Wound Closure Flashcards
1
Q
What to consider in a wound assessment? (6)
A
-
Mechanism of Injury (MOI); how did it happen
- Contaminated?
- Good to know for infection and scarring risk
- Contaminated?
-
Presence of foreign body; glass, metal, gravel
- Consider X-ray
- DO NOT PUT FINGER IN OPEN WOUND TO EXPLORE; take out if you see it with instrument
- Retained can increase risk for delayed wound healing
-
Wound extent; how far in the wound
- ID base of wound
-
Neurovascular or tendon injury
- Circulation + sensation
- Tendon function (ext + flex)
- Flat tendon = DAMAGE
- Age of injury
- Cosmetic significance
2
Q
What are we most worried about in wound?
What if it’s “clean,” non-contaminated
A
INFECTION
Longer wound is open for → longer opportunity for skin flora to invade wound
Clean wound: good for 12-18hrs
3
Q
Other considerations that affect time needed to close wound
A
- Patient co-morbidities/infection risk
- DM, immunocompromised
- Location (larger SA = infection can sit in easily)
4
Q
Wounds on trunk/proximal extremities VS. Head and neck wounds
A
- Trunk/proximal extremities
- MORE SUCCESS with LATER wound closure vs distal - more blood available
- Head/neck wounds
- Consider closure up to 24hrs
- More blood supply to area → more immune system available
5
Q
Which wounds should be closed by secondary intention? (left open)
A
- Stab/puncture wounds
- Contaminated wounds
- Animal bites (mammal)
- Abscess cavities (pus contains infection)
- Active infection/ inflammation (abx tx)
- Wound presents to you after significant amount of time since injury
6
Q
When would you use a delayed closure?
A
- Uncomplicated wounds presenting after safe period for primary closure (present to tx too late)
- Wounds > 24hrs not properly cleansed/debrided
- Wounds > 24hrs increased for infection risk
- Complex animal/human bites - ok to leave open → plastics close in 2-3d
7
Q
What is a delayed closure?
A
Patient usually has some kind of cleaning performed by you and some “loose sutures placed or steri strips applied
8
Q
Considerations for delayed closure
A
- Must be irrigated/debrided and wait several days prior to closing
- Consider abx use in patients you are considering for this
- Pt referred → plastic surgeon for proper closure
9
Q
Hemostasis
A
- Stopping flow of blood by applying direct pressure on efferent arteries or wound bed itself
10
Q
Hemostasis methods
A
- Methods
- Hemostat (scissor)
- Cautery (bovi)
- Gelfoam or Surgicel on wound
- Silver Nitrate (give some anesthetic before putting this on - stings)
- Topical TXA (lysing enzyme: plasminogen → plasmin)
- Potato starch (sterile) - stops oozing
11
Q
Debridment & process
A
- Process of removing dead tissue from wound
- Use dissecting scissors to snip/clean edges
- Scalpel to scrape away dead skin or foreign material
- Sufficient tissue must remain for adequate wound closure
- Only be done if no damage done to underlying structures
12
Q
Irrigation & process
A
- Using solution to wash the wound
- Normal Saline or tap water for uncomplicated wounds
- STERILE SALINE BEST
- No antiseptic solution (EtOH, H2O2) → kills living tissue too
- Can use diluted solution of betadine for dirty/bite wounds
- Ideal pressure unknown, recommend 5-8 PSI
- 30-60mL syringe w/18G needle and splash guard
13
Q
Other (2) considerations for debridement and irrigation
A
- Remove any VISIBLE foreign body - can use instrument
- Avoid shaving area = increases wound contamination via tiny cuts
14
Q
Methods of wound closure (5)
A
- Sutures
- Staples
- Scalp - not see scar
- Tissue adhesives
- Reapproximate edge over area by getting it wet to pull it over - biologic dressing
- Dermabond
- Steri-strips
- Partial thickness tears in elderly
15
Q
Dermabond benefits
A
- No need for local anesthetic (not cutting/suturing)
- Faster repair time
- No removal required
- Great in pedi patients
- Looks great after - cosmetic result
- Bond strength peaks at 2 mins
- As strong as healed tissues at 7d post repair
- Water-resistant
16
Q
Dermabond contraindications
A
-
Cannot use on jagged or stellate (cross) lacerations
- Needs to be straight line mostly
- Not able to approximate edges appropriately
- Bites, puncture wounds, crush wounds
- Contaminated wounds
-
Mucosal surfaces
- High-moisture areas - won’t stick
- Axillae, perineum (high-moisture areas)
-
Hands, feet, joints
- Unless immobilized
- Very close to eyelids (on them as can seal them shut)
17
Q
Tetanus prophylaxis
A
- Huge risk for wound infection
- Ask how recent was their tetanus boost and how many have they had
- Clean/minor wounds: IF < 3 doses or unknown → give TD/TDAP dose
- Give TD or TDAP if last dose was > 10yrs ago
- All other wounds: IF < 3 doses or unknown → give TD or TDAP + TG dose
- Give TD or TDAP if last dose was > 5yrs ago
- Clean/minor wounds: IF < 3 doses or unknown → give TD/TDAP dose
18
Q
When do you not use antibiotics for wounds?
A
If the patient is healthy and wound is clean
19
Q
When should you consider using antibiotics for wounds?
A
- Significant contamination
- Wound is over joint/tendon, areas of vascular insufficiency
- Immunocompromised
- DM w/LE wounds
- Chronic steroid use
- Areas of increased bacterial growth (axilla, mouth, groin, etc), obesity, etc
- Always teach pts s/s of infection to monitor for post closure
20
Q
Bacterial vs Viral mammal Bites
A
- Bacterial: Pasturella - found in feline and canine oral cavities
-
Viral: Rabies virus carried by mammals only - rabid animals bite more than non-rabid ones
- Nocturnal mammal that’s usually afraid of humans (raccoon) bit pt during daytime - SUSPICIOUS
- Mice, rats, moles, voles, and rabbits do not “carry” rabies
- Bats carry rabies - spread w/saliva
21
Q
Treating mammal bites
What if it’s feline or other sharp and narrow-tooth mammal?
A
- Cleanse wound w/irrigation and 4% CHG (chlorohexadine gluconate)
- Debride any devitalized tissue - won’t heal, obstruct
- Feline/sharp/narrow
- After using local anesthesia, open tooth marks with #11 blade, and irrigate along them w/blunt tip catheter or needle
- Loosen hole up to rinse bacteria out
- After using local anesthesia, open tooth marks with #11 blade, and irrigate along them w/blunt tip catheter or needle
- Close only wounds that definitely require it - cosmetic reasons
- Others can be closed loosely with sutures, or have steri-strips applied
- Consider plastic surgery consultation
42
Q
Simple Interrupted suture
A
- MOTHER SUTURE - most common
- Most commonly used in outpatient setting
- Good for irregular wounds
- Do not place ties over wound - on side (at least 3)
43
Q
Running suture
A
- Simple continuous suture
- Quick, good option for long, linear wounds
- Lacerations W/O TENSION
- IF one knot fails → whole closure compromised
- DO NOT USE W/INFECTION → can propagate along suture line
44
Q
Running locked suture
A
- Good cosmetic result - face if long and straight cut
- Use w/moderate tension
- DO NOT USE W/INFECTION → can propagate along suture line
45
Q
Mattress sutures
two types
A
- Vertical and Horizontal
- Vertical: in areas where skin tends to invert; far, far, near, near
- Horizontal: good for fragile skin
- Elderly, chronic corticosteroid use
- Good for hemostasis, gaping, high tension wounds
- Good tissue approximation and for hard-to-evert wound edges OR too far from each other
- Good in creases or when need to close under tension
- Joints too
- Help to minimize dead space
48
Q
Basic Technique
Suturing approximation
A
- Approximate and slightly EVERT wound edges
- Ensure edges are aligned and sutures not too loose
- If sutures are too tight, can cause necrosis
- Don’t place too many sutures too close together
- Remember area may swell
- Rule of Halves
49
Q
Rule of halves
A
First suture placed halfway along wound then divide by halves
50
Q
What to avoid creating when suturing? Why?
A
Avoid DEAD SPACE → delayed wound healing and infection risk
