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
22
Q
Rabies prophylaxis
A
- Augmentin (Amoxicillin/Clavulanic acid) 875mg PO BID 7d for pasturella - DRUG OF CHOICE
- Update tetanus boost
- Given w/in 72hrs post bite - closer to time of bite - better
- Consists of:
- Rabies vaccine (1cc IM) given on day (4-7 INJ)
- Rabies immune globulin (RIg 10u/kg IM) on day 0 (4-7 INJs)
23
Q
When should you consult/refer?
A
- Deep wounds of hand or foot
- Full-thickness lacerations of eyelid, lip, ear
- Wounds to the eyelid that involve tarsal plate
- Lining up vermillion border (btwn lip + face)
- Hematoma in ear (cauliflower ear)
- Lacerations involving nerves, arteries, bones, joints
- Penetrating wounds of unknown depth
- Severe crush injuries
- Severely contaminated wounds requiring drainage
- Wounds leading to strong concern about cosmetic outcome
- “difficult patient”
- Lack of comfortability
24
Q
Risks of suturing
A
- Pain
- Bleeding
- Dehiscence
- Infection
- Scarring - always will be present
- Remind them that doing nothing will lead to more scarring
25
What to do before suturing a wound on a patient?
* Review risks
* Obtain consent
* Document informed consent
* Review nature of procedure, risks, and alternatives
26
Local anesthetics
Purpose, Process, Indications
* _Purpose_: help explore/heal wound better
* _Process:_ Infused directly into tissue being treated into SQ layer around + within wound
* _Indications_: Small wounds
27
Regional anesthetics
Purpose, Process, Indications
* _Purpose:_ “Nerve block”
* _Process:_ Anesthetic infiltrated near peripheral nerve to produce distal anesthesia
* Sterile procedure
* _Indications:_ Digital block
* **Avoid toxic doses of anesthetic in large wounds**
28
Digital block
What do you assess before injecting anesthetic?
* Inject into palmar digital crease, insert 25G needle to bone, withdraw slowly. while injecting, once in tendon sheath lidocaine will flow easily
* Want to get all three digital nerves
* ASSESS NERVE VASCULAR INTEGRITY
29
When do you use ONLY use epinephrine for _regional_ anesthetic?
Certain dental blocks ONLY if you know how
30
Using Epinephrine w/local anesthetic PROS
* Decreases bleeding - vasoconstrictor
* Reduces systemic absorption of anesthetic
* D/t this, longer duration of action
31
Using Epinephrine with local anesthetic CONS
* Large wounds
* Avoid if patient has co-morbid conditions affected by EPI
* Hyperthyroidism, CAD, severe HTN (some EPI absorbed systemically)
* Wound on extremitiy
* **Do not use in fingers, nose, toes, or hose** - only one bloody supply
* Avoid in PAD
* If patient cannot tolerate pain - makes the injection more painful d/t vasoconstriction
32
Local anesthetics Procedure
* Cleanse site of infiltration w/pocidone-iodine or chlorhexidine or other similar antiseptic - allow to air dry w/ sterile gauze
* _Open wounds_
* Few drops on wound → place needle into SQ through wound margin
* _Intact skin_
* Needle in SQ layer
* Slowly inject small volumes of anesthetic → slowly advance needle and infiltrate (not while advancing)
* Only aspirate if close to major blood vessels
* Anesthetize adjacent areas until entire area infiltrated
* Wait a few minutes → test skin/wound margins sensation (feel pressure, not pain)
33
Tips to consider in local anesthetic injections
* Injecting the local anesthetic is the **most painful part**
* Tell pt what to expect → pinching then burning sensation
* Burning = anesthetic is working
* Consider _topical preparations to numb skin first_: EMLA, ehtyl chloride, LET; esp in pedi
* Can buffer lidocaine w/Na Bicarb to _decrease stinging_
* Neutralizes pH
* Small gauge needle (25G-27G) 30G in facial wound
* Aspirate first in vascular area
* Infiltrate lidocaine while WITHDRAWING needle, not in advancing
34
Different suture material (3)
* Multifilament
* Monofilament
* Absorbable sutures
35
Multifilament suture material
* Braided - highly tensile
* Can harbor bacteria b/c braided - AVOID CONTAMINATED WOUNDS
* Ties well
* Silk, Polyester
36
Monofilament suture material
* Lower infection risk but have lower tensile strength (can snap)
* Nylon (ethilon)
* Prolene (fishing line)
37
Absorbable suture material
* Deep, multiple-layer lacerations
* Absorb w/in 4-8 weeks
* Complication rate appears comparable to non-absorbable sutures
* Good for mucosal lacerations (mouth, tongue, genitalia) - mucosa heals fast
* Polygalactin 910 (vicryl)
* Polyglycolic acid (Dexon)
* Poliglecaprone 25 (Monocryl)
38
Suture size for which part of the body
Selecting: what to consider?
Numbers = which body part?
* Material thickness
* Higher the number = less thick the material
* When selecting size think about **skin thickness + wound tension + anatomic location**
* 3-0 or 4-0 = trunk
* 4-0 or 5-0 extremities, scalp
* 5-0 to 7-0 on face
39
Suture color differentiation
Blue sutures are good to help differentiate suture from hair
40
Suture needle
* Different sizes, think about wound tensions and size of wound
* Different needle tips
* Curved
* **Lower PS rating = longer, broader needle is**
41
Suture techniques (4)
* Simple interrupted
* Running
* Running locked
* Mattress sutures
42
Simple Interrupted suture
* 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
Running suture
* 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
Running locked suture
* Good **cosmetic result** - face if long and straight cut
* Use w/moderate tension
* DO NOT USE W/INFECTION → can propagate along suture line
45
Mattress sutures
two types
* 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
46
Suture materials
* Needle driver
* Dissecting scissors
* Mosquito Hemostat
* Suture scissors
* Addison forceps
* Needle holder
* Skin hook
* Suture/needle/thread
47
Basic needle technique
Needle holder
* Needle should be secured ½ to ⅔ down length of needle from tip
* Hold w/thumb + 4th finger
* Insert skin at 90 degree angle
* Trailing suture following curve of needle
* Twist wrist
* Take “equal bites” of skin on either side of the wound
48
Basic Technique
Suturing approximation
* 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
Rule of halves
First suture placed halfway along wound then divide by halves
50
What to avoid creating when suturing? Why?
Avoid DEAD SPACE → delayed wound healing and infection risk
51
How to suture dead space?
* Vertical mattress or buried sutures - deeper wound
* Multilevel closure
52
Post suture care: Removal timing
Don't exceed how many days over to remove suture?
* Depends on anatomic site
* Eyelids: 3d (ok for 7d)
* Neck - 3-4d (ok for 7d)
* Face - 5d (ok for 7d)
* Scalp - 7-14d
* Trunk and UEs - 7d
* LEs - 8-10d (more like 10d)
## Footnote
**Don't exceed more than 14d - skin will grow over suture!**
53
Post suture care: Patient education
* Topical abx (Bacitracin) or vaseline post laceration repair OK
* Leave **initial** dressing in place for **24hrs**, then can typically be left open to air
* Showering and washing OK **after 24hrs**
* Avoiding swimming in pools or natural bodies of water - no immersing in water
* Review s/s infection w/pt
* REMIND THEM TO NEVER REMOVE SUTURES THEMSELVES
54
S/s of suture infection
* Increased swelling, gradual contracting, increased pain, spreading redness from wound, pus (creamy + smelly + yellow), unexplained fever
