Tricks of the Trade: Closing a Pediatric Scalp Laceration
By Michelle Lin, M.D.
Children in the emergency department receive special consideration that focuses on minimizing pain and anxiety. In this installment of "Tricks of the Trade," we'll review techniques you might consider in managing a frightened 5-year-old boy with a 3-cm scalp laceration.
- How can you distract the patient in order to examine the laceration?
There are many distractions available to draw the pediatric patient's attention away from your physical exam. This may include blowing up a medical glove to create a mini balloon, drawing a face on a tongue blade, or giving the child your penlight to hold.
On the high-tech end of distractors, there is a free iPhone application called Eye Handbook.
This app has many useful features, but the most useful one is the section on pediatric fixation. There are simple cartoon animations, which frequently mesmerize the patient. These animations include barking seals juggling balls, dancing hippos, roaring crocodiles, and squeaking butterflies.
For a video demonstration, visit http://academiclifeinem.blogspot.com/2010/01/trick-of-trade-pediatric-distractors.html.
Being able to quiet a crying child is an invaluable tool not only for examining lacerations, but also for performing pulmonary and abdominal exams.
- How can you minimize soaking the patient with irrigation fluid?
Irrigation is the key to minimizing wound infections. Irrigating scalp lacerations provides a unique challenge when you want to keep the patient as dry as possible. Being thoroughly soaked with cold fluid can be quite stressful to the already frightened child.
1) Collect irrigation fluid using a disposable basin with a cut-out hole. Image courtesy Dr. Michelle Lin
There are several commercial irrigation collection bins available, but you can also build one from a disposable plastic bin commonly found in emergency departments.
Cut out a rectangular or semicircular hole from one edge of the bin to create a portable head basin, similar to those used in a hair salon (image 1). Be sure to leave a short lip at the bottom of the basin so that fluid can collect in the container. As you are cutting out the hole, you can describe to the patient that you are building a "space helmet" for him/her.
Thanks to Dr. John Fowler from Turkey for sparking this idea.
- In a child with relatively short hair, how would you repair the scalp laceration?
Dr. Fowler is also a co-author of an article on the Modified Hair Apposition Technique (HAT) method (Am. J. Emerg. Med. 2009;27:1050-1).
The traditional HAT trick is an alternative to scalp staples in closing uncomplicated scalp lacerations. This trick uses the manual twisting and gluing of scalp hair bundles to close the wound.
Applying one drop of tissue adhesive glue onto each twist secures the hair bundle in place. For wounds longer than a centimeter, multiple iterations of this HAT technique should be performed along the length of the laceration.
Click image for larger view
2) Cross-sectional diagram of a patient's scalp (gray) illustrates the Modified Hair Apposition Technique method. Figure 3: Cross-sectional diagram of a patient's scalp (gray) and the Modified Hair Apposition Technique method.Image courtesy Dr. Michelle Lin
Instead of manually twisting the hair bundles, the Modified HAT trick recommends using two instruments, such as Kelly clamps, to provide a tighter grasp of both hair bundles, located on either side of the laceration (image 2).
This technique is especially useful for patients with short hair, where the provider's fingers may not provide enough grip stability.
Both the HAT and modified HAT tricks are useful alternatives to the more painful stapling procedure, traditionally used for scalp laceration closure. Because the tissue adhesive glue will spontaneously unravel after 7-10 days, staple or suture removal is unnecessary for these patients.
Dr. Lin is an associate professor of clinical emergency medicine at the University of California, San Francisco, and practices at San Francisco General Hospital. Contact Dr. Lin via e-mail at firstname.lastname@example.org with comments or suggestions for other "tricks of the trade."