What is the appropriate emergency management of a child with multiple wounds, including assessment, wound cleaning, analgesia, tetanus prophylaxis, antibiotic therapy, and follow‑up?

Emergency Management of Multiple Wounds in Children

For a child with multiple wounds, immediately irrigate all wounds with copious running tap water or sterile saline until debris is removed, provide early analgesia with topical agents when possible, administer tetanus prophylaxis if the last dose was >5 years ago for contaminated wounds, prescribe amoxicillin-clavulanate for high-risk wounds (hand injuries, puncture wounds, animal bites, or wounds >8 hours old), and arrange 24-hour follow-up. 1, 2, 1

Initial Assessment & Stabilization

Patient-Centered Approach

• Gain the child's trust before examination by using age-appropriate communication and involving parents 3, 4
• Provide early pain relief to facilitate examination—topical anesthetics (lidocaine-prilocaine cream or gel) work well for superficial wounds 3, 4
• Use flexible, creative examination techniques adapted to the child's developmental stage 3, 4

Wound Evaluation Priorities

• Assess each wound for depth, contamination level, foreign bodies, and proximity to underlying structures (nerves, tendons, vessels, joints, bone) 4, 5
• Document wound dimensions, surrounding cellulitis, drainage characteristics, and photograph when feasible 6
• Probe deeper wounds to determine fascial, tendon, muscle, joint, or bone penetration 6
• Look for serious infection signs: cellulitis extending >2 cm from wound edges, crepitus, bullae, tissue discoloration, necrosis, fever, hypotension, or altered mental status 6

Critical pitfall: Superficial appearance can mask deep-structure injury, especially in puncture wounds and hand injuries. Pain disproportionate to visible injury suggests periosteal or joint involvement. 2, 7

Wound Cleaning & Irrigation

Irrigation Technique

• Use copious running tap water or sterile saline—both are equally effective and superior to antiseptic solutions like povidone-iodine 1, 2, 3, 4
• Continue irrigation until all visible debris is removed 1, 2
• Avoid high-pressure irrigation, which can drive bacteria deeper into tissue 6, 7
• Remove all foreign material, callus, and superficial necrotic tissue 6, 4

Debridement

• Perform sharp debridement of devitalized tissue using scalpel or scissors, but avoid aggressive debridement that enlarges the wound unnecessarily 2, 6, 7
• Deeper wounds with suspected nerve, tendon, or vascular damage require formal exploration under general anesthesia 3, 4

Critical pitfall: Do not use antiseptic solutions (povidone-iodine, chlorhexidine) for irrigation—they provide no benefit over water/saline and may impair healing. 1, 2

Analgesia

Topical Anesthesia

• Apply topical lidocaine-prilocaine preparations for superficial wounds in children with intact sensation 6, 3
• Topical agents reduce procedural anxiety and facilitate cooperation 3, 4

Local Infiltration

• Use local anesthetic infiltration for deeper wounds requiring suturing 6, 3
• Omit local anesthesia in patients with complete sensory loss 6

Tetanus Prophylaxis

Vaccination Decision Algorithm

• Clean, minor wounds: Give tetanus booster if >10 years since last dose 1
• All other wounds (contaminated, puncture, crush, >8 hours old): Give tetanus booster if >5 years since last dose 1, 2, 8
• Unknown or incomplete vaccination history: Administer age-appropriate tetanus vaccine immediately 1
  • Children <7 years: DTaP 1
  • Children 7-10 years: Td 1
  • Children ≥11 years: Tdap 1

Tetanus Immune Globulin (TIG)

• Administer TIG 250 units IM for tetanus-prone wounds when primary vaccination series is uncertain or incomplete 1
• Use separate injection sites when giving TIG and tetanus toxoid concurrently 1
• In mass-casualty settings with limited TIG supply, prioritize patients >60 years and immigrants from regions outside North America/Europe 1

Critical pitfall: A 79-year-old with proper vaccination who sustained a high-risk agricultural wound developed generalized tetanus because prophylaxis was not given when her last booster was >5 years prior. Always administer tetanus toxoid for contaminated wounds if >5 years since last dose, regardless of complete primary series. 8

Antibiotic Therapy

Indications for Prophylactic Antibiotics

Prescribe antibiotics for: 2, 4

• Hand wounds (highest infection risk location)
• Puncture wounds
• Cat or dog bites
• Human bites (10-20% infection rate)
• Wounds presenting >8 hours after injury
• Wounds with extensive contamination or tissue damage
• Crush injuries with devitalized tissue
• Wounds near bone or joint
• Immunocompromised patients or those with implanted devices

Antibiotic Selection

First-line: Amoxicillin-clavulanate for animal bites, human bites, and contaminated wounds 2, 7

Penicillin-allergic alternatives: 2, 7

• Doxycycline (if age-appropriate)
• Fluoroquinolone + metronidazole or clindamycin

Avoid: First-generation cephalosporins (cephalexin), macrolides, clindamycin monotherapy, and penicillinase-resistant penicillins alone—all have poor activity against Pasteurella multocida (animal bites) or Eikenella corrodens (human bites) 2, 7

Duration

• Prophylactic courses: 3-5 days 2, 7
• Do not prescribe antibiotics for bite wounds presenting ≥24 hours after injury without infection signs 2, 7

Critical pitfall: Cat bites have 50% infection rate vs. 15-20% for dog bites and harbor P. multocida in 75% of cases. Always prescribe prophylactic antibiotics for cat bites. 2

Wound Closure Decisions

Timing-Based Algorithm

• <8 hours, clean wounds: May close primarily or approximate with Steri-Strips 2, 6
• >8 hours or contaminated: Do NOT close primarily; use delayed primary closure (2-5 days) or secondary intention healing 2, 6
• Infected wounds: Never close, regardless of timing 2, 6

Location-Specific Exceptions

• Facial wounds: May close primarily even after 8 hours with meticulous irrigation and prophylactic antibiotics 2, 6, 7
• Hand wounds: Avoid primary closure due to high infection risk; use Steri-Strips and delayed closure 2, 7
• Human bite wounds: Do not suture (except face); approximate with Steri-Strips to allow drainage 7

Closure Technique

• For wounds requiring closure, approximate deep layers first when extending to fascia 6
• Align skin edges without excessive tension 6
• Consider tissue adhesives for superficial lacerations in children—excellent cosmetic results with less anxiety 3, 4

Dressing & Wound Care

• Cover clean wounds with occlusive dressings (film, petrolatum, hydrogel) to promote healing—superior to dry dressings 1, 2
• Apply thin layer of antibiotic ointment to superficial wounds (if no allergy) 6
• Elevate injured extremity to reduce swelling and accelerate healing 2, 7

Critical pitfall: Antibiotic or antibacterial dressings do not improve healing or reduce infection rates in clean wounds. 1

Follow-Up & Monitoring

Immediate Follow-Up

• Arrange contact (phone or office visit) within 24 hours for all significant wounds 2, 7
• Instruct parents to return immediately for: 1, 2
  • Increasing redness or swelling
  • Foul-smelling drainage
  • Increased pain (especially near joints or bone)
  • Fever
  • Red streaking from wound

Wound Check

• All patients should return within 48 hours for wound examination to detect early infection 5

Special Wound Types

Animal Bites

• Early antibiotics prevent infection in high-risk bites (hand, cat bites) 1
• Assess rabies risk based on species, geography, attack circumstances, and animal vaccination status 2
• For suspected rabies exposure: administer rabies immune globulin day 0 + rabies vaccine days 0,3,7,14,28 2

Human Bites

• Clenched-fist injuries require immediate hand surgery consultation due to high risk of septic arthritis and osteomyelitis 2, 7
• Assess for hepatitis B, hepatitis C, and HIV transmission risk 7
• Amoxicillin-clavulanate covers polymicrobial flora (Streptococcus, Staphylococcus, Eikenella corrodens, anaerobes) 7

Contaminated/Dirty Wounds

• Barb-wire, soil-contaminated, or crush injuries require immediate antibiotics 6
• Moderate contamination: cefazolin 6
• Severe soil contamination: cefazolin + penicillin (for Clostridium coverage) 6
• Continue antibiotics 48-72 hours; extend only if infection develops 6

Critical pitfall: Do not close contaminated wounds with purulent material, significant tissue devitalization, or wounds >8 hours old. These require delayed primary closure or healing by secondary intention. 6