CS2 - Wound Closure Flashcards
Wound closure indications?
Decrease time of wound healing
Reduce risk of infection
Cosmetic, reduce scar tissue
Repair the loss of structure and/or function of tissue
Wound closure precautions/contraindications
- Most need closed w/i 8 hours of injury
- increased vascularity can be closed w/i 24 hours
- Contaminated wounds
- Wounds with foreign body
- Wounds with extensive involvement of tendons, nerves, or arteries
What are the potential complications of wound closure?
Infection
Scarring
Keloid formation
Loss of function/structure
Cosmetic
Wound dehiscence
Tetanus
Describe the epidermis
Stratum germinativum - provides cells for new epidermal formation
In what later of the skin are the nerves and blood vessels?
subcutaneous fat and fascia
Describe langer lines
tension/cleavage lines; orientation of collagen fibers
parallel wounds = approximate better
perpendicular wounds = can lead to gaping wounds
What are the types of wounds?
Clean
clean-contaminated
contaminated
infected
Describe a clean wound
Aseptic technique is utilized to created wound; excludes GI, respiratory or GU tract
Describe a clean-contaminated wound
Aseptic technique utilized but involves the GI, GU or respiratory tract
Describe a contaminated wound
Traumatic wounds
Describe an infected wound
Infection present prior to incision, i.e. abscess (I&D) and highly contaminated wounds
What is primary intention
All layers are closed
Clean or clean-contaminated wounds
What is secondary intention
Closure of deep layers, superficial layers left open
When is wound care required for secondary intention
irrigation, packing, and/or dressing
When is secondary intention indicated?
wounds with infection or tissue loss
What is third intention/delayed primary intention
Deep layers closed, superficial layers are left open and reassessed for closure on day 4-5
In the case of third intention, if the wound is reassessed and granulation has begun with no infection, what should be done?
irrigate and close
In the case of third intention, if the wound is reassessed and there is an infection, what should be done?
Secondary intention
When is third intention/delayed primary intention indicated?
Contaminated wounds
What history should be gathered from a patient with a wound
- injury related questions
- PMHx, Social/occupational hx, meds, allergies
- Tetanus status***
What should be objectively evaluated when a patient presents with a wound
- Type of wound and location
- Extent of injury
- Contamination
- Sensory and motor examination***
What size/timeframe makes a wound tetanus-prone?
> 6 hours and > 1 cm deep
What shape/tissue type makes a wound tetanus-prone?
Stellate or avulsion wound
Devitalized tissue
What types of contamination make a wound tetanus-prone?
Soil
Feces
Saliva
What mechanisms of injury make a wound tetanus-prone
missile
puncture
crush
burn
frostbite
What should be considered about tetanus update if primary immunizations were completed?
Non-tetanus prone - 10 years
Tetanus prone - 5 years
If tetanus and >5 years, give Tdap if less than 65; if >65 case by case decision
If Hx of Tdap, Td recommended
What should be considered about tetanus if immunization status is inadequate or unknown
If tetanus prone, give Tdap and TIG at time of injury:
step 1: Tdap
step 2: Td 4-8 weeks
step 3: Td 6-12 weeks after #2
What is the use of local anesthesia?
Reversible blockage of sensory nerves responsible for perception of pain, temperature, and pressure
What are the two main categories of local anesthesia
Esters and amides
What are the esters
Benzocaine and novocaine
What are the amides
Lidocaine and carbocaine
When is local anesthesia indicated
Minor surgical procedures like laceration repair
What can be added to anesthetic and why?
Epinephrine:
1. decrease blood flow which reduces systemic absorption
2. Shortens the time of onset of anesthetic
3. Lengthens the duration of anesthetic effect
When is local anesthesia contraindicated?
Allergy to the substance
Unstable BP
Amide - severe liver disease
Ester - severe renal disease
When is epi contraindicated?
- Locations with a single blood supply (fingers/toes, tip of nose, ears, penis)
- Untreated hyperthyroidism or pheochromocytoma
- Severe HTN or CAD
What are the relative contraindications for epi?
Pregnancy
Untreated HTN
Concurrent BB
MAOIs
TCAs
What are the potential complications of local anesthesia?
Vasovagal syncope
Bruising
Infection
Temporary nerve paralysis
What are the systemic complications of local anesthesia?
Hypotension
Bradycardia
CNS depression
What are the complications of using epi with local anesthesia?
Cardiac dysrhythmias
Hypertension
Anxiety
Tissue necrosis
What are the needle/syringe sizes for local anesthesia?
18 gauge needle for drawing up solution
27-30 gauge with 0.5 to 1.5 inch needle for injection
5-10 mL syringe
Describe the procedure when directly infiltrating the wound with local anesthesia
- Start proximally and inject at the area between the dermis and subQ
- Prior to injection, aspirate to ensure not in a vessel
- Reposition, then repeat until all edges are anesthetized
How much anesthesia should be given according to laceration size?
A 3-4 cm laceration = 3-5 mL of anesthesia
What should be done to the wound before closure?
Irrigation
Cleansing
Debridement
How should the wound be irrigated?
Use 60mL syringe and irrigation needle to adequately irrigate wound with short bursts of NSS; small = 250-500mL, larger = liters
How should the wound be cleansed
Apply chosen cleansing agent to wound edges and surrounding skin in a circular motion; repeat 3 times
Avoid cleansing within wound
Place sterile fenestrated drape over wound and additional sterile drapes as needed
How should the wound be debrided?
If needed, scalpel or tissue scissors to remove the dead tissue
What are the 2 main types of suture material
Absorbable and non-absorbable
When is it indicated to use absorbable sutures?
mucosal surface
oral cavity
deep closures
What are examples of absorbable sutures?
plain or chromic gut
Vicryl
What are the two types of absorbable sutures?
Monofilament: single stranded
Multifilament: braided strands
What materials can make up monofilament sutures?
Nylon
Polypropylene (Prolene)
What is an example of material for multifilament sutures?
silk
What size monofilament for the scalp?
5-0/4-0
What size monofilament for the Face?
6-0
What size monofilament for the trunk/back/extremities
5-0/4-0
What size monofilament for the foot?
4-0/3-0
What type of suture needle should be used for skin?
Conventional cutting needle
What type of suture needle should be used for skin and tougher tissue like ligaments?
Reverse cutting needle
What type of suture needle should be used for the peritoneum?
Taper needle
What is the correct grasp of needle rule?
2/3: 1/3 ratio
What type of stitch should be done for simple laceration repairs?
simple interrupted stitch
What are some additional stitching techniques?
continuous running stitch
running subcuticular stitch
vertical mattress (deep wounds)
horizontal mattress (redistribute tension)
Retention sutures
When are skin staples indicated?
Linear lesions located at the scalp or the trunk
When are skin staples not indicated?
Face, hands, joints, and potential for imaging
When are skin adhesives indicated?
surgical incisions; fast and non-invasive application
When are skin adhesives not indicated?
Skin creases
hands
infection
mucosal surfaces
areas of dense hair distribution
How long does skin adhesive last?
5-10 days
What are some post-procedure instructions for patients?
- keep clean and dry, do not soak
- provide info on wound checks and dressing changes
- review signs/symptoms of infection
- consider immobilization
- discuss analgesics
- educate pt. on healing, scarring, avoid sun, and timing of removal
- +/- antibiotics
How long should sutures/staples stay in scalp?
6-8 days
How long should sutures stay in face?
4-5 days
How long should sutures stay in chest/abdoment?
8-10 days
How long should sutures stay in back?
12-14 days
How long should sutures stay in arms/legs?
~10 days (add 2-3 if extensor surface)
How long should sutures stay in hands/feet?
10-14 days (add 2-3 if extensor surface)
How should sutures be removed?
Avoid pulling exposed material through the wound
Remove all suture material in its entirety
How should staples be removed?
Align remover in the middle of the staple
Squeeze device on staple, then lift up
What should the aftercare include for suture/staple removal?
+/- antibacterial ointment
Most do not require additional dressing
Mild redness is normal
