Efficacy of tetracaine-adrenaline-cocaine topical anesthetic without tetracaine for facial laceration repair in children

To determine whether the tetracaine component traditionally used in tetracaine-adrenaline-cocaine (TAC) is necessary to obtain effective topical anesthesia, a prospective study was performed to compare TAC and adrenaline-cocaine preparations for the repair of facial lacerations in children. Physicians were "blind" to which preparation was being used. Of 55 patients studied, 24 received TAC (103 sutures placed) and 31 received adrenaline-cocaine (151 sutures placed). The anesthetic efficacy of each preparation was approximately 95%; there were no adverse reactions related to administration of either medication or complications of wound healing noted in either group. The tetracaine component of TAC is superfluous for obtaining topical anesthesia of minor dermal lacerations of the face in children. The TAC formulation can be simplified by omitting tetracaine without compromising anesthetic efficacy.     

Half-strength TAC topical anesthetic. For selected dermal lacerations

A prospective evaluation of 75 consecutive children with lacerations of the face, lip, and scalp who received TAC (tetracaine, epinephrine [adrenalin], cocaine) topical anesthetic for the repair of their wound was performed. The TAC preparation contained one-half the conventional concentration of cocaine (5.9%) and tetracaine (0.25%) previously used in other studies that have evaluated its anesthetic efficacy. A maximal dosage of 3 ml of TAC (containing 175 mg cocaine and 7.5 mg tetracaine) was applied to each laceration. The diluted TAC preparation provided complete anesthesia for approximately 95% of the more than 400 sutures placed. No adverse reactions were noted in any patient who received TAC, and in no instance did a complication of wound healing occur. The original formulation of TAC was arbitrarily composed, and the maximum concentration per dosage of the potentially toxic component medications of TAC that can be "safely" applied to dermal lacerations in children remains to be defined. Utilization of this diluted preparation will diminish the risk of potential systemic toxicity from the absorbed component medications of TAC without compromising anesthetic efficacy.     

A comparison of three formulations of TAC (tetracaine, adrenalin, cocaine) for anesthesia of minor lacerations in children

A randomized, prospective, double-blind study comparing three formulations of the topical anesthetic solution TAC for laceration repair was undertaken in 250 children. The children's wounds were anesthetized with either TAC I (original formulation--0.5% tetracaine, 1:2000 Adrenalin, 11.8% cocaine), TAC II (1.0% tetracaine, 1:4000 Adrenalin, 7.0% cocaine), or TAC III (1.0% tetracaine, 1:4000 Adrenalin, 4.0% cocaine) prior to repair. The solutions were compared with respect to efficacy, acceptability, wound complications, and side effects. We found comparable efficacy of the three formulations, with similar efficacy to 1% lidocaine infiltration for facial and scalp wounds. Anesthesia for extremity wounds was adequate in only 39.9% of cases, regardless of TAC strength. Wound complications and side effects were within expected and acceptable limits. Our findings support use of TAC for face and scalp lacerations and a change to a less concentrated TAC preparation, such as our "TAC III," which is presumably safer for widespread use.     

Influence of topical anesthesia on the sedation of pediatric emergency department patients with lacerations

Local anesthetic infiltration of wounds causes pain which distresses children. A painless topical anesthetic solution containing tetracaine, adrenaline, and cocaine (TAC) may reduce this distress. We hypothesized that the use of TAC for anesthesia may reduce the utilization of sedation for laceration repair. We performed a retrospective review of all pediatric emergency department (PED) patients receiving parenteral meperidine, promethazine, and chlorpromazine (DPT) during the period after TAC became routinely available. For comparison, data from a recent retrospective study of DPT (preTAC) use in the same PED were used. There was a reduction in the percent of total PED patients receiving DPT, from 1.7% preTAC to 1.2% during the TAC period (P less than 0.05). During the TAC period, there were no significant changes in patient volume or case-mix indicators. Of the major indications for DPT, there was no significant change in the percent receiving DPT for fractures, abscesses, burns, foreign body removal, or head injuries. However, there was a significant reduction in the percent of patients with lacerations receiving DPT during the experimental period, from 12% to 7.6% (P less than 0.05). There were no significant differences in laceration frequency (119/mo and 116/mo), length (2.7 and 2.7 cm), location (85% and 93% total for face and digits), or complexity (64% and 63%) for preTAC and TAC periods, respectively. We conclude that TAC used for local anesthesia may reduce the need for sedation in PED patients with lacerations that require suturing.     

New non-cocaine-containing topical anesthetics compared with tetracaine-adrenaline-cocaine during repair of lacerations

OBJECTIVE: To compare the effectiveness of three new topical anesthetics that do not contain cocaine (prilocaine-phenylephrine, tetracaine-phenylephrine [tetraphen], and tetracaine-lidocaine-phenylephrine) to that of tetracaine-adrenaline-cocaine (TAC) during laceration repair in children. DESIGN: Prospective, randomized, double-blind clinical trial. SETTING: The emergency department of an urban children's hospital. PARTICIPANTS: Children 1 year of age or older with a laceration /= 5 years of age using a visual analogue scale (VAS). Suture technicians, research assistants, and parents also scored pain using a seven-point Likert scale. In addition, suture technicians completed an anesthetic effectiveness scale. RESULTS: There was consistently no difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. A statistically significant difference was seen among anesthetics when comparing VAS and Likert scale scores of suture technicians and Likert scale scores of research assistants. Based on post hoc analyses, these statistically significant differences were between TAC and prilocaine-phenylephrine (suture technician VAS and Likert scale) and between TAC and tetracaine-lidocaine-phenyl-ephrine (suture technician Likert scale), but not between TAC and tetraphen. When power analyses were performed using alpha = 0.05 and beta = 0.20, it was possible to detect a difference of 1.2 VAS units for each of the observer groups. Based on anesthetic effectiveness scale scores, the three new topical preparations collectively performed significantly better on the face and scalp than on the extremities (relative risk = 1.83; 95% confidence interval 1.20 < relative risk < 2.79). CONCLUSION: This study demonstrated the effectiveness and safety of three new non-cocaine-containing topical anesthetics. Consistently, there was no statistical difference demonstrated between the effectiveness of tetraphen and that of TAC for each outcome measure of each observer group. Tetraphen offers an effective alternative to TAC during laceration repair in children.     

New concepts in wound management

Children with lacerations and other minor wounds are among the most often encountered in the ED. The steps in management of these patients are well-known and often well-researched, but dogma still permeates the process. Local anesthetics are effective, and several choices are available. New topical creams and expanded indications for the currently available anesthetics will enhance patient comfort during laceration cleaning and repair. Irrigation with tap water is a safe, effective and economic method of cleaning wounds, and perhaps even the use of sterile gloves is superfluous in preventing wound contamination. Several alternative wound-closure materials are currently available including tissue adhesive in an array of applicators and formulations, adhesive strips, staples, and nonabsorbable as well as absorbable suture material. Finally, prophylaxis for tetanus is a simple, if possibly underused, technique. Further research into new materials and procedures will only improve our care of patients who have sustained skin trauma.     

Lacerations involving glass. The role of routine roentgenograms.

OBJECTIVE--To determine, when evaluating a laceration caused by glass, whether seeing that the bottom of the wound is free of glass eliminates the possibility that glass is present in the wound. RESEARCH DESIGN--Prospective patient series. SETTING--Two pediatric emergency departments. PARTICIPANTS--226 children with lacerations due to glass occurring in a period of 21 months. SELECTION PROCEDURES--Consecutive sample. INTERVENTIONS--Before obtaining a roentgenogram, the triage nurse or the managing physician visually inspected each wound and recorded whether the bottom of the wound was seen, if glass was seen in the wound, and the length and depth of the wound. Further treatment of the wound was at the discretion of the managing physician. MEASUREMENTS/MAIN RESULTS--Glass was seen in the wounds of 10 children on initial inspection. Of the remaining 216 injuries, glass was contained in 12 (21.4%) of the 56 lacerations when the bottom of the wound was not visualized, and in 11 (6.9%) of the 160 lacerations when the bottom of the wound was visualized. There was a significant association between the depth of the wound and an inability to see the bottom of the wound, and deeper wounds were significantly more likely to contain glass. All but one of the lacerations containing glass had a depth of at least 0.5 cm. CONCLUSIONS--In the population studied, seeing that the bottom of the laceration was free of glass reduced, but did not eliminate, the possibility that glass was present in the wound. In addition, superficial lacerations (less than 0.5 cm) rarely contained undetected glass fragments. We recommended that further investigation concerning the mechanism of injury, the depth of the wound, and the type of glass involved is needed before physicians abandon routine roentgenography for lacerations due to glass.     

Updates in wound management for the pediatrician

Lacerations are common in children, and skills in wound management, especially laceration repair, are important. The minimization of pain and anxiety should be considered an essential part of the procedure. Newer techniques using topical anesthetics and tissue adhesives have significantly simplified the process of laceration repair promoting application in office, clinic, and emergency department settings. In situations inappropriate for topical anesthesia and closure, the use of buffered lidocaine and attention to the technique of infiltration are important. Although infection is the most common complication, the percentage of lacerations, which become infected in children, is low. Antibiotic prophylaxis is seldom needed. Human and animal bites raise special concerns in the assessment for primary repair and prophylactic antibiotic use.     

Umbilical hernia repair in children: is pressure dressing necessary

The use of pressure dressing to cover the sutured surgical wound is usually considered a routine conclusion to the repair of umbilical hernias in children. The wound is usually left dressed for a minimum of 5–7 days. The main purpose of pressure dressing is prevention of a hematoma formation. The aim of this study was to compare the surgical outcome after umbilical hernia repair in children when the wounds were covered using pressure dressing or left exposed without dressing after the completion of wound closure. Ninety-six patients with umbilical hernia repair were prospectively randomized to receive pressure dressing (n = 52) or have their wounds left exposed without any dressing (n = 44) after the completion of wound closure. None of the hernias were huge umbilical hernia and none required an umbilicoplasty. In the group who received pressure dressing, one patient developed wound infection 1.9% while no patients developed wound infection in the group who had their wounds exposed without any dressing. In children, there was no significant difference in terms of wound infection, hematoma or seroma formation and recurrence rate after applying pressure dressing or leaving the surgical wounds exposed without any dressing after completion of wound closure. Pressure dressing after umbilical hernia repair may be unnecessary.     

Surgical versus conservative management of tongue lacerations in the acute care setting: A systematic review of the literature

ObjectiveThe objective of this study was to determine whether suturing or conservative management of tongue lacerations results in differences in wound healing and functional outcome. The secondary aim was to identify whether antibiotics are required in the treatment of tongue lacerations.MethodsStudies published between December 1954 and August 2020 were extracted from MEDLINE via PubMed, Embase via OVID, CINAHL via EBSCO, Web of Science, and the Cochrane Library and evaluated for inclusion based on predetermined inclusion and exclusion criteria by two independent reviewers in accordance with PRISMA guidelines.ResultsThe search yielded a total of 16,111 articles, 124 of which were evaluated by full-text review, resulting in 11 articles included in this systematic review representing 142 unique cases of tongue lacerations. At least 26 lacerations (18.3%) included penetration of the muscle layer of the tongue, and 24 (16.9%) were classified as full-thickness lacerations. Thirty-five of the 142 tongue lacerations (24.6%) were sutured. The remaining lacerations underwent some form of conservative management. The majority of studies reported excellent healing of tongue lacerations regardless of the management method, with minimal scarring and excellent return to normal functional status. No cases of infection were reported.ConclusionsCurrent literature is inconsistent with regards to indications and guidelines for primary repair of tongue lacerations. The majority of tongue lacerations reported in the literature heal with excellent outcomes regardless of management method. Physician judgement along with patient and parental preference based on potential risks of the procedure should be used when deciding whether a tongue laceration requires primary repair. Tongue lacerations in otherwise healthy individuals are at very low risk of infection.     

Comparison of a topical mixture of lidocaine and prilocaine (EMLA) versus 1% lidocaine infiltration on wound healing

We compared a eutectic mixture of lidocaine and prilocaine (EMLA, Astra Pharmaceuticals, Inc) with 1% lidocaine infiltration to determine the effect on wound healing in a prospective single blind study using the rat model. Thirty-six wounds were assessed. No clinical or histologic evidence of infection or necrosis was present in any wound. Five wounds (two in the lidocaine and three in the EMLA group, P = 1.0) demonstrated a widened scar owing to healing by secondary intention following suture disruption. There was no significant difference between groups in the degree of inflammation (P = 0.08). We conclude that EMLA does not affect wound healing adversely and is comparable to 1% lidocaine infiltration in the animal model. Further study to determine its anesthetic effect in laceration repair is presently being undertaken.     

Human bites in children.

Human bites are common during childhood and usually result from fights or aggressive play with another child. Bites may present as indentation marks, scratches, abrasions, contusions, or lacerations. Most human bite wounds are sustained on the upper extremities, followed by the face and neck, the trunk, and the lower extremities. Infection is the most common complication. Cultures of an infected bite wound yield an average of five microorganisms. This article reviews the current recommendations on the management of human bite wounds in children.     

Treatment of burns in children

Decreases in mortality from major thermal injury over the last 20 years have been due to advances in resuscitation, control of infection, support of the hypermetabolic response, and early closure of the burn wound. Of these advances in burn care, early wound closure has progressed the most in the last five years. The restoration of the protective functions of the skin is of primary importance to the recovery of the burn patient. Biologic dressings (pigskin, amnion, human skin allograft) when applied to fully debrided, relatively uncontaminated wounds have been shown to adhere to the wound surface, reduce the wound colony counts, limit fluid and protein loss, reduce pain, and increase the rate of epithelialization over that obtained with application of topical antimicrobial agents.     

Metal lawn and garden edging: the hidden knife?

OBJECTIVE: Lacerations account for many visits to the pediatric emergency department. We observed children presenting to local emergency departments in a large metropolitan area with lacerations incurred from metal lawn and garden edging, a landscaping tool. We sought to describe the severity of lacerations caused by metal edging, the characteristics of wound repair, and the need for subspecialty consultation. DESIGN: A retrospective chart review including all pediatric patients (< 18 years) presenting with lacerations caused by metal lawn and garden edging from January 1995 to October 1997 was performed. Patients were seen at one of three emergency departments in Colorado. RESULTS: One hundred twenty-six patients were enrolled (76% male, 24% female), with a median age of 9 years. The most frequent location of laceration was the foot (40%), followed by the knee (26%). The median length of laceration was 3 cm (range 1-22 cm). Sixteen patients (13%) received either intravenous or oral antibiotics, and six patients (5%) received orthopedic evaluation. CONCLUSIONS: Metal lawn and garden edging in landscaped neighborhoods presents a previously undescribed laceration danger to children. Some lacerations sustained from the metal lawn edging are extensive, receiving either multiple layer closure and/or the need for subspecialty consultation.     

Local application of honey for treatment of neonatal postoperative wound infection

Honey has been described in ancient and modern medicine as being effective in the healing of various infected wounds. In this report we present our experience in nine infants with large, open, infected wounds that failed to heal with conventional treatment. Conventional treatment was defined as having failed if after ≥14 d of intravenous antibiotic and cleaning the wound with chlorhexidine 0.05% W/V in aqueous solution and fusidic acid ointment the wound was still open, oozing pus, and swab cultures were positive. All infants showed marked clinical improvement after 5d of treatment with topical application of 5–10 ml of fresh unprocessed honey twice daily. The wounds were closed, clean and sterile in all infants after 21 d of honey application. There were no adverse reactions to the treatment. We conclude that honey is useful in the treatment of post-surgical wounds that are infected and do not respond to conventional systemic and local antibiotic treatment.     

Repair of compound-depressed skull fractures in children with replacement of bone fragments

A retrospective study of 31 consecutive cases of compound-depressed skull fractures treated by bone fragment replacement between October 1983 and August 1990 was performed. Epidemiology, clinical features, therapy, and outcome were examined and compared with previous series. A protocol is presented for bone fragment treatment intraoperatively and use of intravenous antibiotics (nafcillin and Claforan) perioperatively, despite the degree of wound contamination or dural violation. Of the 31 cases, 15 had dural lacerations with 4 of these requiring patching with pericranium. The degree of wound contamination varied, with only 8 cases considered clean. The average age of patients treated was 8.6 years. At follow-up (average of 26.5 months), all patients had solid bone fusions and well-healed wounds. There were no instances of wound infection or osteomyelitis. No patient required subsequent cranioplasty. It is proposed that bone fragment removal for compound-depressed skull fractures, regardless of the degree of contamination, the presence of dural laceration, or the degree of intracerebral injury, is not necessary and that bone fragment replacement avoids a second operation for cranioplasty.     

浸浴结合人工生物敷料和血小板胶治烧伤患儿后期残余创面的观察

目的 观察浸浴结合人工生物敷料和血小板胶治疗烧伤后期残余创面的效果.方法 将有烧伤后期残余创面的56例患儿分为实验组(28例)和对照组(28例).实验组患儿浸浴后,用血小板胶喷洒于创面,将生物敷料覆盖于创面行半暴露疗法,用血小板胶喷湿敷料2次/d,每2至3 d浸浴1次并更换敷料;对照组创面消毒后仅以单层碘伏纱布覆盖行半暴露疗法.1个疗程(10 d)结束后,比较二组患儿的治愈率、有效率、创面细菌学情况及相关安全性指标.结果 实验组和对照组患儿的治愈率、有效率、细菌清除率分别为64.3%、89.3%、92.3%和32.1%、67.9%、72.0%,二组上述指标比较,差异均有统计学意义(P<0.01).二组患儿未发生不良反应.结论 浸浴结合应用新型人工生物敷料和血小板胶治疗烧伤患儿后期残余创面安全、有效,可控制创面感染、提高治愈率.     

Comparing wound closure using tissue glue versus subcuticular suture for pediatric surgical incisions: a prospective,randomised trial

Tissue adhesives have gained favour for quicker and painless closure of lacerations. To compare the tissue adhesive 2-octylcyanoacrylate with our current standard subcuticular suture for closure of surgical incisions in children, looking at outcome measures of time efficiency, cosmesis, and wound complications, a prospective, randomised, controlled trial was conducted at our institution's ambulatory surgery centre. All healthy patients undergoing unilateral or bilateral herniotomies were recruited prospectively with informed consent and randomly allocated to suture or glue. The exclusion criteria were neonates or children with allergy to tissue glue. Time of wound closure was measured from the subcutaneous layer to application of the dressing. An independent, blinded observer assessed cosmesis at 2 to 3 weeks using a validated wound scale ranging from worst (0) to best (6). Parent satisfaction with wound appearance was recorded on a 100-mm visual analogue scale (VAS). A total of 59 patients were recruited into the study with 26 in the glue group and 33 in the suture group. There was no difference in mean time of closure (glue 181 +/- 62 s vs suture 161 +/- 45 s, P = 0.18). Two patients in each group had a suboptimal Hollander wound score of 5 (7.7% glue, 6.1% suture). There was also no difference in parent satisfaction (VAS: glue 78 +/- 19 mm vs suture 81 +/- 15 mm, P = 0.68). No patient reported any rash, wound infection, or dehiscence. Tissue glue is easy to use with no complications and has equivalent cosmetic results, but is not faster than a subcuticular suture.     

Contact burns of the hand

Contact burns of the hand in children present difficult management questions. Because visual inspection of the acute wound often fails to distinguish major burns requiring inpatient treatment from minor burns amenable to outpatient therapy, we sought to identify characteristics of patients that would aid in decision making at the time the burn patient is seen. During the 5-year period, 1980 to 1984, 32 children less than 14 years of age were admitted to our medical center with contact burns of the hand. Patients were divided into two groups: those with major burns requiring greater than or equal to seven days of hospitalization (n = 16) and those with minor burns requiring less than seven days of hospitalization (n = 16). Compared with patients in the minor burn group, patients in the major burn group were hospitalized longer (16.9 v 2.8 days), were more likely to require surgical excision and grafting (63% v 0%), and had more extensive follow-up (5.3 v 2.5 visits). There were no significant differences between the two groups with regard to percentage of area burned, age, sex, primary admission v referral, and cause of burn. These data support the recommendation that all such burns be managed initially on an inpatient basis.     

Microbiology and management of post-surgical wounds infection in children

The recent increased recovery of anaerobic bacteria from children has led to greater appreciation of their role in paediatric infections at all body sites, including post-surgical wounds (PSW). In studies that employed adequate method for recovery of aerobic and anaerobic bacteria polymicrobial, aerobic and anaerobes were isolated from over half of the patients with PSW. The wounds studied were those that developed following these surgical procedures: head and neck surgery for malignancies, post-thoracotomy, spinal fusion and gastrostomy tube insertion. Staphylococcus aureus and aerobic gram-negative bacilli were found at all sites. However, a correlation was generally found between the site of the wounds and microbial flora recovered from the wound. Organisms that resided in the mucous membranes close to the surgical site predominated in the wound next to these areas. Enteric Gram-negative rods, Group D enterococcus and Bacteroides fragilis group predominated in wounds relating to the gut flora, while Streptococcus spp., pigmented Prevotella and Porphyromonas spp. and Fusobacterium spp. were most frequently recovered in wounds proximal to the oral area. Management of PSW should include administration of antimicrobials effective against the polymicrobial bacterial flora adjacent to the anatomic site of the wound.