Ed the Ped
I was always taught to have a very healthy respect for infections of the Hands, Feet, or Face. Certainly, the infection May 31, In Charlotte, it has been unseasonably HOT and many of us have been considering escaping to the mountains. Maybe not exactly May 24, A common theme amongst the Ped EM Morsels is remaining vigilant while maintaining a reasonable approach to the care of children May 17, Keeping children comfortable benefits everyone! Patients have less pain and psychological trauma.
Their families think you are amazing and… your procedure May 10, Call me crazy, but discussing Measles last week got me feeling nostalgic. Mumps, Tetanus, and Chicken Pox similarly harken back to March 29, Part of the challenge with evaluating children is the ever present concern for an unusual emergent condition masquerading as a common March 22, Pain and fever complaints March 1, Caring for the child in shock is challenging!
Vascular access has to be attained. Fluids have to be given quickly and February 22, We have discussed, previously, how the unique anatomic and physiologic differences kids have may make conditions more subtle and challenging to In penicillin-allergic patients, extended spectrum cephalosporins or trimethoprim-sulfamethoxazole plus clindamycin is recommended. One meta-analysis of prophylactic antibiotics for dog-bite wounds found that a relative risk of infection was 0. Capnocytophaga canimorsus is a serious but uncommon complication of bite wounds.
Approximately cases have been reported since , most often associated with dog bites in immunocompromised patients. Cat bites. Cat bites are almost always puncture wounds, and when located on the hand they frequently enter into the joint space. Therefore, when treating cat bites to the hand, the potential for the delayed complication of joint infection should always be considered.
Pasteurella multocida, S. Cats frequently clean their claws, so even scratches to the hand carry the risk of infection. Puncture wounds should not be irrigated directly into the puncture site unless it is a through-and-through injury, and wounds should not be closed primarily. Due to the high rate of infection, most cat bites in general and all cat bites to the hand require prophylactic antibiotics. Penicillin-allergic patients can be given extended spectrum macrolides such as azithromycin, fluoroquinolones, or TMP-SMX.
Cat-scratch disease is a potential but uncommon complication of cat bites. It is caused by the organism Bartonella henselae.
The primary lesion is a crusted papule that develops at the injury site days after the bite or scratch. Rare occurrences of encephalopathy and atypical pneumonia have been seen in association with this condition. The course is usually self-limited and resolves in months without treatment. Severe cases can be treated with tetracyclines. Human bites.
Another common pediatric injury is human bites. In young children, bites to the hand from other children that do not penetrate the skin need nothing more than local wound care. As with all human-inflicted wounds, child abuse should always be a consideration. Wound care and evaluation is similar to that of all other bites, including imaging as necessary. The "fight bite" is the most recognized human bite wound to the hand and carries with it a multitude of complications. Fight bites are more common in older children and occur when a clenched fist strikes a tooth, resulting in a deep laceration at the MCP joint.
Upon relaxation of the fist, oral flora is inoculated in the relatively avascular fascial layer. The presence of an extensor tendon injury is highly predictive of joint penetration, requiring evaluation by a hand surgeon. These patients need to be placed on IV antibiotics and be considered for surgical debridement. Human bites are usually polymicrobial, with Streptococcus and Staphylococcus being the most common. Infected wounds may also require anaerobic coverage, and consideration on a case-by-case basis for infectious disease transmission of pathogens such as Hepatitis B, Hepatitis C, HIV, herpes, and syphilis.
Monkey bites. While rare, monkey bites deserve mention as they are reported to carry some of the highest risk for bacterial infection.
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All bites to the hand should receive prophylactic antibiotics selection similar to that for human bites. B virus Cercopithecine herpesvirus can be transmitted by wounds from infected macaque monkeys, in particular rhesus and cynomolgus. Wounds from potentially infected animals need to be cleaned immediately with chlorhexidine or povidone-iodine solutions for 15 minutes. If the exposure is high-risk actively infected animal or one with visible lesions , then prophylactic anti-virals should be considered.
A detailed discussion of rabies treatment is beyond the scope of this article, although some basics can be outlined here. Post-exposure prophylaxis is indicated if the animal is known or suspected to be rabid. High-risk animals include bats and wild carnivores bobcat, coyote, fox, raccoon, skunk, and wolf. Bites from healthy animals that can be observed for 10 days, or animals who can be examined for rabies, do not require prophylaxis. Rabbit or rodent bites usually do not require treatment, but consult local public health officials about the prevalence of rabies in these animals.
As much immune globulin as possible should be given directly at the bite site, with the remainder given in the deltoid. Human diploid cell rabies vaccine 1 mL is indicated on days 0, 3, 7, 14, and In the pediatric population, the amount that can be infiltrated near a hand injury will be minimal.
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As with all wounds, thorough cleaning of the injured area is the most important step to prevent infection with rabies. Tetanus prophylaxis should be considered in all patients with a vaccination status more than five years out of date. DPT is recommended for children younger than 7 years old. Tdap is recommended for adolescents age years in place of Td. Dog, cat, and human bites are the three most common animal bites seen; they are also the most common hand injuries that present with delayed infection.
Pediatric hand injuries are commonplace in the ED. While some may need operative intervention, after a careful assessment and an awareness of potential pitfalls, the skilled emergency physician should be able to successfully diagnose and optimally treat these frequent pediatric injuries. Doraiswamy NV. Childhood finger injuries in children, incidence and etiology.
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Injury ; Rosenthal EA. Treatment of fingertip and nail bed injuries. Orthop Clin North Am ; Hand, finger nail and tip injuries. June 28, Factors affecting composite graft survival in digital tip amputations. Ann Plast Surg ; Selbst S, Attia M. Minor Trauma-Lacerations. Textbook of Pediatric Emergency Medicine , 5th ed. Jackson EA. The V-Y plasty in the treatment of fingertip amputations.
Am Fam Phys ; Treatment of fingertip amputation using the Hirase technique.
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Hand Surg ; Braga-Silva J, Jeager M. Repositioning and flap placement in fingertip injuries. Ann Plast Surg ; Lyn E, Antosia R. Rosen's Emergency Medicine, 6th ed. Philadelphia: Mosby; Fingertip trauma in children from doors. Scott Med J ; Simon RR, Wolgin M. Subungual hematoma: Association with occult laceration requiring repair.
Am J Emerg Med ;5: Roser SE, Gellman H. Comparison of nail bed repair versus nail trephination for subungual hematomas in children. J Hand Surg ;24A The deformed fingernail: A frequent result of failure to repair nail bed injuries.
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J Trauma ; Fastle RK, Bothner J. Subungual hematoma. Up to Date. Zacher JB. Management of injuries of the distal phalanx. Surg Clin North Am ; Treatment of subungual hematomas with nail trephination: A prospective study. Am J Emerg Med ; Antibiotics in open fractures of the distal phalanx? J Hand Surgery British edition ; Role of antibiotics in open fractures of the finger. J Hand Surgery ; Hand injuries in children presenting to a pediatric emergency department.
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Ann Emerg Med ; Hand and fingertip injuries in children. Pediatr Emerg Care ; Evaluation and management of traumatic lacerations. N Engl J Med ; In: Wolson AB, et al. Greenes D, Madsen J. Textbook of Pediatric Emergency Medicine, 5th ed. Rosh A, Kwon N. Extensor tendon repair.
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