Wound Closure Flashcards
Key Pearls of the History and PE for a wound that may impact closure
Location: look at skin tension lines!
Mechanism of Injury
- FB?
- bite
- puncture
- contamination
- crush v stab wound
Allergies
Age of Wound & Extent of injuries
NV compromise
Tetanus shot!
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Poor Wound Healing Increased if…
- FB still retained
- contaminated
-its been > 24 hours for the face
- its been > 18 hours for the body
- deeper wounds
- crush wounds
- tissue loss (poor flow, poor outcome)
- DM and obese pt. (poor healing)
- PAD & smoker
- khistory of keloid
- connetice tissue d/o immunosuppressed
- renal impairment or poor nutrtional stautus
Wound Management: Anesthesia to the location
- Open Wound
- Digital Block
- Field Block
Steps
- assess the wound for signs of NV compromise
- clean with betadine or chlorhexadine
for Open Wound Technique
- insert needle to subcut. through the margin of wound (opening)
- aspirate before injection to ensure your not in vessel
- inject as you withdraw needle & repeat along the wound
Digital Block
- within the web spaces of the fingers
- within the flexor sheath (transthecal) on palm both sides
Field Block
- used for highly contaminated wounds
- you anesthetize around the wound margins (not inserting needle into the wound)
then you directly infiltarte (if its clean laceration with uninfected skin)
Anesthesia for Wound Closure
types of anesthesia use
LET (topical)
smaller needle (27-30) slow and subcut > intradermal = less pain this numbs up the free nerve endings in the epidermal layer
Topical LET: lidocaine, epinephrine & tetracaine
- used in children because there is lsee needle sticks
- its topical: 30-60 mins, lasting 45-60 mins
Types of Anesthesia : Lidocaine with Epinephrine
- local vasoconstriction, decreases local bleeding & reduces systemic lidocaine absorbtion
Lidocaine without epinephrine MAY be used on the face (nose, ear, digits and genitalia)
- dont used lipo without epi. for digital anesthsia without PAD
How is Hemostasis Achieved in a Wound Lac.
Hemostatisis needs to be achieved in order to see the full extent of the lacteration
First Line: direct pressure for 10-15 minutes
- can give lido with epi (epi will vasoconstrcit)
- can use gelatin foam (to absorb bleeding)
- silver nitrate : used for epistaxis
- electrocautery: risk of necrosis
- Tournaquet: caution damange of other structures (always label tme and initials if you put one on) max time 30-60 minutes on large extremities
Exploration of the Wound
waht are you looking for
FB removal
exploration: the bleeding has stopped, now do this
- identify base of the wound (how deep)
- NV status: assess circualtion and sensation
- tendon injury
- joint spaces invovled?
- FB? removal can be done bedside, may need surgical consult (ask self if FB in NV, joint, causing underlying fracture)
Foreign Body Removal
- if stayed in, increased infection risk & delayed healing
- need good hx. of how it got in there, etc.
- visually inpect
- palpated: assess point tenderness
- can use xray or US to see it
Wound Closure: Skin Disinfection & Irrigation & Debriedment
Disinfection
- povidone-iodine solution (Betadine) or Chlorhexidine
- these are used to clean the wound periphery
Hair Removal? only if it will interfere with wound closure: otherwise it doesnt need to go
- shaving = increased infectino risk
Irrigation of Wound
- appropriate PPE
- most importatnt step in decreasing infection risk : dec. bacteria and FB
- isotonic normal saline used
Irrigation Pressures
- HIGH: for moderately/high contaminated wounds (OR)
- very high: ihgly contaminated woulds or debridement of necrosied tissue
- low: loose skin, uncomtaminated wounds
Volume of Irrigation
- less for smaller, cleaner wounds with high vasculature
- minimum amount: 250-500 mL
Debridement
- removal devitalized tissue: if left can delay healing and reduce clean wound edges
- irrigation or scalpel removal is best
Wound Closure
indications to close
complications
Indications
- decreased infection and scarring
- decrease healing time
- repair loss of structure or function
COmplications
- bleeding
- poor cosmetic result
- need to additionally repair
- infection
- wound dehiscence
Primary Clousre
- wound closed imediately
Secondary Closure
- wound left open to close on its own
- deep stab wounds/puncture wounds
- contaminated wounds
- delayed presenation for medical attention
- bites
Delayed Primary
- wound cleaned, debreided and packed, coverd with gauze for 4-5 days then pirmary closure afterwards if no infection signs present
- Bites
- wounds > 24 hours that are poorly cleaned
- wound > 24 hours with pt. (DM, older age)
Langer Lines
always follow langer lines of skin tension
- these are the collagen tension lines
- parallel to the wound: they will approxate better
Closure techniques: Suturing
- indications
- contraindications
- equiptment
Indications
- clean, uninfected wounds
- up to 24 hours later: can suture the face
- up to 12-18 hours later: can suture the body
- beyond 12 hours = greatest risk of infection with closing
Contraindications
- a deep puncture wound
- extremely contaminated
- infected wound
+/- if bites should be closed
Equiptment for Suturing
- PPE, clean gloves or sterile
- eye protection
- anesthesia: lidocaine + 27 gauge needle
- irrigation: saline
- suture stuff: drapes, needle holder, forceps, scisssors, sterile gauze (in tray)
- suture and scapel
Sutures: Absorbable v Nonabsborable
Absorbable Sutures
- for the deeper skin
- lose most strength within 60 dyas
- secure knot with 3-4 throws
- example: Vicryl or Moncryl or Chromic gut/fast-absorbing
Nonabsorbable
- retain strength for at least 60 days
- secure with 4-5 throws
- outermost layers of skin used here
- examples: Nylon or Prolene
larger the suture number, smaller the thread
6-0 for face
4/5-0 for body, scalp
3/4-= for tension wounds or extremities
larger = increased risk of scarring and inflammation
Simple Interrupted Percut. Suture
-technique
Simple Inturrupted Percut.
- most common, used for small uncomplicated wounds
- needle: penitrates at 90degrees to skin
- evert edges, penitrate skin as wide as it is deep, and tie off each penitration
- if dermal (deeper) consider absorbale sutures: a deep dermal sututre can help prevent deadspcae
Running Percutaneous Suture
technique
Indications
- well aligned, long straight wounds
- good because it evenly distributes the tension along the wound and is a fast closure technique of longe wounds
- negatives: if the stich breaks the whole wound comes apart
tehcnique
- drive the needle at an oblique (45degree) angle of the wound: this will created straight perpendicualr suture lines across the wound
Continuous Running Subcurticular suture
Indications
- used in surgery, plastics or facial lacerations
- leds to better cosmetic outcomes and used with abosrbable sutures
- can impede with wound drainge!
- this is like a deeper continuouse suture like the running
Vertical Mattress Suture technique
Far far Near Near or Near Near Far Far
Indications
- wound under tension so the edges would evert
- areas with thin skin or decreased subcut. fat
- positives: this helps to close dead space in an alterantiveway to doing a deep dermal
- negatives: this excess tension can breakdownt he would
technique
- throw a stich further out on both sides
- then come back through a small suture
- making two V’s shape to close at one location
- tie it off and do the next
Horizontal Mattress Suture
Indications
- wound under tensions where the edges will invert
- this helps distrubute tension along the wound edges
- good for wide lacerations
- negatives: can lead to scarring and wound breakdown
Technique
- the stiches are placed horzional and aligned with the wound, throwing one in, and across, then repuncturing the skin on the same side next to it
Post Suture Wound Care
- care for the wound
- role of abx.
- topical abx. after repair placed on then BID until sutures are removed
- dress the wound for 24 hours then leave it open to air
- no showering for first 24 hours, then after that you can but do not soak teh suture, pat to dry and be cautious
Prophylatic antibiotics
- healthy pt. with no risk factors: no abx. needed\
- bites: augmentin
- intraoral lac.: augmentin
- nail bed injury cefalexin
- contaiminated wounds: need abx. appropriate for area
Return for Removal
- can have a wound check in 48 hours they reture to look
- if signs/symptoms of infection = come back
Types of Wound Dressings
Role of a Dressing
- promote healing and protect from infection and drama
- absorb any drainage & assiste with hemostatis via compression
- help immobilize the wound
Types
For a Sutured Laceration: nonadhearant dressings: (gauze, kling/kerlix)
For Puncture Wound: dry dressing (guaze)
Chronic Ulcer: foam, hydrocolloid
Dry Wound: hydrogel for hydration
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note on types
hydrogels: add moisture t owound
hydrocolloid: a gel substance is created to keep wounds moist – god for light drainge
foams:for those iwth moderate drainage
aliginate: for excessive drainage
occlusive dressing: never used over puncture wounds or contamined
Time to Suture Removal
face
scalp
trunk
UE
LE
digits palms and soles
Face = 4-5 days
Scalp, Trunk, UE = 7-10
LE = 8-10
digits, palms, soles = 10-14 days
same time frame for staples
Staples
inidciations
contraindications
Indications
- theyre fast!!
- linear lacteraions with staright sharp edges
- good for scalp lac., limbs or trunk
Contraindications
- lac. to face
- CT/MRI needed, cant close with this
Preparaion
- can use topical (LET) /local anesthisia (or just do it)
- wound irrigation
- gloves, dressing, staples, staple removeal, abx. ointment
How its done
- approximate edges with fingers/forceps (slightly evert the skin
- algin stapler in the middle
- press firmly and place stables 0.5-1cm apart
Wound Care
- apply abx. ointmenet and cover for 24 hours
- the remove same time frame as sutures
Tissue Adhesive and Tapes
indications
contraindications
+ and - of it
Indications
- short (< 5cm for glue, < 2.5 for tape) clean and linera wounds with low tension and easy approximation
- thos whos skin tear easily (elderly)
- those with hx. keloid
- face lac
COntraindications
- high tension
- wounds over hands, feet or joints
- mucosal surfaces and moist or hairy
- bite wounds
- allergies
- infected
Positives
- fast, painless and quick
- barrier on its own, no need for a dressing or removal
Negatives
- not initally as strong as a suture
- runoff
- no deep tissue approx.
adhesive glue
procedure
post-procedure
Prep the area: ittigate, no anethesia
hemostaiss
evert wound edges: with fingers/forceps
crush the vital like a glowstick to saturate tip
swipe over edges of wound
allow to dry 30-40 and reapply 3/4 times in an oval pattern
allow 5 minutes for entire drying
Post-Procedure
- no abx. ointment or bandages needed
- slough off in 5-10 days; only come back if infected
Adhesive Tape
indications and procedure
Indications
- fast painless
- negative = does not evert the wound site
Procedure
- irrigate
- apply tape perpendicaulr to the wound 2-3 mm apart
- can use with benzoin
- keep clean for 48 hours and it will fall off in 5
Puncture Wounds
procdure andhow theyre closed
complications
necesary stepts before addressing wound
- pt. (DM, comorbidities)
- FB?
- Xray to asses possible damange or FB (CT or US too)
Procedure
- clean and debriedment of wound
- closure via secondary intension: on their own
- high risk for infection? = wound chekc iwthin 48 hours
Complicatins
- cellulitis
- abcess formation (FB remained) septic arthritis
- tensynovitis
- osteomyleitis
- necortizing soft tissue infection
Puncture Wounds: ABx use
emperic ABX. should be give 3-5 days
- if actively infected: give for 7-11 days
Non-plantar Wounds = risk of staph and beta-hemolyic strep
- emperic abx. = cephalexin
- if already infected: IV cephazolin
- can cover for other bugs depending on hx. of puncture
Plantar Wound = need to cover gor pseudomonas too!! along with strep and staph
Emperic: cipro/levo + cephalexin
MRS RF: IV: zosyn + vanco + cipro if suceptible
