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You are repairing a large laceration extending from the occipital scalp over the top of the head and onto the forehead of a 5 year old 20 kg child. You have the parent and nurse place the child his head in a sink under tap water to irrigate the wound. You anesthetize the wound with a total of 14 mL of 1% lidocaine. You put on a surgical mask and nonsterile gloves. You use staples on the scalp, transitioning to 5-0 polyglactin irradiated suture for the forehead.
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July 6, 2021 at 7:44 am
The amount of lidocaine is above the amount one should utilize for this patient’s size. An alternative such as a topical application would be safer or at a minimum, addition of epinephrine to decrease systemic absorption would bring the dose closer to acceptable.
Tap water is an excellent way to irrigate wounds and is familiar to most children. Sterile gloves have no impact on wound infection and are therefore an unnecessary increased cost to the procedure. Some individuals prefer the fit of these gloves over non-sterile gloves – which is reasonable. However, sterility is not necessary.
I personally find staples to be painful upon removal and therefore do not utilize them in children anymore. For the scalp I would utilize a chromic gut absorbable suture to avoid the need for removal. Chromic gut last too long and is too tissue reactive for the forehead, but works very well in the scalp.
We do not have the irradiated polyglactin sutures but utilize the fast absorbing gut instead. They have similar absorptive properties.
July 6, 2021 at 11:48 am
Thank you for the comment – great pearls from experience!
July 6, 2021 at 10:26 pm
B) Anesthetizing the wound with 14 mL of 1% lidocaine
Use of tap water for irrigation and nonsterile gloves have been shown to be acceptable with no increase in wound infection. Similarly it is appropriate to use staples on the scalp, transitioning to suture (or tissue adhesive) for forehead skin. Some practitioners use polyglactin irradiated suture, which is absorbable, to avoid the need for suture removal in young children or in those who have difficulty obtaining / attending follow-up appointments. The maximum lidocaine without epinephrine dose is 5 mg/kg. A 20 kg child could receive 100 mg, which is 10 mL. The maximum lidocaine with epinephrine dose is 7 mg/kg, and in that case, 14 mL would be acceptable.