Exam 3 - Suturing Flashcards
Patients presenting to the ED for wounds average age and gender
74% males, 23
Most common location for wounds
51% face & scalp
34% arms
13% legs
what is the most common complication for wounds
infection ~5%, increased chance with bite wounds, LE and FB
Goals of wound care
Hemostasis Anesthesia Wound irrigation Wound exploration Removal infected/bad tissue Tissue preservation Closure tension Deep sutures Tissue Handling Wound infection Dressing F/U
Examples of topical anesthesia
benzocaine
cocaine
tetracaine
Lidocaine
what is the only topical anesthesia that vasoconstricts?
cocaine - nose
what are examples of direct infiltration anesthesia?
Lidocaine (Xylocaine) 1-2% w/ or w/o epi
Mepivacaine
Tetracaine
what type of anesthetic is best used on the face
topical anesthesia
what is used for lacerations of 5cm of less?
topical anesthesia
Where do you not use topical anesthesia ?
mucous membranes or conjunctivae
what is good about acid and bad about base’s in injectable local anesthesia ?
acid prolongs shelf life but has a burning sensation
base reduces acidity and shelf life and epi but it does not sting
what is epinephrine and what does it do?
vasoconstrictor and it decreased blood flowing systemic absorption, it also extends duration of action and shortens onset time so you numb faster
where do you not used epi?
terminal capillary flow like tips of finger and toes, tip of nose and pinna of ear
Where do you inject local anesthesia for immediate onset?
junction of dermis and subcutaneous fat /painless/short duration (30-60 min)
where do you inject local anesthesia for slower onset?
digital nerve blocks cause nerve is bigger but it lasts longer ( 1-2 hrs)
where do you inject for direct infiltration of a wound?
junction of the dermis and subcutaneous fat
where do you inject for local infiltration into INTACT skin?
dermis-subcutaneous junction
what technique for anesthesia is used for large areas and for grossly contaminated wounds?
field block (make a square around the wound)
What technique is used for procedures distal to the mid proximal phalanx?
digital block (epidermis then advance to bone) - 4 total injections - DISTAL TO THE WEB SPACE IN THE MIDDLE OF THE DIGIT
how long can clean wound be open for?
6-8 hrs
wound on the face or scalp can be closed for up to 24 hrs why?
cause the face is very vascular
contraindications to wound closure:
increased risk of infection disruption of nerve, art. tendons FB punctured wound - drives bacteria deep high pressure wound
clean wound
surgery ( aseptic technique)
clean-contaminated wound
like aseptic during surgery but it involves the GI, GU or respiratory tract
contaminated wound
traumatic wound with gross spillage
infected wound
like an abscess
Primary intention for wound closure
all layers closed - minimum scarring
Secondary intention for wound closure
deep layers closed, superficial layers granulate form inside to out - wide scar
Third intention for wound closure
deep layers closed, reassess at day 4-5 for infection. If no infection then superficial layers are closed - usually with contaminated wound (primary delayed intention)
where do you use absorbable sutures?
mucosal areas, intradermal
Dexon and Vicryl
Surgical gut - plain or chromic
where do you used non-abosrobale suture material?
superficial layers
Silk
Nylon
Prolene ( blue)
Stainless steel wiring
Monofilament
weaker but pass easier and less chance of infection
Multifilament
more flexible and stronger but increased risk of infection
Higher number of zeros equals
= smaller diameter
Face suture size
5-0 to 6-0 (56)
Scalp suture size
3-0 to 5-0 (35)
Chest suture size
3-0 to 4-0 (34)
Back suture size
34
abdomen suture size
34
extremity suture size
45
joint suture size
34
oral suture size
35 - absorbable
suture instruments are
needle driver
skin forceps - with or w/o teeth
suture scissors
instrument tie
2 wraps around needle driver for first knot, then single wraps
what is the most frequently used suture type used to stitch and close lacerations?
simple interrupted - enter at 90 degrees to skin - start half way point
How do you correct dog ears and what are they?
they are asymmetrical end of wound after sticking and to fix them you make an incision at 45 degree angle and excise the triangle
What type of suture do you not used on dirty wounds and can cause tenosynovitis and can leaved “railroad tracks”?
continuous, running, baseball suture ( this method is quick)
what suture type is used for deep wounds to eliminate dead space within the wound?
vertical mattress ( far/far-near/near)
what is the second most commonly used stitch?
vertical mattress
what stitch lies perpendicular to the skin plane?
vertical mattress
what suture type lies parallel to the skin plane?
horizontal mattress
What suture type is used for flap-wounds - tip repair
horizontal mattress
what suture type adds strength in fascial closure and is also used in calloused skin like palms and soles?
horizontal mattress
what suture type is used for surgical incisions or very clean wounds?
running subcuticular - for face and better cosmetic results (not used for tension wounds)
running subcuticular stitch require a __________ suture?
absorbable
equally passes through dermal wound edges in horizontal plane?
running subcuticular
initial and final knot is buried
running subcuticular
used for long linear laceration of the scalp , trunk and extremities, NOT FOR FACE HANDS OR OVER A JOINT?
skin staples
used for face trunk and limbs and is quick and painless
skin adhesives
what is painted over wound edges 3x with 30 sec of drying time in between?
skin adhesives
how long does it take for skin adhesives to get to full strength?
2.5 minutes ( starts to slough of in 5-10 days)
what do you add first before stern strips?
benzoin, aids adhesion
cate bites ABS and bacteria?
Augmentin / Pasteurella multocida
When do you want to consider ABS?
12 hrs old wounds Human or animal bite crush wounds contaminated wounds wound in avascular area severe paronychia severe felon IS patients if pt has heart disease
how long before you remove sutures of the scalp?
6-8 days
how long before you remove sutures of the face?
4-5 days
how long before you remove sutures of the ear?
4-5days
how long before you remove sutures of the chest/abdomen?
8-10 days
how long before you remove sutures of the back?
12-14 days
how long before you remove sutures of the arm/leg?
8-10 days
how long before you remove sutures of the hand?
8-10 days
how long before you remove sutures of the fingertip?
8-12 days
how long before you remove sutures of the foot?
12-14 days
During suture removal
use sterile instruments and avoid dragging contaminated suture through the patients body
when do you not want to perform a punch biopsy?
if the lesion can be easily excised
how large much a lesion be to do an elliptical excision to avoid dog ears?
8mm or larger
Punch Biopsy extends to which layer of the skin?
subcutaneous fat
use tip of blade for corner of the ellipse and belly of the blade for the rest?
excisional biopsy (30 degrees)
where do you not want to I & D furuncles ?
on central face
I & D uses a ___________ to anesthetize the area
field block (5-10 min)
Iodoform gauze
prevents incision from healing over and allows drainage of abscess, replace 12-24 hrs and it heals from inside out
patient education on wound healing time :
suture removed, wound still weak
several months to a year for final scar appearance
scar revision may be possible at a later date
all wounds leave a scar
