Child Lacerations--What every mother needs to know
Article by Elan B. Singer, MD
Manhattan Plastic Surgeon
Childhood injuries are a part of everyday life. Thankfully, most are nothing more than bumps and bruises. Given their constant activity and relatively thin skin, young children are prone to lacerations. When this happens, it is important to remember to take a deep breath and remain calm. Lacerations bleed, that’s what they do, but in the overwhelming amount of cases, it is simply a soft tissue injury and nothing more.
So what is the first step? Stop the bleeding. This is easily done with a clean towel. Firm direct pressure directly over the laceration is the best way to control bleeding. Most lacerations will stop actively bleeding in 4-5 minutes. Once this occurs, take a look. If all you see is an abrasion (road rash) but no clear skin defect, then the treatment is simple wound cleansing with soap and water followed by bacitracin ointment and a band-aid. If there is a skin defect and you see underlying fatty tissue or if the skin edges are spread apart, then you need to seek further medical attention. Crushed ice will help keep swelling down while you make your way to the hospital. Expect to wait in the emergency room, but you should indicate to the triage nurse that you would like a plastic surgeon to treat your child. That way she can call him or her early which will decrease your time in the hospital. Additionally, try to remain calm and your child will follow your lead.
Which lacerations require a plastic surgeon? This is a difficult question as emergency room doctors have a wide variety of surgical skills. The ultimate goal of any laceration repair is reapproximation of clean skin edges with minimal tension. While most emergency room doctors I come across have the ability to close simple wounds, they are unlikely to pay close attention to the subtleties that separate an adequate laceration repair from an excellent one. This is less significant if the laceration is on an arm or a leg, but when you have a jagged laceration on a child’s face, most emergency room doctors are unlikely to revise the skin edges and close the wound in two layers which will ultimately lead to the better scar. Plastic surgery does not guarantee a scarless repair—in fact, some form of scar is almost certain. It does, however, assure parents that they are receiving the best possible attempt at minimizing their child’s scar.
Does my child need to be put to sleep? Most lacerations can be closed with local anesthesia alone.
Only those lacerations that are dangerously close to the eye require IV sedation in addition to local anesthesia. While IV sedation is safe if performed by trained personnel, it is still not as safe as not using it. Once the local anesthesia is injected, there is 100% analgesia and your child is not experiencing any pain. Most young kids will cry, not because they are experiencing pain, but rather because they are being restrained. If this occurs, the better approach is to assist the staff in calming the child down rather than insisting on IV sedation.
Should I ask for dissolvable sutures? You should leave this up to the treating physician. Dissolvable sutures are nice because they just fall out after several days once they get a little wet. However, the downside is that they are significantly weaker than permanent suture material. Thus, if there is tension on the skin edges or if the child is likely to pick at the wound, they can fall out prematurely and you’ll end up having to go through the entire procedure all over again! There is a place for them, but this decision is best left up to the surgeon.
What do I do after the sutures come out? In most cases, nothing! Kids heal very well with no further intervention. Most wounds will stay red for several weeks, but after 6 to12 months, most scars have matured and are best left alone. On rare occasions, hypertrophic or even keloid (very rare) scars occur and various types of treatment can then be undertaken including steroid injection, scar creams, and silicone sheeting. Scar revision is usually not used until the scar has fully matured (about 12 months) and the child is past their growth spurt.
If I forget everything and can only remember one thing what should it be? Deep and/or jagged lacerations on the face are best handled by a plastic surgeon. And remember, while this is an extraordinary circumstance for you, emergency room staff and most plastic surgeons deal with pediatric lacerations on a regular basis. A child who remains still is much more likely to obtain a better result than a child who is agitated. Accordingly, your child is best served by a calm parent who is comforting and reassuring.