Acute Injuries

Children with injuries frequently present to the urgent care setting. When evaluating these patients, the mechanism of injury, age, and location of the wound or injury; underlying medical issues; and vaccination status (particularly the need for tetanus or rabies vaccination) are important to consider. On exam, hemostasis, neurovascular status, and signs of infection are important to assess. It is important to address the patient’s pain as well as potential need for anxiolysis or sedation for procedures during the initial evaluation. Information on how to manage procedural anxiety in children can be found here.

This guide covers the following topics related to acute injuries:

• Wound Management

  • Management of Bite Wounds

  • Laceration Repair

• Foreign Body Removal

  • Ear

  • Nose

• Paronychia

• Subungual Hematoma

Musculoskeletal injuries (e.g., noninfectious limp, extremity pain, and joint pain) are covered in the section on Musculoskeletal Conditions in this rotation guide.

Wound Management

Initial evaluation: When a patient presents after an injury, a thorough skin exam is indicated to evaluate all wounds. Initial evaluation should include:

• history of tetanus immunization

• cleaning and inspection of the wound

• evaluation for possible foreign body

• examination for neurovascular compromise

• recognition of wounds suspicious for nonaccidental trauma

Initial management of wounds consists of controlling the bleeding and cleaning the wound. In the urgent care setting, pressure irrigation with 100 mL/cm of tap water, sterile water, or saline is effective for removing bacteria and small foreign bodies. Anesthesia prior to wound irrigation can be achieved with topical agents such as lidocaine-epinephrine-tetracaine (LET), local anesthetic, or regional blocks. Avoid the use of anesthesia with epinephrine on end-arteriolar areas (e.g., digits, tip of nose, or penis) to reduce the risk of epinephrine-induced vasoconstriction and tissue necrosis.

• In general, wounds should be closed within 12 hours, but up to 24 hours may be appropriate for some clean wounds (e.g., scalp and facial wounds) that have good vascular supply.

  • Older wounds are at higher risk of infection and should not be sutured.

• Some wounds (e.g., animal bites, infected wounds, and human bites) should be left open to heal by secondary intention.

• A surgical consult or transfer to higher level of care should be considered for complex facial lacerations (particularly those involving the eye or ear), complex vermilion-border lacerations, wounds with crepitus, deep wounds, or those with neurovascular compromise.

• Imaging should be obtained prior to suturing if there is concern for a foreign body or a fracture.

Oral antibiotics: Oral antibiotics for infection prophylaxis are not necessary for most clean simple wounds but should be considered in the following circumstances:

• animal or human bites

• wounds near joints, hands, feet, or genitals

• wounds with delayed primary closure (6-24 hours depending on the injury)

• deep puncture wounds

• immunocompromised hosts

• puncture wounds through a shoe concerning for Pseudomonas infection

Oral antibiotics are recommended based on the type of wound and presumed microflora exposure. Pasteurella is the most common organism in both dog and cat bites; anaerobic organisms can also infect animal bite wounds. For oral animal or human flora, 3-5 days of amoxicillin-clavulanate is recommended for prophylaxis. For an injury sustained in seawater (e.g., stepping on an oyster shell or stingray barb), doxycycline or ciprofloxacin should be considered to cover Vibrio infections.

Management of Bite Wounds

Bite wounds should be cleaned extensively, and the patient should receive a thorough neurovascular exam. Lab testing is generally not indicated. However, a wound culture could be useful if the wound appears infected, and a blood culture may be indicated if the patient is febrile or immunocompromised. Most bite wounds should not be closed because of a high risk for infection and will require antibiotic prophylaxis (3-5 days of amoxicillin-clavulanate) as described above.

Human bites can occur directly or indirectly. Frequently, indirect human-bite wounds can result from a punch to the face when a hand or knuckle strikes a tooth. In contrast with animal bites, oral flora from a human bite are often mixed, including Streptococcus, Staphylococcus, and anaerobes (especially Eikenella species). Human bite wounds should be treated with oral antibiotics, especially if the wound is near a joint (e.g., the knuckle) where there is higher risk of infection and subsequent tendon damage.

Animal bites: Dog bites are the most common bites affecting children and comprise 90% of animal bites treated in the emergency department or urgent care. Cat bites are at high risk for becoming infected due to deep puncture wounds. In contrast with human bites, dog bites are likely to carry Staphylococcus, Pasteurella, or gram-negative rods.

Rabies vaccination: Need for rabies vaccination should be considered for any animal bite. Depending on the animal and whether the animal can be observed, the recommendations differ. The following table describes rabies postexposure prophylaxis recommendations from the American Academy of Pediatrics (AAP) Committee on Infectious Diseases.

Tetanus prophylaxis: Tetanus immunization should always be considered after a wound is sustained. The decision to administer tetanus immunization is based on the patient’s vaccination status and whether the wound is clean or dirty.

Examples of dirty wounds include those that are contaminated with saliva, soil, or feces; puncture wounds; avulsions; and wounds related to burns or frostbite.

Laceration Repair

A wound requiring closure is defined as a laceration. Many techniques are available for laceration closure, depending on location, length, depth, and tension. The initial steps of anesthetizing and cleaning a wound should be performed, regardless of method of closure.

Methods for closure of a laceration include:

• Tissue adhesives (e.g., Dermabond and SurgiSeal) are effective and significantly less painful than sutures for small lacerations under minor tension. Tissue adhesives are made of a cyanoacrylate polymer; they are liquid substances that solidify when activated, allowing for closure of the wound. Because the liquid substance solidifies very quickly, often within 2 minutes of application, it is important to have everything prepared prior to opening the package. Avoid using tissue adhesives for lacerations in areas under high tension, over a joint with repetitive movement, on a mucosal surface, or over bite wounds (or other wounds at high risk for infection). This method is not helpful in achieving hemostasis.

  • Topical ointments, such as antibiotic ointments, will dissolve tissue adhesives, so parents should be instructed not to use these products until the tissue adhesive has worn off.

• Wound closure tapes are similar to tissue adhesives and are useful for small, lower-tension wounds as a less painful alternative.

• Staples are advantageous because they can be placed easily and rapidly compared to sutures. They are effective for linear lacerations with straight, sharp edges and on body parts where cosmesis is less of a concern, such as on the scalp.

• Hair apposition is a less painful alternative for scalp lacerations that require clamps and a tissue adhesive. View the hair apposition technique here.

• Suturing: View a video of basic laceration repair.

Foreign Body Removal

Whether it is a child with an eraser in his ear or a toddler with a bean stuck in her nose, foreign body removal is a common procedure in the urgent care setting. In this section, we review techniques for removing orificial foreign bodies. Management of inhaled foreign bodies is covered in the Pediatric Emergency Medicine rotation guide.

Foreign Bodies in the Ear Canal

Commonly found foreign objects in the ear canal include beads, pebbles, beans, paper, toys, popcorn, and insects. Patients may complain of pain, or they may be asymptomatic and the foreign body is an incidental finding. Purulent or bloody drainage is rare. Objects requiring urgent removal include button batteries, magnets, insects, and sharp foreign bodies that may penetrate the tympanic membrane. Of note, insects should be killed with lidocaine or mineral oil prior to attempted removal. If removal in the urgent care setting is unsuccessful, other foreign bodies can be removed electively by otolaryngology as long as the patient is asymptomatic. See a video demonstration of removal of foreign bodies from the ear and nose.

Techniques for removal:

• Irrigation of the ear canal using lukewarm water and a syringe is useful for removal of small objects or insects. However, it is contraindicated in patients with perforated tympanic membranes or tympanostomy tubes or for removal of button battery or vegetative objects (e.g., seeds or beans) that can swell.

• Cyanoacrylate adhesives (tissue adhesives) can be utilized as “glue” to remove foreign bodies. The tissue adhesive can be placed on the end of a cotton swab and inserted into the ear canal to glue the object onto the cotton swab. This technique is most helpful for removal of smooth, round objects (e.g., plastic beads).

• Forceps can be utilized to remove flat or soft objects with irregular edges.

• Suction

• Curette or hook

Foreign Bodies in the Nose

Similar to foreign bodies in the ear, intranasal foreign bodies are generally placed accidentally and patients are often asymptomatic. A nasal foreign body that has been in the nose for a long duration can cause unilateral, foul-smelling, purulent nasal discharge. Whereas a foreign body in the ear is rarely an emergent issue, a foreign body in the nose is urgent because of the risk of aspiration.

Intranasal foreign bodies may be difficult to visualize if they are in the posterior nasal cavity. Generally, radiographs are not useful for foreign bodies in the naris unless there is concern for a button battery or magnetic object. If direct visualization is not possible or the foreign body cannot be removed in the urgent care setting, a consult to otolaryngology is indicated to visualize the object with fiberoptic endoscopy.

Techniques for removal: Because the nose is connected to the airway, air can be utilized to help remove the foreign body. Suction and use of decongestants (e.g., oxymetazoline nasal spray) to reduce inflammation can aid in visualization and removal. See a video demonstration of removal of foreign bodies from the ear and nose.

• Positive pressure is the simplest method for removal of a foreign body from the nose and consists of sneezing or blowing the nose while occluding the opposing nostril. If the child is not old enough to cooperate, the parent can perform short puffs of mouth-to-mouth blowing while occluding the unaffected naris. Wall oxygen can also be utilized in the unaffected naris.

• Forceps can be utilized to remove flat or soft objects with irregular edges from the nose (similar to its use for removal of foreign bodies in the ear).

• Tissue adhesives can be placed on the end of a cotton swab and inserted into the naris to glue a foreign object onto the cotton swab (similar to their use in removal of foreign bodies in the ear).

• Suction

• Curette

• A Katz extractor acts like a small Foley catheter, allowing the provider to inflate a small balloon behind the object and push it out of the orifice.

Paronychia

Paronychia is a polymicrobial infection of the nail fold generally after a minor trauma. Patients present with redness and swelling of the nail fold. Diagnosis of paronychia is clinical. If concern for fracture or further infection exists, radiographs of the finger or laboratory tests may be helpful to determine an alternate diagnosis.

(Source: Wikipedia Commons 2007, Accessed March 29,2024.)

Treatment: It is important to determine whether the patient has an isolated paronychia or also a felon. A felon is an infection of the finger pad. A felon presents with redness, swelling, and tenderness of the finger pad. This is an important clinical determination, because a felon will require immediate surgical treatment to prevent osteomyelitis.

• Acute paronychia requires incision and drainage.

• A simple eponychium (isolated to the cuticle) can be treated with warm soaks and hygiene. Topical antibiotics, oral antibiotics, or both can be considered, depending on the clinical scenario.

Subungual Hematoma

Subungual hematomas are collections of blood under the nail space that can occur after a crush injury or dropping a heavy object onto the finger or toe. Bleeding in the nail bed leads to a throbbing pain sensation.

(Image courtesy of Hannah Lee, MD.)

Treatment: Most subungual hematomas can be treated with nail trephination (making a burr hole), which provides immediate relief from the pressure of the hematoma. See a video of trephination of a fingernail subungual hematoma.

• Trephination can be performed if the nail bed and nail folds are intact. It is most effective on hematomas <48 hours old that are not spontaneously draining. The nail should be cleaned prior to the procedure. Trephination is ideally performed utilizing electrocautery, which uses heat to puncture the nail. Analgesia is generally not necessary, but oral analgesia may be helpful.

If an underlying fracture is found in the presence of a nail bed injury, prophylactic antibiotics should be given to cover skin flora to prevent the development of osteomyelitis.