CS2 - Wound Closure Flashcards by Bree Henry

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

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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

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What are the potential complications of wound closure?

Infection
Scarring
Keloid formation
Loss of function/structure
Cosmetic
Wound dehiscence
Tetanus

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Describe the epidermis

Stratum germinativum - provides cells for new epidermal formation

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In what later of the skin are the nerves and blood vessels?

subcutaneous fat and fascia

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Describe langer lines

tension/cleavage lines; orientation of collagen fibers
parallel wounds = approximate better
perpendicular wounds = can lead to gaping wounds

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What are the types of wounds?

Clean
clean-contaminated
contaminated
infected

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Describe a clean wound

Aseptic technique is utilized to created wound; excludes GI, respiratory or GU tract

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Describe a clean-contaminated wound

Aseptic technique utilized but involves the GI, GU or respiratory tract

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Describe a contaminated wound

Traumatic wounds

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Describe an infected wound

Infection present prior to incision, i.e. abscess (I&D) and highly contaminated wounds

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What is primary intention

All layers are closed
Clean or clean-contaminated wounds

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What is secondary intention

Closure of deep layers, superficial layers left open

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When is wound care required for secondary intention

irrigation, packing, and/or dressing

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When is secondary intention indicated?

wounds with infection or tissue loss

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What is third intention/delayed primary intention

Deep layers closed, superficial layers are left open and reassessed for closure on day 4-5

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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

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In the case of third intention, if the wound is reassessed and there is an infection, what should be done?

Secondary intention

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When is third intention/delayed primary intention indicated?

Contaminated wounds

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What history should be gathered from a patient with a wound

injury related questions
PMHx, Social/occupational hx, meds, allergies
Tetanus status***

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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***

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What size/timeframe makes a wound tetanus-prone?

> 6 hours and > 1 cm deep

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What shape/tissue type makes a wound tetanus-prone?

Stellate or avulsion wound
Devitalized tissue

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What types of contamination make a wound tetanus-prone?

Soil
Feces
Saliva

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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?

1. Locations with a single blood supply (fingers/toes, tip of nose, ears, penis) 2. Untreated hyperthyroidism or pheochromocytoma 3. 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

1. Start proximally and inject at the area between the dermis and subQ 2. Prior to injection, aspirate to ensure not in a vessel 3. 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?

1. keep clean and dry, do not soak 2. provide info on wound checks and dressing changes 3. review signs/symptoms of infection 4. consider immobilization 5. discuss analgesics 6. educate pt. on healing, scarring, avoid sun, and timing of removal 7. +/- 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