Week Eight - Questions

Question 1

What are several ways to deal with bleeders that may appear in a surgical wound or traumatic laceration?

Answer 1

• Allow them to stop on their own
• Clamp with hemostat
• Cauterize
• Suture

Question 2

What are the differences in the control of small bleeders (and oozers) versus large bleeders?

Answer 2

Small bleeders/oozers

• Wait for them to stop on their own
• Apply pressure with a sterile gauze
• Clamp with hemostat, then twist around several times
• Cauterize with a battery-powered high temp cautery pen (“hot wire loop”) or cauterize with the hyfrecator or radiosurgery tip directly to the tissue

Large bleeders

• Clamp with hemostat and tie off with dissolvable suture
• Cauterize by touching the hyfrecator tip to the hemostat
• Tie off with a figure-of-8 suture

Question 3

What are the other steps in laceration evaluation and treatment?

Answer 3

• Assess for wound contamination and tissue damage
• Check flexion/extension of all joints against resistance for underlying nerve and tendon damage
• R/O fractures
• In relatively clean wounds, inject anesthesia with a 25-27g needle from inside of the wound outward just under the skin to reduce injection pain
• In contaminated wounds, clean skin first
• If needed, inject anesthesia in a fan-like pattern through the skin surface around the laceration
• Clean and debride as needed
• Culture if risk of infection; decide about prophylactic antibiotic coverage
• Close wound and bandage appropriately

Question 4

What are the differences in the treatment of an area of skin loss up to 1 cm2 in a fingertip vs a larger wound or avulsion of the fingertip?

Answer 4

Skin loss up to 1 cm2

• Very common
• Treat only with dressings changed regularly
• Heal with good return of sensation

Larger wounds

• Refer for plastic surgical opinion and treatment
• May need skin graft and/or re-attachment of severed parts

Question 5

What are the particular concerns about palm wounds?

Answer 5

• May be more concerning in very young children
• Deeper structures (nerves and tendons) may be involved
• If in doubt, consult plastic surgeon
• Compound injuries (fracture and laceration) should have antibiotic coverage
• Foreign bodies can cause patient discomfort, localized/systemic infections, delayed wound healing, or deformity and loss of function

Question 6

What are the guidelines for tetanus and tetanus immune globulin administration guidelines?

Answer 6

• If unsure whether the patient has had the last dose of the primary series or a booster within the last five years, given tetanus toxoid
• If the patient has received fewer than two doses of tetanus in their life and the wound is heavily contaminated, give both tetanus toxoid and tetanus immune globulin (confers immediate passive immunity)

Question 7

What are the controllable and the uncontrollable issues that affect wound healing?

Answer 7

Controllable

• Tissue handling - use gentle, meticulous handling, especially of the face
• Do careful, thorough cleaning of the injured tissue
• Splint/cast wounds located near joints to help prevent dehiscence and to minimize scarring

Uncontrollable

• Mechanism of injury
• Location of the wound
• Age and race of the patient
• Patient’s inherent ability to heal
• Patient’s tendency toward abnormal scar formation
• Patient’s nutritional status

Question 8

What must you do before applying anesthesia?

Answer 8

• Assess the wound site for tissue damage, contamination, and possible underlying nerve, tendon, muscle, and boney damage

Question 9

Where should anesthesia be administered?

Answer 9

• Usually by injecting from the inside or center of the laceration out through the side of the wound into the tissue rather than through the skin surface because it will be less painful
• Unless it is significantly contaminated!

Question 10

Should all wounds be considered contaminated?

Answer 10

• All wounds should be considered contaminated

- Especially human bite wounds, which generally should not be closed (at least initially)

Question 11

How do you prevent skin “tattooing” from embedded foreign materials?

Answer 11

• Must remove all foreign material with a forceps and scissors/scalpel or hypodermic needle
• Wound must be copiously irrigated with sterile saline, preferably under pressure

Question 12

What should be removed during debridement?

Answer 12

• All debris and devitalized and necrotic tissue

Question 13

What should you do regarding debridement if there’s any question concerning the tissue’s viability?

Answer 13

• Usually best to minimize debridement

- Better to opt for delayed primary closure

Question 14

What will shaving hair cause?

Answer 14

• Micro-trauma to the skin
• Increased risk of infection
• Scissors and clippers are okay

Question 15

What might not regrow after being shaved off?

Answer 15

• Eyebrows

Question 16

What is the goal of trimming a wound edge?

Answer 16

• To produce an opening wider at the base than the surface

- Helps produce eversion of the wound edges

Question 17

What are the alternatives to consider if a wound can’t be closed by primary intention?

Answer 17

• Steri-strips

- Glue

Question 18

What are the factors that affect the appearance of a wound site after healing?

Answer 18

• Same as wound closure techniques?

Question 19

How can excessive scar formation be minimized?

Answer 19

• Gentle handling

- Careful cleaning of the injured tissue

Question 20

Is there a “golden period” of 12-24 hours after which a wound should not be surgically closed?

Answer 20

• No, wounds can be closed even when days old as long as they are properly debrided and cleaned
• Best results will occur within 8 hours of occurrence, except for facial wounds which can have good results even within 24 hours

Question 21

What three types of wounds are Steri-Strips and glue usually not sufficient for repairing?

Answer 21

• Lacerations into the deeper dermal layers and sub-q
• Wounds missing tissue
• Wounds with increased wound tension

Question 22

What are the 7 Wound Closure Technique Basics?

Answer 22

• Handle tissues gently with forceps
• Ensure hemostasis
• Use as fine a suture as feasible
• Enter needle at 90* to the skin surface
• Evert the wound edges
• Keep the skin edges relaxed but well opposed
• Remove sutures as early as reasonably possible to reduce scarring

Question 23

What are the closure options for clean vs contaminated/dirty wounds?

Answer 23

Clean
- Small
     > Use primary closure
- Large
     > Undermine if cannot close easily
     > If still cannot be closed, allow for secondary closure or refer for a skin graft or skin flap

Contaminated/Dirty 
- Small
     > Use secondary closure
- Large
     > Use delayed primary closure

Question 24

Should a drain be inserted into a traumatic laceration? If so, when?

Answer 24

• No, unless an infection is anticipated

Question 25

What is the technique for suture removal?

Answer 25

• Cleanse with alcohol
• Grasp one end of the suture or knot and shift it back and forth
• Cut the suture with a scissors or scalpel blade close to the skin surface
• Pull the freed knot across the suture line to reduce wound stress, help avoid dehiscence, and reduce infection risk

Question 26

What are the typical suture removal times for various parts of the body?

Answer 26

• Face: 3-5 days
• Scalp: 5-7 days
• Extremity (low-tension): 6-10 days
• Extremity (high-tension): 10-14 days
• Abdomen: 6-12 days
• Chest and Back: 6-12 days

Question 27

When and where on the body would you choose to use a three-point corner stitch?

Answer 27

• For better closure of 3-point lacerations
• To reduce the chance of compromising circulation at the triangulated tips of wounds
• For advanced specialty and plastic surgery procedures