Carina Cure’ Nelson PA-C Surgical Hospitalist

Carina Cure’ Nelson PA-CSurgical Hospitalist

Plastic Surgery Emergencies

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Objectives •Evaluation and treatment of facial lacerations in the pediatric population

•Classification and treatment of burns not greater than 10% BSA

•Repair and appropriate treatment for animal bites

•Evaluation and recommendations for facial fractures

Facial Lacerations

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History•Mechanism of injury

•How long ago did the injury occur?-Less than 24 hours for facial wounds is ideal

•Last tetanus booster-Any grossly contaminated deep wound should receive tetanus prophylaxis if > 5 years since booster

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Assessment •Note size, location, and shape

•Evaluate for foreign bodies

•Palpate for depressions, focal tenderness, edema, and crepitus

•Assess cranial nerve function

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Examination of Cranial Nerves •Assess cranial nerves II-XII for any facial trauma

•Sensory innervation of the face is provided primarily by the trigeminal nerve (CN V)

•Motor innervation to the muscles of facial expression is supplied by the facial nerve (CN VII)

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Sensory Innervation of the Face •Trigeminal Nerve (CN V)

-Ophthalmic branch (V1) – sensory

•Exits via the supraorbital foramen

- Maxillary branch (V2) – sensory

•Exits via the infraorbital foramen

- Mandibular branch (V3) – sensory & motor

•Exits via the mental foramen

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Sensory Innervation of the Face •Assessment of CN V

-Sensory – Light touch is assessed along the 3 main branches bilaterally

•Ask patient if the sensation of touch is felt the same on both sides of the face

-Motor – Ask patient to bite down and open, feeling for deviation at the temporal-mandibular joint

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Motor Innervation of the Face •The facial nerve (CN VII) is responsible for supplying the majority of motor innervation to the face

•Facial nerve deficits will present as hemifacialweakness

•To assess the facial nerve ask patient to:-Close eyes tightly then open

-Puff out cheeks

-Raise eyebrows

-Smile and frown

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Treatment

•Hemostasis

•Pain Control

-Local and topical anesthesia

•Irrigation

-Pressurized saline wound wash for smaller wounds

-1 L normal saline for larger areas

•Repair

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Local and Topical Anesthesia •Pain control is key in the pediatric population

•Application of LET (lidocaine-epinephrine-tetracaine)

- Apply gel directly to wound for 20-30 minutes prior to repair. Analgesia is achieved when skin blanches.

•Injection of lidocaine with epinephrine (if needed)

-Epinephrine aides in hemostasis and prolongs duration of anesthesia

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Application of LET

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Suture Selection•Absorbable sutures are preferred in the pediatric population

Suture Type Absorption Profile Common UsesFast gut 7 days (least tensile

strength)Preferred for facial lacerations

Plain gut 10-14 days Nail bed lacerations, facial lacerations

Chromic gut 21 days Mucosa, extremity lacerations

Monocryl 3 months Deep dermal

Vicryl 2-3 months Deep dermal, muscle

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Repair of Facial Lacerations •Simple interrupted for the majority of lacerations

•If gaping, use Monocryl for deep dermal sutures to reduce wound tension. When in doubt, place a deep dermal suture.

•Apply steri strips with Mastisol liquid adhesive to cover wound and keep dry.

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Post-operative Care of Lacerations•Keep wounds covered and dry for the first 48 hours

•Wounds are most susceptible to infection within the first 48 hours

•If scabs form over the sutures, use clean Q-tip and soap to remove after daily cleansing

•Bacitracin for 3-5 days to help create moist wound environment

•Sunscreen to help improve cosmetic outcome of scar

Animal Bites

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Assessment •Determine if rabies and tetanus prophylaxis is appropriate

•Local anesthesia

•Evaluate for any foreign bodies (retained teeth etc.)

•Assess for crepitus

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Treatment•Copious irrigation with normal saline and debridement with 4x4 gauze

•Loosely close wounds and apply bacitracin. Avoid steristrips.

•Do NOT close puncture wounds as they have a high rate of infection

•Administer antibiotics-First line: Augmentin BID x 10 days - IV Unasyn for severely infected wounds-PCN Allergy: Clindamycin + Bactrim

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Burns •Scope of Care for Burns at TCH:

-<10% BSA without inhalation injury excluding face, feet, genitals, perineum, hands or crossing major joints

•Basic Wound Care:-Liberal application of bacitracin, Xeroform or other non-stick dressing, and cover with gauze dressing

-Keep dressing in place for first 48 hours prior to first dressing change

-Change dressing daily until follow-up

-Follow-up with plastic surgery clinic in 1 week

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Rule of Nines

Patient’s palm is 1% BSA

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Classification of Burns First Degree

- Involves epidermis only

-Sunburn like

-Non-blanching erythema

-Very painful, heals in 1 week

Superficial Partial-Thickness- Involves epidermis and upper dermis

-Blistering common

-Painful

-Minimal scarring, heals in 2 weeks

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Classification of Burns Deep Partial-Thickness

- Extends deeper into the dermis

- Mottled pink and white

- Heals in 2 to 4 weeks

- Scarring more likely

Full-Thickness- Extends completely through the dermis

- Wound appears white and dry

- Wounds are painless

- Referral to burn center likely

Facial Fractures

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Evaluation•Maxillofacial CT scan is preferred

to evaluate for fractures

•Assess cranial nerves

-Facial nerve

-Trigeminal Nerve

•Assess for crepitus and bony

step-offs

•Any extension into the sinuses

requires antibiotics

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Orbital Fractures•Consult ophthalmology if suspected injury to globe

-Patient will need detailed ophthalmologic exam

•Most commonly involve orbital floor or medial wall

•Assess CN III, IV, and VI

•Assess sensory and motor innervation of the face

•Assess for entrapment

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•Assess for orbital entrapment of the periorbital fat

or inferior rectus muscle

•Symptoms of entrapment: Severe pain with movement or

diplopia with limited movement

•If entrapment is present, urgent

surgical intervention is indicated

•Majority of orbital floor fractures can be followed in

plastic surgery clinic with possible delayed surgical

intervention, if needed

Orbital Floor Fracture

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Sinus Precautions •Elevate head of bed

•Avoid forcefully blowing nose

•Avoid traveling on airplanes

•Sneeze with your mouth open

•Avoid using straws

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Nasal Fractures•Control epistaxis

-Hold pressure for 15 minutes

-Administer Afrin if bleeding continue

•Evaluate for septal hematomas-Bleeding between the septum and mucosa

-Clinical diagnosis

-Requires immediate drainage and compression dressing

- If not addressed, can lead to necrosis of the septum

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Mandibular Fractures•Evaluate for malocclusion and loose teeth

-Have patient open and bite down

•Non-operative management

-Soft chew diet for 6 weeks

-Peridex mouthwash for intraoral lacerations

•Maxillomandibular Fixation (MMF) -Reserved for comminuted, open, or displaced fractures

Hand Injuries

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Sensory Examination of the Hand

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Motor Innervation of the Hand•Median Nerve

-AIN (anterior interosseous nerve)-“Okay” sign

•Radial Nerve-PIN (posterior interosseous nerve)-Thumbs up!

•Ulnar Nerve-Able to cross fingers-Resisted abduction-Adducting fingers against a piece of paper

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Tendon Assessment

Any concern for tendinous injury should be referred to hand surgery

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Assessment Continued

•Ask about hand dominance

•Capillary refill -Less than 3 seconds is normal

•Palpate radial artery

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Fingertip Injuries•Crush injury commonly seen in children

•Can occur with nail avulsion and tuft fracture

•Repair-Digital block performed

-Copious irrigation

-Nail is removed

-Nail bed is repaired

-Nail is replaced to ensure growth of new nail

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Post-operative Care of Fingertip Injuries

•Keep wounds covered and dry for the first 48 hours

•Xeroform or petroleum gauze to prevent dressing from sticking to wound

•Splint tuft fractures

•Antibiotics prescribed for open fractures

•Follow-up in hand clinic in 1 week

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Digit Amputation•Timing is critical

•Warm ischemia <12 hours

•Cold ischemia <24 hours (preferred)-Wrap severed digit in saline soaked gauze-Place in plastic bag then on ice-Container should be labeled and not leave patient’s side

•Hand surgeon to attempt replantation of severed digit in pediatric population

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Compartment Syndrome•Any crush injury of the extremity should be evaluated for compartment syndrome

•Symptoms:-Pain out of proportion to injury-Pain with passive extension-Tense compartments -Late signs:

•Decreased sensation•Cool extremity•Absent pulse

•Diagnosis-Stryker needle pressure >30mmg -Positive clinical signs

•Treatment is urgent Fasciotomy

Thank you

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References •Attum B. Physical Exam of the Hand. Orthobullets. https://www.orthobullets.com/hand/6008/physical-exam-of-the-hand.

•Bullocks JM, Hsu PW, Izaddoost SA, Hollier LH. Plastic Surgery Emergencies: Principles and Techniques. NY, NY: Thieme; 2017

•Jancin B. LET Gel Eases the Pain of Pediatric Wound Suturing. Pediatric News. 2012;46(2):22. doi:10.1016/s0031-398x(12)70047-4.

•UpToDate. https://www.uptodate.com/contents/assessment-and-management-of-facial-lacerations.

Carina Cure’ Nelson PA-C Surgical Hospitalist

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