk of rabies transmission is very low. If status cannot be verified, the animal should be observed for 10 days to watch for a change in condition or should be sacrificed to have the brain examined for evidence of rabies. If the animal cannot be found, or is otherwise considered high-risk, RPEP should be administered. Behavior of the offending animal is not a reliable sign of rabies: 80% of rabies cases are “furious” rabies; 20% are “dumb” rabies.
In the United States, rabies is concentrated in the eastern and southern geographic areas, but is found in all areas. Consult local public health officials to determine risk of exposure.
Management of High-Risk Exposures
Adequate irrigation is essential. Combined with proper RPEP, irrigation is the cornerstone of proper rabies prophylaxis.
Two forms of vaccine are available in the United States for use in humans for postexposure prophylaxis to confer active immunity. Immunizations are given on days 0, 3, 7, and 14 IM at a site distant from the rabies immune globulin (see RIG, next section). If a patient has received the vaccine prior to exposure, the vaccine should be given on day 0 and 3.
Rabies immune globulin (RIG) is given to confer passive immunity to the patient while the patient’s immune system generates antibodies through active immunization with the rabies vaccine. RIG is not indicated for those who have been fully immunized pre-exposure.
RIG is given as an injection of 20 IU/kg. As much of the RIG should be infiltrated around the wound edges as is feasible, which may represent an increased challenge in the pediatric patient depending on the volume of the solution. The remaining dose should be given IM at a site distant from the vaccine site.
Patients and their families should be given clear and concise discharge instructions. There is increasing evidence that patients do not comprehend the instructions they are given and are inappropriately confident in their misunderstandings. Patients should receive written instructions, which are reinforced by oral discussion of the information. Instructions should be given in common vernacular, appropriate for the level of understanding of the patient and family. Salient features include proper home wound care, the date sutures or staples will be removed, as well as what to do if concerning symptoms develop.
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