Trick of the Trade: Double staple gun

How do you approach the repair of scalp lacerations in a child? What factors are you considering?

Is the wound suspicious for child abuse?
Procedural sedation versus local anesthesia of the wound
Staples versus hair apposition technique (HAT trick) for wound closure

This trick of the trade pearl addresses the stapling technique for scalp laceration repair. Perhaps the child’s hair is too short for the HAT trick.

Many scalp lacerations in pediatrics presenting to the Emergency Department can be repaired with two staples. If you’ve ever stapled an awake child’s scalp laceration, you probably have experienced a significant delay after placing the first staple. No matter how well you attempt to anesthetize the scalp locally, the patient still likely experiences some discomfort. In general scalps are difficulty to completely anesthetize. Both pain and anxiety make it difficult to calm and immobilize the child before placing that second staple.

Trick: Double Staple Gun Technique

For patients with a small scalp laceration only requiring 2 staples, I recruit an assistant with a second staple gun. We both line up the staple guns along the scalp laceration (see photo). After we agree on the positioning, we angle the staple guns directly perpendicular with the scalp.

“3 – 2 – 1 – GO”

Both staple guns are fired simultaneously to yield a completely closed scalp laceration. While it is a less efficient use of equipment, you can tell the patient (and the family) that the procedure is over. No need to chase the patient around the room for the second staple.