Suturing Flashcards
4 main factors that play a role in deciding to close a wound
- tissue type
- the length of time the wound has been open
- the degree of contamination of the wound
- cosmetic or functional affect of the wound.
how does tissue type effect suturing?
Healthy tissue with good blood supply heals well and extends the length of time one can wait to safely perform closure. For such reasons, wounds of the scalp (with a large blood supply) heal marvelously, even with long delays to closure. But poorly vascularized areas (i.e. the digits) often heal poorly
outline endogenous risks that will affect healing
- underlying vascular conditions (vasculitis, peripheral vascular disease)
- immunosuppression (HIV, prednisone)
- areas of low blood flow (distal extremities)
outline exogenous risks that will affect healing
exogenous factors that play a role in the blood supply include devascularization of the tissue by the wound (i.e. skin flaps) or vascular trauma. Any of these exogenous or endogenous factors predispose the wound to higher infection rates, and these wounds should only be closed after weighing the risks and benefits.
How does time affect wound healing
The longer a wound is open, the more likely that a significant amount of bacteria have gained access to the wound. Likewise, the degree of contamination of the wound obviously plays a role in infection. Wounds made by a sterile razor are less likely to deposit a significant amount of bacteria in the wound than those made by a rusty nail from barnyard.
healing by secondary intention
n this case the wound is cleaned and bandaged and heals by granulation. This does increase the size of the scar, but may be appropriate for wounds that have too much tissue loss to suture or for wounds with high infective risks and low cosmetic importance.
healing by delayd primary closure
his technique is useful for wounds that cosmetically or functionally need closure, but the risk of infection is deemed too high to close at the time of presentation. In delayed primary closure, the wound is cleaned and dead tissue debrided. The wound is then packed with nonstick sterile gauze and bandaged. The patient changes the dressing daily and the wound is reexamined a few days after the injury. If there are no signs of infection, the wound is then sutured closed
The first goal of the stitch is tissue __ and wound __. In other words we want to bring all the tissues together to let the process of healing occur.
The first goal of the stitch is tissue apposition and wound eversion. In other words we want to bring all the tissues together to let the process of healing occur.
The other goal of suturing is to create mild eversion of the edges of the wound. As wounds heal, the scar tends to flatten. Thus, a laceration that is closed with slight eversion (i.e. the skin puckered up slightly) will eventually heal flat. Again, proper sizing of you suture needle will assist in this.
when is a horizontal mattress suture good to use?
useful for fragile skin and can be used as a highly effective hemostatic suture enclosing a bleeding vessel. The eyelid, dorsum of the hand, foot or finger are areas where placement of horizontal mattress sutures can be considered as well. Care must be taken not to tie the sutures too tightly as a larger area of tissue is susceptible to ischemia.
when do most kids get their first tetanus shot? when is booster? if you cut yourself 10 years after booster, what should you give?
usually give them at 2, 4, 6, and 18 months of age, then at 5 years ld, then at 14-16 years.
- after 10 years, must give tetanus toxoid booster.
n persons who may not have current tetanus immunity (i.e. greater than 10 years since last tetanus immunization, or have not completed a primary series of immunizations) and have heavily contaminated, tetanus prone wounds, we enlist our other weapon in the war on tetanus. This is
TETATNUS IMMUNE GLOBULIN (as well as tetanus toxoid)
explain needle sizes for local anesthetic
- local anesthetic is adminsterest with the smallest needle available because they ar less painful and are less likely to damage the wound even more. it is often drawn up with a larger 18 gauge needle and then replaced with the small er needle for wound infiltration.
inject slowly to minimize pain.
he most commonly used local anesthetic is lidocaineThere are two formulations of lidocaine;
those with epinephrine and those without epinephrine. The addition of epinephrine causes vasoconstriction of the tissues and provides us with a less bloody field to work in. This is helpful in most wounds, but does need to be used with care in areas of poor blood supply as it can cause ischemic necrosis.
Epinephrine does need to be used with care in areas of poor blood supply as it can cause ischemic necrosis. Although somewhat controversial, Epinephrine should NOT be used in the following areas:
(a) Nose (b) Ears (c) Digits (d) Penis
Those of you who are aspiring physiologists may also remember that lidocaine is actually an anti-arrhythmic drug (a Ib Sodium Channel Blocker). Thus, patients who receive too much lidocaine can get cardiac and neurological side effects.
maximal doses for lidocaine
The maximal dose for lidocaine WITH epinephrine is 7mg/kg, while the maximal dose for lidocaine without epinephrine is 5mg/kg. Now this is good examination material, so let’s do an example.
