Midterm Review Flashcards
Primary intention healing
Healing of wound edges in direct contact
Secondary intention healing
Non-closure of a wound
Very dirty or infected wounds
Animal bites to hands, feet
Tertiary intent healing
AKA delayed closure
Refers to closure of a wound after observation (~ 3-5 days)
What is the best thing to do to prepare the wound?
Thorough irrigation before closure
Pulsing works best
Preparing the wound- irrigation
Remove all visible debris and devitalized tissue
Wounds not in delicate or friable tissue should be scrubbed
-Do not scrub tongue or mouth
Inspect wound to base
-Anesthetize first
-Look for FBs, tendon and muscle injuries
Reusing open bottles of saline for wound irrigation
No, common route of cross-contamination between pts
Components of nylon
Mono filament Time required for absorption: NA Color: black Common use: General Advantages: More secure knots
Components of polypropylene
Mono filament Time required for absorption: NA Color: Blue Common use: General Advantages: strength
Components of polyglactin
Multi filament Time required for absorption: 60-90 days Color: White Common use: Buried, lower layer in layered closure Advantages: Dissolves slowly
Components of chromic gut
Mono filament Time required for absorption: 15-60 days Color: tan Common use: tongue Advantages: dssolves more slowly
What size suture should be used for what part of the body?
3-0 for trunk
4-0 for extremities
5-0 for digits
6-0 for face
General suture placement rules
Introduce the suture needle into the skin at a 90-degree angle
Suture depth should be just above bottom of wound and should be at least as wide as it is deep
VERY IMPORTANT to enter dermis at the same level as where you exited the other side of the wound
Simple running
Faster, but harder to get tight and comes unraveled if any loop breaks
Vertical mattress stitch
Provides layered closure with one stitch
Creates everted wound edges
Good for wound over a joint
Horizontal mattress stitch
Good for high tension wounds or wounds that need to hold most of the tension on one side
Subcuticular stitch
Can do interrupted or running Avoids "train track" or scar appearance Used for surgical or very clean wounds Sutures are placed upside-down to bury knots Final tail is hidden
Special considerations in wound care
Shaving traumatizes skin and contaminates wound
NEVER shave an eyebrow
Take special care to align all natural (and unnatural landmarks)
Try to make any incision along natural skin tension lines
Excessively dirty wounds need recheck
Reasons to use staples for wound care
Easy to use and very quick Can often be placed without anesthesia Don't require sterile technique Don't have to wrestle with tying Automatically evert wound However, leave scars
Tissue adhesive for wound care
Very quick, no anesthesia or sterile technique required
Be very judicious about where and how you use it
Wound must be clean/dry
NO ACTIVE BLEEDING
May pull off sooner in an area with a lot of tension
Mostly just use for forehead and around the eyes, volar part of the arm
Wound tape
Rarely used for primary wound closure
More effective for reinforcing
Sometimes used to re-approximate skin tears
Often used in conjunction with glue
Can be useful to reinforce thin skin when suturing
Wound care
Keep dry and covered for 24 hrs Dirty wounds need recheck in 48 hrs No submersion for several more days Elevate (if applicable) Clean 2-3x daily with soap and water Watch for signs of infection APAP and NSAIDs for pain
High-risk wounds
Wounds >12 hrs old at presentation Tooth-related wounds Crush wounds Heavily contaminated wounds Wounds of relatively avascular areas Wounds involving joint spaces, tendons, or bones Severe paronychia and felons Wounds in pts with hx of valvular heart dz Wounds in immunocompromised pts
Tetanus prophylaxis in wound care
A non-tetanus prone wound in a pt who has not had a Td in the past 10 yrs
A tetanus prone wound in a pt who has not had a Td in the past 5 yrs
Any wound in an adult pt who has not had adequate immunization
Tetanus prone wounds
> 6 hrs old > 1 cm deep Stellate or avulsion configuration Associated with devitalized tissue Contaminated with soil, feces, or saliva From a missile From a puncture or crush Associated with burn or frostbite
Suture removal intervals
Scalp: 6-8 days Face: 3-5 days Ear: 4-5 days Chest/abdomen: 8-10 days Back: 12-14 days Extremity: 8-10 days Hand: 8-10 days Finger: 10-12 days Foot: 12-14 days
When to add 2-3 days for suture removal times
Extensor surfaces Age > 65 Diabetics Chronic steroid use Smokers
Informed consent for procedure/refusal
If competent can refuse
Written consent is needed before procedures
-Signature of pt by itself does not meet legal requirements
-Must give significant info to base decision on
Exceptions for informed consent rule
Age
Intoxication
Acute mental status change
Underlying medical conditions
What must you do screening exams and treat for in minors regardless of a consenting adult?
STI Pregnancy Drug, alcohol, dependency Rape Mental illness
AMA
Discover why pt wants to leave
Discuss tx option and potential for worsening sx or even death
Ask pt to sign AMA form with witness/family
Always document pt’s mental capacity and your discussion with pt
Eloping
Pt leaves without you knowing
If mental status or medical emergency can call for search and rescue
DNR
If not available, should resume care
Does not mean “no care”
Advanced Directive and Power of Attorney
Do criminals retain the right to refuse tx?
Yes, unless AMS
