Wk 8

Question 1

Name the several different ways to deal with “bleeders” that may appear in a surgical wound or traumatic laceration.

Answer 1

Venous/capillary: (First control the bleed) wait for them to stop on their own, apply pressure, clamp with hemostat, cauterize.

Arterial bleeders: clamp with hemostat and tie off with suture, cauterize by touching hyfrecator tip to the hemostat, tie off with figure 8 knot.

Question 2

Contrast control of small bleeder (and “oozers”) with larger bleeders.

Answer 2

Oozers = venous/capillary.

Large bleeders = arterial

Question 3

What is Quikclot? When should you consider using it?

Answer 3

“clotting product”= gauzy wound pads infused with kaolin. Should be used if direct pressure isn’t stopping the bleeding, the compress become saturated with blood quickly and repeatedly, you are miles away from medical care

Question 4

What is SURGICEL? When should it be used?

Answer 4

First and only absorbable hemostat. Use only adjunct to ligation or other conventional methods to control capillary, venous, and small arterial hemorrhage. NOT to be used to control hemorrhage from a large artery.

Question 5

Contrast 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 5

Area of skin loss up to 1 cm2: very common, treat with dressings changed regularly, with with good return of sensation. Larger wound: refer for plastic surgeon opinion

Question 6

What are particular concerns about palm wounds?

Answer 6

Assess wound carefully, especially small children. Deeper structures (nerves and tendons) maybe be involved. If in doubt consult a plastic surgeon. Compound injuries (fracture and laceration) should have antibiotic coverage. Foreign bodies are frequently missed on initial evaluation in palm (also in digit, and sole of the foot)

Question 7

Be familiar with tetanus and tetanus immune globulin administration guidelines.

Answer 7

If not certain if pt has had the last dose of primary series or a booster within the past 10 years, give tetanus toxoid. If pt has received fewer than two doses of tetanus toxoid in his/her life and would is heavily contaminated, give BOTH tetanus toxoid and tetanus immune globulin. Look at algorithm on pg 20 of notes.

Question 8

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

Answer 8

Controllable: 1) tissue handling – use gentle meticulous tissue handling, especially on the face 2) careful, thorough cleaning of the injured tissue. 3) splint/cast wounds near joints to help prevent dehiscence → reduced scarring. Uncontrollable: 1) Mechanism of injury 2) Location of wound 3) Age and race of pt 4) Pt’s inherent ability to heal 5) Pt’s tendency toward abnormal scar formation 6) pt’s nutritional status (I would argue we can help with #4 and 6 of the “uncontrollable”)

Question 9

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

Answer 9

Secondary or delayed primary closure ??? I guessed

Question 10

Name the factors that affect the appearance of a wound site after healing.

Answer 10

1) handle tissues gently 2) ensure hemostasis 3) use as fine a suture as feasible 4) enter needle at 90 degree to skin surface 5) evert the wound edges 6) keep the skin edges relaxed but well opposed 7) remove sutures as early as reasonably possible to reduce scaring.

Question 11

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

Answer 11

Historically there was, several large studies refute this. Each case needs individual consideration, most wounds even days old, can be surgically repaired as long as they are properly debrided and cleaned. For best results most wounds should be closed within 6 hours of occurrence. Wounds on the face may be closed up to 24 hours with good results (excellent blood supply)

Question 12

Steri-strips and glue are usually not sufficient for repairing what three types of wound?

Answer 12

1) Lacerations into the deeper dermal layer and SubQ 2) Wounds missing tissue 3) Wounds with increased wound tension.

Question 13

Name the 7 “Wound Closure Technique Basics”.

Answer 13

1) handle tissues gently 2) ensure hemostasis 3) use as fine a suture as feasible 4) enter needle at 90 degree to skin surface 5) evert the wound edges 6) keep the skin edges relaxed but well opposed 7) remove sutures as early as reasonably possible to reduce scaring.

Question 14

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

Answer 14

“clean” wounds – small: use primary closure. Large: if wound edges cannot be easily approximated, undermine to reduce skin tension and allow closure. If still cannot be closed – allow to heal by secondary intention or refer for a skin graft or skin flap. “contaminated/dirty” – small: “secondary closure”. Large: choose “delayed primary closure” (DPC).

Question 15

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

Answer 15

If it is a routine traumatic laceration, do not use drain. Only use if an infection is anticipated. Historically surgical drains were placed in potentially infected wounds, this increased infection rates.

Question 16

Understand suture removal technique.

Answer 16

1) grasp an end of the suture/knot, shift it back and forth to free it up so you can see clearly where to cut. 2) cut the suture with a scissors or scalpel blade and pull the freed know ACROSS the suture line. 3) Pulling the suture out in this manner helps reduce wound “stress” and helps avoid dehiscence. 4) Practice correctly using this technique in class.

Question 17

Know the typical removal times for sutures placed in various parts of the body.

Answer 17

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, 
over jts on soles or palms: no sooner than 12-14 days.

Question 18

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

Answer 18

Used for lacerations and more advanced specialty and plastic surgery procedures. Used to reduce tip ischemia

Question 19

BEFORE APPLYING ANESTHESIA assess the wound site for tissue damage, contamination and possible underlying nerve, tendon, muscle and boney damage.

FACT: Anesthetic usually should be administered by injecting from the inside or center of the laceration out through the side of the wound (unless it is significantly contaminated) into the tissue rather than through the skin surface because it will be less painful.

FACT: All wounds should be considered contaminated, especially human bite wounds, which generally should be closed, at lease not initially.

FACT: To prevent wound “tattooing”, embedded foreign material must be removed with a forceps or hypodermic needle and the wound copiously irrigated with sterile saline preferably under pressure.

Answer 19

FACT: As part of debridement, all debris and devitalized and necrotic tissue should be removed from the wound. However, if there is any question concerning a tissue’s viability, it’s usually best to minimize the debridement and rather then either close it at that time or opt for delayed primary closure.

FACT: Shaving hair will cause micro-trauma to the skin and increase infection risk! Scissors and clippers are OK.

FACT: Do not shave eyebrows which sometimes do not regrow!

FACT: The goal of trimming a wound edge is to produce an opening wider at the base than the surface, which helps produce eversion of the wound edges.

FACT: Excessive scar formation can be minimized through gentle handling and careful cleaning of the injured tissue.