Suturing and Wounds – Flashcards

Hemostasis, Inflammation, epithelialization, neovascularization, fibroblast growth, scar remodeling. Can take up to 6 months.

Linear lacerations without evidence of FB or secondary infection

Explore for foreign bodies and tendon involvement Animal bites Bony involvement Gross contamination Age greater than 24 hours Exception: facial wounds

Wounds heal better when kept moist Most wounds should be closed within 8 hours Facial wounds can be sutured up to 24 hours after injury Antibiotics are not necessary for most uncomplicated wounds Animal bites generally should not be sutured Large and deep wounds may need subcutaneous closure to reduce dead space and reduce the risk of infection Scalp wounds must be aggressively managed to prevent hemorrhage and hypovolemic shock

The goals of primary wound closure are to stop bleeding, prevent infection, preserve function, and restore cosmetic appearance

Age General health status Past medical history Medications Allergies to anesthetics, antibiotics, tape or latex Age and location of wound and mechanism of injury Possible foreign body or bony involvement Metal, rocks and glass are radiopaque and may be picked up by x-ray Plastic and wood are frequently missed Previous injury in same area Tetanus status Most cases of tetanus occur in patients > 50 yrs of age

Tetanus prone: If the history of tetanus shots are unknown or if there have been less than 3, give both tdap or td and HyperTET

Clean and minor wound: give td or tdap but not Hypertet.

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Ensure adequate lighting Consider if the wound is tetanus prone Assess neurovascular status Always anesthetize before exploring or irrigating wounds PUT ON PPE including EYE PROTECTION Magnification may be required Assess for possible retained foreign bodies Order imaging studies if indicated (bites, glass, metal) Wounds overlying joints must be flexed and extended for assessment of tendons through full ROM Document "wound explored for foreign body, bony and tendon involvement" Measure length of wound for chart documentation

Time since injury Degree of contamination Degree of tissue devitalization

Clean Minimal contamination Minimal tissue loss No devitalized tissue May use sutures, staples, skin glue or steri-strips Repair within 6-12 hours May repair the face up to 24 hours after injury Carefully examine wound edges for evidence of epithelialization

Healing by secondary intention Ulcerations Abscess cavities Punctures Animal bites Exception: large cosmetically disfiguring wounds Partial thickness abrasions and avulsions

Too contaminated for primary closure Requires thorough cleaning and debridement Place on antibiotics Place a drain for deep wounds If tendon involved splint extremity in position of function Return for delayed closure

Diabetes Infection Drugs Nutritional Problems Tissue Necrosis Hypoxia Excessive Tension Another Wound Low Temperature

Prior history of keloid formation Wounds perpendicular to natural body lines Failure to follow-up for suture removal on time Failure to adhere to wound care instructions after discharge Poor technique: Failed to revise irregular edges Pulled sutures too tightly causing puckering of wound edges

Discuss that all wounds scar Remind patients to follow wound care instructions to improve outcomes Describe in detail how to clean, dress and evaluate healing wounds for signs of infection Use language that the patient can understand and provide written instructions Educate patients that scar remodeling takes at least 6-12 months

Prep skin before anesthetizing by cleansing around the wound to remove debris Hydrogen peroxide is the best agent to remove dried blood and debris Irrigate with tap water or normal saline 500-1000 mL under pressure "The solution to pollution is dilution" Apply Betadine® around wound and allow to dry thoroughly Do not irrigate wound with Betadine® Avoid shaving Sur-Clens® can be used to clean wounds and prep skin if allergy to Betadine®

IRRIGATE under pressure with at least 500 mL of NS or tap water "the solution to pollution is dilution"

Topical LET (lidocaine, epinephrine, and tetracaine) TAC (tetracaine, adrenaline, and cocaine) Emla Viscous xylocaine Injectable Bupivacaine 0.25% or 0.5% (Marcaine, Sensorcaine) Max. adult dose = 175 mg Onset 5-10 min. Duration 1-2.5 hrs If using for a digital block; Onset 7-21 min. Duration 2-6 hrs Lidocaine (Xylocaine) 1% or 2% with/without epinephrine Maximum adult dose = 300 mg Can be buffered by adding 1 mL of sodium bicarb to 9 mL of anesthetic Onset 3-5 min. Duration: 30-60 minutes If using for digital block; Onset 5-10 min. Duration 1-1.5 hrs If allergic to any of these agents mix 50mg/1mL of diphenhydramine solution into 4 mL of NS and use for local infiltration

Added to Marcaine and Lidocaine Potent vasoconstrictor Prolongs duration of anesthesia Never inject in distal areas including fingers, toes, nose, penis or nipples

Always use a 27 or 30 gauge needle for infiltration and inject slowly to reduce pain

Three separate nerves to block in the finger. The addition of sodium bicarbonate to local anesthetics shortens the onset of action by raising tissue pH, reducing the pain of injection.4,5 Lidocaine can be buffered by adding 1 mL of sodium bicarbonate 8.4% (1 mEq/mL) to 9 mL of 1% lidocaine. Bupivacaine can be buffered by adding 1 mL of sodium bicarbonate 8.4% (1 mEq/mL) to 29 mL of bupivacaine 0.25%. However, the mixture of bicarbonate can cause precipitation of the anesthetic agent (most prominently bupivacaine) and accelerate the degradation of epinephrine in the solution, so bicarbonate should not be added to the anesthetic unless it can be used immediately. Aspiration before injection helps to avoid inadvertent deposit of local anesthetic in a vein or artery. The addition of epinephrine to the injected local anesthetic solution increases the duration of anesthesia, helps to control wound bleeding, and slows the systemic absorption.7 The use of local anesthetic with epinephrine appears to be safe for use in end-arterial fields (fingers, toes, etc.) in selected healthy patients,8-10 but probably should be avoided in suspected digital vascular injury; patients with vascular disease, such as Raynaud or Berger disease; or other conditions in which end-arterial vascular supply is problematic. In patients with true allergies to local anesthetics diphenhydramine 50 mg/mL can be used. Consider topical anesthetics whenever appropriate.

Absorbable: Vicryl, chromic Non-absorbable: Nylon, silk or metal Thread is sized by number; larger the number, smaller the material (e.g.,7-0 is smaller than 3-0) Face: use small (6-0 or 7-0) Scalp and chest may require smaller thread size if cosmetic appearance is important; i.e., bald or upper chest on a woman Extremities: (4-0 - 5-0) Back, scalp (2-0 - 4-0)

Ethilon is black and rough in texture knotting more easily Prolene is blue and slick and slides easily. Prolene is expensive.

Choose smaller needles for face Larger needles for deeper, wider wounds to reduce scarring and establish hemostasis

Procedure Notes must include the following: Location of wound including, type (linear, stellate, curved, L-shaped, flap) Wound length and depth Prep procedure Method of anesthetic and amount Method of irrigation and amount Wound exploration and if foreign bodies, bony or tendon involvement Suture material used, suturing method, and number of sutures placed Type of dressing Conclude the note as follows: "Wound was well approximated. Patient tolerated procedure well."

Wash wound twice daily with soap and water Apply antibiotic ointment and dressing Leave wound open and dry the evening before suture removal Avoid exposing wounds to lake water, swimming pools or dishwater until sutures removed Observe for increased redness, pain, purulent draining or streaking Once sutures are removed, apply sunscreen daily and Vit E oil or Mederma® to reduce scarring

Begin in the middle of the cut Continue by dividing wound segments in half until the wound is well-approximated Always use for infection prone wounds

Far-Far-Near-Near sequence Preferred in high tension areas Promotes eversion of edges Prone to being pulled to tightly The vertical mattress suture is placed in a "far-far-near-near" sequence (shown). The "far-far" loop enters and exits the skin surface at a 90-degree angle, 4-8 mm from the wound margin, and passes deep into the dermis. The "near-near" loop enters and exits the skin surface 1-2 mm from the wound margin. Bites must be symmetrical or the wound will invariably misalign. The knot is tightened only enough to achieve approximation and eversion of wound edges. The vertical mattress suture (shown) is the preferred technique for many wounds due to its ability to simultaneously achieve deep and superficial wound closure, eversion of wound edges, and precise vertical alignment of the wound margins. Placing each suture precisely and taking symmetrical bites is crucial with this suture. The vertical mattress suture does have a greater tendency to create crosshatched marks on the skin, limiting its use in cosmetically sensitive areas, such as the face.

Great for repairing torn tissue thin skin Can be used in combination with other techniques Don't use on hands because it will degrade quickly with repeated washing

Wound edges are even without devitalized tissue Able to be re-approximated without gaps Bleeding controlled Adhesive run-off can be controlled

Position patient to encourage run-off away from eyes Use gauze to shield the eye Make a Tegaderm patch around the laceration Apply petroleum jelly around the wound to create a rim or apply along eyelid If tissue adhesive gets onto eyelid or lashes apply petroleum jelly and gently rub to remove If adhesive remains apply antibiotic ophthalmic ointment such as erythromycin or polysporin to further loosen product Reassure patient that product will degrade within 5-10 days Refer to ophthomologist for FU

Great for long wounds and scalp wounds (after CT or MRI) Avoid on face or chest

Avoid wet to dry dressings for debridement Advise against use of hydrogen peroxide Antibiotic ointment promotes a moist environment and epithelialization Question patients about adhesive sensitivities Splint wounds over joints

The vermillion border is the first suture to place in a lip wound For all other wounds always begin in the center of the wound For stellate and wounds with a flap start with a corner stitch Apply a splint if wound is over a joint to reduce tension

Lacerations surrounding the eye Perform through eye exam including visual acuity Assess for FB or injury using flourescein stain and lid eversion Test extraocular movements Assess sensory/motor function of facial nerve (CN VII) Never shave eyebrow Use Dermabond with caution Eyelid lacerations should be referred to ophthalmology

Procedure Notes must include the following: Location of wound including, type (linear, stellate, curved, L-shaped, flap) Wound length and depth Prep procedure Method of anesthetic and amount Method of irrigation and amount Wound exploration and if foreign bodies, bony or tendon involvement Suture material used, suturing method, and number of sutures placed Type of dressing Conclude the note as follows: "Wound was well approximated. Patient tolerated procedure well."

Wash wound twice daily with soap and water Apply antibiotic ointment and dressing Leave wound open and dry the evening before suture removal Avoid exposing wounds to lake water, swimming pools or dishwater until sutures removed Observe for increased redness, pain, purulent draining or streaking Once sutures are removed, apply sunscreen daily and Vit E oil or Mederma® to reduce scarring

Face 3-5 days Scalp 6-8 days Back 12-14 days Hands 8-10 days* Fingertip 10-12 days Chest/abdomen 8-10 days Foot 12-14 days Arm/leg 8-12 * * Areas of stress add 2-3 days for joint extensor surfaces Delaying removal can increase scarring Removing too early can lead to wound dehiscence

Check the chart to avoid removing too soon Eyelid: 3 days Face: 5 days Ear, scalp: 5-7 days Extremities: 7-10+ days Back, chest, abdomen: 7-10+ days Areas of stress 10-14 days