THE REPAIR OF FACIAL LACERATIONS IN CHILDREN

Medical & Injury History

• Are there any indications of more serious head injury?
  Loss of consciousness (LOC)? Ataxia? Dizziness? Nausea/vomiting? Blurred vision? Pupils equal, reactive to light, and accommodation (PERRLA)? Ears clear? Awake and oriented to person, place, and time (A & O x 3)? Does the child recognize and respond to parents?
  
  
• How did the injury happen? Is the injury consistent with history
  
  
• Are there injuries other than the chief complaint?
  
  
• Does the child have any significant systemic illness or syndrome?
  
  
• Does the child have any allergies?
  
  
• Is the child taking any medications?
  
  
• Are all immunizations up to date? How many DPT vaccinations? Las DPT <5 years?
  
  
• What sort of treatment has been rendered for the current injury?
  
  
• Is there a history of similar injuries in the past?

Armamentarium

• Prep solution
  Betadine © or Surgiscrub ©
  Sterile Saline
  A 50:50 mixture of water and 5% hydrogen peroxide
  
  
• Local anesthetic
  I-2% lidocaine, 0.25-0.5% bupivicaine, or 2% mepivicaine. A vasoconstrictor may be used in some cases to help with hemostasis.
  Do not use a local anesthetic with vasoconstrictor on distal appendages such as noses and ears. Due to the lack of collateral circulation to these areas the vasoconstrictive action of the vasoconstrictor can cause necrosis and loss of the tissue distal to the injection site.
  
  
• Suggested suture types and sizes
  3-0 or 4-0 chromic gut or 4-0 Vicryl © for deep sutures
  4-0, 5-0 or 6-0 nylon for superficial skin closure
  
  
• Minor surgical set
  Needle holder, scissors, Addison type tissue forceps, hemostat, cotton, forceps, containers for prep solutions, clean towels, sterile drapes, 4x4 sponges, irrigation syringe.
  
  
• Antibiotic ointment such as Bacitracin © ointment

Suturing

• Consider sedation (if there are no indications of CNS complications)
  It is essential that the child be appropriately monitored in accordance with the current AAPD guidelines if sedation is used.
  
  
• Administer anesthesia
  Regional blocks have the advantage of requiring only a single injection. Local infiltration into the wound margins provide better homeostasis. Local infiltrations can be made significantly less painful by dropping some local anesthetic solution into the wound 60 seconds prior to injecting.
  
  
• Prep the skin area around the wound with the Betadine © or Surgiscrub © solution, cleanse the inner wound area with the H2O/ H2O2 mixture, irrigate the wound with copious amounts of saline, debride the wound, remove necrotic tissue, smooth "ragged" edges and copiously re-irrigate with saline. Do not shave the eyebrows, they may not grow back.
  
  
• Consider using a sterile drape
  
  
• Place deep resorbable sutures if wound depth requires.
  Tie the knots so they lie at the base of the wound, not on the skin side.
  
  
• Place superficial sutures, ensure the wound margins are everted to minimize scarring. Do not pull the sutures taut. Do not leave the knots over the wound, but position them to one side of the wound margin. Blue nylon sutures are easier to distinguish from hair during removal.
  
  
• After closure, recleanse the wound area with the H2O/ H2O2 mixture followed by saline. Remove dried blood and Betadine © from the skin.
  
  
• Apply a thin coat of antibiotic ointment over the wound and instruct the parent to apply the ointment to the wound 3-4 times daily; especially after washing the face.
  
  
• Remove the superficial sutures in 4-5 days to prevent "suture tracks" from developing. As an aid to suture removal have the patient hold a 4x4 gauze soaked in the H2O/ H2O2 mixture on the wound for 5-10 minutes prior to removing the sutures.
  
  
• Consider antibiotics if the wound was especially dirty. If the wound is the result of an animal or human bite, antibiotics are required. Order tetanus toxoid and/or IgG as appropriate.*

Suggested Initial Antibiotic Therapy

"DIRTY" WOUNDS (usually a 7-10 day course of antibiotics is recommended) Penicillin 250-500 mg PO qid, Ampicillin 250-500 mg PO qid, Amoxicillin 250-500 mg PO tid, Augmentin© (250-500 mg amoxicillin plus potassium clavulonic acid) PO tid. Clindamycin 150-300 mg PO qid for patients allergic to Penicillin (base dosage on weight)

BITE WOUNDS
Augmentin© (250-500 mg amoxicillin plus potassium clavulonic acid) PO tid, Clindamycin 150-300 mg PO qid for patients allergic to Penicillin. (base dosage on weight)

Tetanus Guidelines

"CLEAN" WOUNDS

• If less than 5 years since last DPT, no immunization is required.
• If more than 5 years since last DPT of the patient is uncertain of last immunization, tetanus toxoid should be ordered.

"DIRTY" WOUNDS

• If patient has had less than three DPT vaccinations or is uncertain, then both tetanus toxoid and tetanus immunoglobulin should be ordered.
• If the patient has had more than three DPT vaccinations then follow the guidelines for clean wounds.

Prepared by: Michael G. Page, DMD, Major, Pediatric Dentistry Residency Training Program, Fort Lewis, WA 98431