Care of Abrasions and Minor Lacerations in Pediatric Age

Introduction

Abrasions and minor lacerations are common injuries in children, often resulting from falls, sports activities, or everyday play. While usually not life-threatening, proper management is essential to promote healing, prevent infection, minimize scarring, and reduce psychological distress. This guide provides a comprehensive overview of assessment, treatment, and follow-up care for these injuries in pediatric patients, with emphasis on age-specific considerations and family-centered approaches.

Initial Assessment

History

A thorough history is crucial for appropriate management and identification of potential abuse:

Mechanism of injury: When, where, and how did the injury occur?
Tetanus immunization status
Allergies, especially to topical antibiotics or adhesives
Underlying medical conditions (e.g., diabetes, immunodeficiency, bleeding disorders)
Current medications, including blood thinners or steroids

Physical Examination

Conduct a systematic examination, keeping in mind that children may have difficulty localizing pain or articulating symptoms:

Vital signs: Assess for signs of significant blood loss or systemic response to injury.
General appearance: Evaluate overall demeanor, interaction with caregivers, and signs of distress.
Wound characteristics:
- Location, size, depth, and configuration
- Presence of foreign bodies or contamination
- Edges (ragged, stellate, linear)
- Signs of infection (erythema, warmth, purulent drainage)
Neurovascular status: Assess sensation, motor function, and perfusion distal to the injury.
Joint or tendon involvement: Evaluate range of motion and integrity of underlying structures.
Associated injuries: Thoroughly examine for additional injuries, especially in cases of trauma.

Red Flags

Be vigilant for signs that may indicate a more serious condition or necessitate specialist referral:

Injuries inconsistent with the reported mechanism or developmental stage
Multiple injuries in various stages of healing (suspect abuse)
Wounds crossing joints or involving tendons, nerves, or blood vessels
Bites (human or animal)
High-risk locations (face, hands, feet, genitalia)
Retained foreign body or gross contamination
Delayed presentation (>8 hours)

Management of Abrasions

Cleansing

Irrigate copiously with normal saline or tap water to remove debris and reduce bacterial load. High-pressure irrigation (5-8 psi) can be achieved using a 20-35 mL syringe with an 18-gauge needle or commercial wound irrigation device.
Gently scrub the wound with gauze or a soft brush to remove embedded particles, minimizing additional trauma.
Consider topical anesthetic (e.g., LET gel: lidocaine 4%, epinephrine 0.1%, tetracaine 0.5%) for pain control during cleansing, especially for large or contaminated abrasions.

Dressing Selection

Choose a dressing based on wound characteristics, location, and patient factors:

Semi-permeable films (e.g., Tegaderm, Opsite) for minimally exudative abrasions. They maintain a moist environment, allow visual inspection, and provide a barrier against contaminants.
Hydrogels for dry abrasions, promoting a moist healing environment.
Foam dressings for moderately exudative wounds, providing absorption and cushioning.
Silver-impregnated dressings for high-risk or infected abrasions, offering antimicrobial properties.

Follow-up Care

Educate caregivers on dressing changes, typically every 2-3 days or when soiled.
Advise gentle cleansing with each dressing change, avoiding aggressive scrubbing of newly formed epithelium.
Recommend keeping the wound moist to promote re-epithelialization and minimize scab formation.
Emphasize sun protection of the healed abrasion for 6-12 months to prevent hyperpigmentation.

Management of Minor Lacerations

Anesthesia

Adequate pain control is essential for wound management and to minimize psychological trauma:

Topical anesthetics (e.g., LET gel) applied for 20-30 minutes can provide sufficient anesthesia for many superficial lacerations.
For deeper wounds or when suturing is anticipated, consider injectable local anesthetics:
- 1% lidocaine with epinephrine 1:100,000 (max dose 4-5 mg/kg)
- Buffering with sodium bicarbonate (9:1 ratio) reduces pain on injection
- Use of small-gauge needles (27-30G) and slow infiltration technique
Distraction techniques, positioning (e.g., swaddling infants), and parental presence can augment pharmacologic approaches.

Wound Preparation

Irrigate thoroughly as described for abrasions. Avoid high-pressure irrigation for stellate or gaping wounds to prevent further tissue damage.
Debride devitalized tissue conservatively; children have robust blood supply and tissues often recover well.
Achieve meticulous hemostasis using direct pressure, absorbable gelatin sponges, or cautious electrocautery.

Closure Methods

Select the appropriate closure technique based on wound characteristics, cosmetic considerations, and patient factors:

1. Tissue Adhesives (e.g., Dermabond, Histoacryl)

Ideal for linear, well-approximated lacerations <4 cm, under low tension
Contraindicated for mucous membranes, wet areas, or areas of high mobility
Apply multiple thin layers while maintaining wound edge approximation
Advantages: Quick application, painless, no need for removal

2. Adhesive Strips (e.g., Steri-Strips)

Suitable for superficial lacerations with well-approximated edges
Apply to dry skin after using benzoin tincture for better adhesion
Place strips perpendicular to the wound, leaving slight gaps for drainage

3. Sutures

Consider for deeper lacerations, those under tension, or in cosmetically sensitive areas
Choice of suture material:
- Absorbable (e.g., fast-absorbing gut, poliglecaprone) for mucosal or intraoral wounds
- Non-absorbable (e.g., nylon, polypropylene) for cutaneous repairs, especially on the face
Use the smallest gauge suture that provides adequate tensile strength
Avoid excessive tension; children are prone to hypertrophic scarring

4. Staples

Quick application for linear lacerations on the scalp or extremities
Less cosmetically acceptable; avoid on the face
May be frightening for children; requires removal

Aftercare Instructions

Keep the wound clean and dry for the first 24-48 hours.
After this period, allow gentle cleansing and briefly moisten the area during bathing.
Apply a thin layer of petrolatum or antibiotic ointment to prevent scab formation and minimize scarring.
Protect the wound from direct sunlight.
Arrange for suture or staple removal:
- Face: 3-5 days
- Scalp: 7-10 days
- Trunk and extremities: 7-14 days

Special Considerations

Facial Lacerations

Prioritize meticulous wound edge approximation for optimal cosmetic outcomes.
Consider early plastic surgery consultation for complex lacerations (e.g., those involving vermilion border, eyelid margin, or cartilage).
Use 6-0 or 7-0 monofilament sutures; remove early to prevent suture marks.

Scalp Lacerations

Shave hair around the wound for better visualization, if necessary.
Evaluate for underlying skull fracture or hematoma.
Close with staples or sutures; avoid tissue adhesives due to difficulty controlling bleeding and hair interference.

Lip Lacerations

Align the vermilion border precisely; even 1 mm of malalignment is noticeable.
For through-and-through lacerations, repair mucosa with absorbable sutures, muscle layer if gaping, and skin with non-absorbable sutures.

Friction Burns (Road Rash)

Often deeper than they appear; treat as partial-thickness burns.
Require meticulous cleansing to remove embedded debris and prevent "traumatic tattooing."
Consider hydrocolloid or foam dressings for comfort and optimal healing environment.

Bite Wounds

High risk of infection; do not primarily close except on the face.
Irrigate extensively and debride nonviable tissue.
Consider antibiotic prophylaxis (amoxicillin-clavulanate) for:
- Moderate to severe injuries
- Deep puncture wounds
- Immunocompromised patients
- Wounds involving the hand, foot, or face
Update tetanus prophylaxis as indicated.
Consult local guidelines for rabies post-exposure prophylaxis in animal bites.

Pain Management

Effective analgesia is crucial throughout the care process:

Offer oral acetaminophen or ibuprofen for mild to moderate pain.
Consider short-acting opioids for severe pain, titrated cautiously.
Utilize non-pharmacological strategies:
- Distraction (age-appropriate toys, music, or electronic devices)
- Guided imagery or breathing exercises for older children
- Comfort positioning (e.g., allowing the child to sit on a parent's lap when feasible)

Psychological Aspects

Minor injuries can be emotionally distressing for children and their families:

Use age-appropriate communication to explain procedures.
Validate the child's feelings and provide reassurance.
Involve parents or caregivers in the treatment process when possible.
Offer praise and small rewards (e.g., stickers) for cooperation.
Be alert for signs of heightened anxiety or needle phobia, and adapt management accordingly (e.g., consider sedation if multiple procedures are required).

Follow-up and Complications

Routine Follow-up

Arrange wound checks as needed, typically within 2-3 days for sutured wounds.
Educate families on signs of infection or dehiscence.
Schedule suture or staple removal based on anatomic location.

Complications

Early recognition and management of complications are essential:

Infection:
- Clinical signs: Increasing pain, erythema, warmth, purulent drainage, fever.
- Management: Culture wound drainage, initiate empiric antibiotics (e.g., cephalexin or clindamycin), consider imaging to rule out abscess, and provide more frequent follow-up.
Dehiscence:
- Small areas may heal by secondary intention with appropriate wound care.
- Larger dehiscence may require referral for possible re-closure.
Hypertrophic or keloid scarring:
- More common in certain anatomic locations (chest, shoulders) and in patients with darker skin types.
- Early intervention with silicone sheets or gels, and/or intralesional corticosteroids can improve outcomes.

Long-term Scar Management

Advise patients and families that scar remodeling continues for up to 12-18 months.
Recommend daily sunscreen application to prevent hyperpigmentation.
Consider scar massage with moisturizer once the wound is well-healed (usually after 2-4 weeks) to improve pliability and cosmetic appearance.
Refer to plastic surgery or dermatology for persistent hypertrophic scars or keloids.

Prevention Strategies

Healthcare providers play a crucial role in injury prevention education:

Age-appropriate safety counseling (e.g., helmet use, childproofing homes).
Anticipatory guidance on developmental changes that may predispose to injuries.
Promotion of adult supervision during high-risk activities.
Advocacy for community-based prevention programs and legislation (e.g., safe playground design).

Documentation and Medical-Legal Considerations

Thorough documentation is essential for continuity of care and potential legal issues:

Detailed description of the wound (size, depth, location, edges, contamination).
Pre- and post-procedure photographs (with appropriate consent).
Materials used for closure and wound care.
Tetanus immunization status and prophylaxis if given.
Instructions provided to the family.
For suspected non-accidental trauma:
- Document findings objectively without speculation on intent.
- Use direct quotes from the child and caregiver.
- Follow institutional and legal requirements for reporting.

Quality Improvement

Regularly assess and improve the quality of care for pediatric wounds:

Monitor outcomes (infection rates, dehiscence, cosmetic results).
Solicit feedback from patients and families on their experience.
Review current literature and update protocols based on best practices.
Provide ongoing education and skills training for healthcare staff.

Emerging Technologies

Stay informed about advances that may enhance wound care:

Tissue adhesives with antimicrobial properties.
Advanced dressings (e.g., those incorporating growth factors or stem cells).
Bedside ultrasound for foreign body detection and wound assessment.
3D-printed wound dressings customized to wound topography.
Virtual reality systems for distraction during painful procedures.