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
Q
What to do before suturing a wound on a patient?
A
- Review risks
- Obtain consent
- Document informed consent
- Review nature of procedure, risks, and alternatives
26
Q
Local anesthetics
Purpose, Process, Indications
A
- Purpose: help explore/heal wound better
- Process: Infused directly into tissue being treated into SQ layer around + within wound
- Indications: Small wounds
27
Q
Regional anesthetics
Purpose, Process, Indications
A
- 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
Q
Digital block
What do you assess before injecting anesthetic?
A
- 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
Q
When do you use ONLY use epinephrine for regional anesthetic?
A
Certain dental blocks ONLY if you know how
30
Q
Using Epinephrine w/local anesthetic PROS
A
- Decreases bleeding - vasoconstrictor
- Reduces systemic absorption of anesthetic
- D/t this, longer duration of action
31
Q
Using Epinephrine with local anesthetic CONS
A
- Large wounds
- Avoid if patient has co-morbid conditions affected by EPI
- Hyperthyroidism, CAD, severe HTN (some EPI absorbed systemically)
- Avoid if patient has co-morbid conditions affected by EPI
- 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
Q
Local anesthetics Procedure
A
- 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
Q
Tips to consider in local anesthetic injections
A
- 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
Q
Different suture material (3)
A
- Multifilament
- Monofilament
- Absorbable sutures
35
Q
Multifilament suture material
A
- Braided - highly tensile
- Can harbor bacteria b/c braided - AVOID CONTAMINATED WOUNDS
- Ties well
- Silk, Polyester
36
Q
Monofilament suture material
A
- Lower infection risk but have lower tensile strength (can snap)
- Nylon (ethilon)
- Prolene (fishing line)
37
Q
Absorbable suture material
A
- 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
Q
Suture size for which part of the body
Selecting: what to consider?
Numbers = which body part?
A
- 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
Q
Suture color differentiation
A
Blue sutures are good to help differentiate suture from hair
40
Q
Suture needle
A
- Different sizes, think about wound tensions and size of wound
- Different needle tips
- Curved
- Lower PS rating = longer, broader needle is
41
Q
Suture techniques (4)
A
- Simple interrupted
- Running
- Running locked
- Mattress sutures
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
46
Q
Suture materials
A
- Needle driver
- Dissecting scissors
- Mosquito Hemostat
- Suture scissors
- Addison forceps
- Needle holder
- Skin hook
- Suture/needle/thread
47
Q
Basic needle technique
Needle holder
A
- 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
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
51
Q
How to suture dead space?
A
- Vertical mattress or buried sutures - deeper wound
- Multilevel closure
52
Q
Post suture care: Removal timing
Don’t exceed how many days over to remove suture?
A
- 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)
Don’t exceed more than 14d - skin will grow over suture!
53
Q
Post suture care: Patient education
A
- 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
Q
S/s of suture infection
A
- Increased swelling, gradual contracting, increased pain, spreading redness from wound, pus (creamy + smelly + yellow), unexplained fever
