23.3 Acute Wound Assessment, Debridement, Laceration Closure, Abscess Drainage & Orthopedic Immobilization

Acute Wound Assessment, Debridement, Laceration Closure, Abscess Drainage & Orthopedic Immobilization

Quick Answer: Examine distal perfusion, sensation and tendon function before anesthesia when feasible. Irrigate and assess for retained debris, deep injury and infection before choosing closure. Calculate local anesthetic dose from the child's weight and the actual formulation. Drain a confirmed abscess and add systemic antibiotics when the child or infection warrants them. Release every circumferential layer and call orthopedics immediately for suspected compartment syndrome in a cast.

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Acute Wound Assessment, Irrigation and Debridement

Examination Before Anesthesia

Assess the mechanism, depth and contamination. Control bleeding and document pulses, refill, color, temperature and age-appropriate sensation before a block when feasible. Compare with the uninjured side. Test active and resisted motion and examine the wound through the relevant range of motion. To isolate flexor digitorum superficialis, hold adjacent fingers extended and ask the child to flex the target proximal interphalangeal (PIP) joint. To test flexor digitorum profundus, stabilize the middle phalanx and ask the child to flex the distal interphalangeal joint. A partial tendon injury can preserve motion and produce pain or weakness with resistance.

A deep periarticular wound may communicate with the joint. Assess its location, mechanism and depth and obtain urgent orthopedic input for suspected joint penetration. The appropriate evaluation depends on the joint and may include imaging or a specialist-directed saline load test. Consult the appropriate service if you cannot exclude deep injury or if perfusion is compromised.

Use saline to irrigate until visible debris is cleared, adapting volume to wound size and contamination. Potable running water is an option for selected simple lacerations. Remove visible foreign material and consider imaging for a retained foreign body when suggested by the mechanism or exam. Protect healthy structures during exploration. CHOP pediatric laceration pathway · Pediatric irrigation study · Pediatric knee arthrotomy study · Hand surgery tendon examination

Debridement and Negative-Pressure Wound Therapy (NPWT)

Collagenase prescribing information · FDA NPWT guidance

Choose the Closure Plan

Primary closure suits a well-irrigated wound with viable tissue, low infection risk and edges that can be brought together without undue tension. Consider elapsed time alongside location, contamination, mechanism, perfusion and host risk. For selected heavily contaminated wounds, clean and debride, dress and arrange reassessment for delayed primary closure if the wound remains viable and free of infection. Some wounds, including small punctures and actively infected wounds, are managed open to heal by secondary intention when appropriate.

Most animal bite punctures and high-risk hand wounds are managed open. Selected facial bite lacerations may benefit from primary repair after copious irrigation, cautious debridement and preemptive antibiotics. For high-risk dog or cat bites, IDSA recommends 3–5 days of preemptive therapy. Amoxicillin-clavulanate is a usual oral option when appropriate. Cat bites can introduce Pasteurella. Human bites can involve Eikenella and a clenched-fist wound over a joint requires urgent assessment for deep injury. IDSA bite and soft tissue infection guidance · Prospective laceration infection study

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Local Anesthesia, Laceration Repair and Prophylaxis

Topical LET, Lidocaine and Regional Blocks

Topical lidocaine–epinephrine–tetracaine (LET) can reduce injection and repair pain in suitable skin lacerations. Follow the institution's formulation, permitted sites and dwell time. Avoid mucosal use. A regional block can anesthetize a finger or other area while preserving wound-edge shape. Select an appropriate agent and use particular care where circulation is compromised.

For pediatric medical procedures, AAP/AAPD guidance lists lidocaine maximums of 4 mg/kg without epinephrine and 7 mg/kg with epinephrine. These are upper limits. Use the lowest effective dose and follow product- and patient-specific limits. Include other local anesthetic exposure when planning the dose, since systemic toxicity can be additive. The US Xylocaine label's 4.5 mg/kg plain ceiling applies to normal healthy adults. Buffering can reduce injection discomfort and does not increase the allowable lidocaine mass.

Worked calculation: With a 4 mg/kg plain limit, a 20-kg child has an 80-mg ceiling. A 1% stock solution contains 10 mg/mL, so 8 mL of that stock contains 80 mg. If buffered, the final mixture occupies more volume, but the lidocaine mass remains 80 mg.

Suspect local anesthetic systemic toxicity (LAST) if neurologic symptoms, seizures or cardiovascular instability develop after administration. Stop injecting, activate resuscitation, support oxygenation and ventilation, treat seizures with a benzodiazepine, and give 20% IV lipid emulsion for life-threatening toxicity per the resuscitation protocol. AAP/AAPD pediatric sedation guidance, Table 3 · US Xylocaine prescribing information · AAP emergency analgesia report · 2025 AHA special circumstances guidance

Closure Technique and Follow-Up

For a simple interrupted stitch, take symmetric bites across the two edges and tie to approximate and slightly evert them without strangulating tissue. Choose the smallest suture that provides adequate support. Consider absorbable sutures when removal would be difficult, and deep absorbable support when needed to relieve skin tension. Tissue adhesive is suitable for selected clean, dry, low-tension wounds with easily approximated edges. Staples or hair apposition can work for selected scalp wounds. Provide the site-specific follow-up and removal plan. For example, a pediatric pathway uses 5-0 or 6-0 nylon on the forehead with removal in 5–7 days, and 4-0 or 5-0 nylon on the scalp with removal at 7 days. That pathway uses removal windows of 7–10 days for limbs and 10–14 days for the trunk. Teach the family to seek reassessment for increasing pain, redness, drainage, fever or wound separation. Pediatric laceration technique and follow-up

Tetanus and Rabies

• Tetanus: Give an age-appropriate tetanus-containing vaccine for any wound when vaccination is unknown or the primary series is incomplete. After a completed series, give a booster at 10 years or more for clean minor wounds or 5 years or more for dirty or major wounds. For dirty or major wounds, give 250 IU of TIG IM when vaccination is unknown, absent or incomplete, or the patient has HIV or severe immunodeficiency. TIG is unnecessary for clean minor wounds. Clean the wound and remove devitalized tissue. Antibiotics do not provide tetanus prophylaxis.
• Rabies: Wash with soap and water and contact public health for exposure risk assessment, including a bat encounter where contact cannot be ruled out. A healthy dog, cat or ferret may be observed for 10 days in coordination with public health. For an unvaccinated person who needs PEP, give human rabies immune globulin 20 IU/kg once, infiltrating the wound as feasible and giving the remainder IM away from the vaccine site. Give vaccine on days 0, 3, 7 and 14. Immunocompromised patients need a day 28 dose and confirmation of the antibody response. Previously vaccinated patients usually receive vaccine on days 0 and 3 without immune globulin. CDC tetanus wound guidance · CDC rabies PEP guidance

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Skin Abscess Drainage and Antibiotics

Point-of-care ultrasound can help identify a fluid collection with posterior enhancement or mobile debris and distinguish it from edema with a cobblestone pattern. Cellulitis can surround an abscess. Assess depth and nearby structures before drainage. Provide analgesia, incise over the safely accessible collection, evacuate pus and obtain a specimen for culture when indicated. A vessel loop through two small incisions can provide ongoing drainage in selected superficial abscesses. Plan reassessment and loop removal if one is used.

With fever or other systemic findings, impaired host defenses, extensive infection or failed initial therapy, reassess severity and add systemic antibiotics when indicated. Choose MRSA coverage according to syndrome, severity and local susceptibility, with additional coverage as indicated. In a young febrile infant or a child with deep, facial, hand or perineal infection, evaluate for complications and use the relevant pediatric pathway. IDSA purulent skin infection guidance · Dell Children's skin and soft tissue infection pathway · Pediatric abscess ultrasound study · Loop drainage randomized trial

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Immobilization and Compartment Syndrome

Select immobilization by the fracture pattern, stability, swelling and orthopedic plan. A well-padded noncircumferential splint can accommodate early swelling. Examples include a posterior short-leg splint for selected ankle injuries, a sugar-tong splint for selected distal forearm injuries and a thumb spica for suspected scaphoid or selected thumb injuries. Pad bony prominences and document perfusion, sensation and movement before and after immobilization. Pediatric cast care · Pediatric distal forearm splint study

POSNA compartment syndrome guidance · BOA compartment syndrome standard