Wound & Repair (last 6 pg's) Flashcards
Most commonly used injectable anesthesia for wound care/repair?
Lidocaine
What can be combined with Lidocaine and what are the benefits?
- Epinephrine
- increases duration of anesthesia
- reduces bleeding
What is the onset time and duration for lidocaine?
- Onset: 4-10 minutes
- Duration: 60-120 minutes
Where should you NEVER use anesthetics with epinephrine and why?!
- In anatomic areas with terminal circulation!
- fingers, toes, ears, penis, nose
- Increases risk of tissue necrosis
What is the onset time and duration for Mepivacaine?
-Onset: 6-10 minutes
-Duration: 30-60 minutes (simple blocks
90-180 minutes (nerve blocks)
One benefit of Mepivacaine over Lidocaine?
Less vasoconstriction with Mepivacaine, no need to use epinephrine with it
What can you use to reverse damage with accidental injection of anesthesia/epinephrine in areas with terminal circulation?
Nitroglyceran paste
What is onset time and duration for Bupivacaine?
- Onset: 8-12 minutes
- Duration: 240-480 minutes
3 main types of topical anesthetics?
- Lidocaine cream
- Ethyl chloride spray
- EMLA (lidocaine/prilocaine)
Lidocaine cream - application and duration/effect?
- App: under occlusive gauze
- Duration/Effect: Apply 45 minutes before procedure
Ethyl Chloride spray - application and duration/effect?
- App: Spray 2.5 cm from skin
- Duration/effect: lasts 1 min; turns skin white and hard
EMLA - application and duration/effect?
- App: under occlusive gauze to intact skin
- Duration/effect: apply 45-60 mins before procedure
Direct Wound Infiltration - use and technique?
- used for most minimally contaminated lacerations as an injection technique
- goes from inside wound to outside to reduce infection risk
- plane of injection: beneath dermis at jxn of superficial fascia
3 main types of injection techniques for infiltration?
- Direction Wound Infiltration
- Parallel Margin Infiltration
- Digital Nerve Blocks
Parallel Margin Infiltration - use and technique?
- Advantage of fewer needle sticks; preferred for grossly contaminated wounds
- approach is through intact skin
Digital Nerve Blocks - use and technique?
- MOST COMMON nerve block in minor wound care
- recommended for lacerations distal to the level of mid-proximal phalanx of finger/toe
- preferred for nail removal/paronychia drainage/repair of digital lacerations
Most common nerve block in minor wound care?
Digital Nerve Blocks
What is the rough guideline for how long from time of injury is considered safe to close a wound up?
6-8 hours
The solution to pollution is…
Dilution! :D
Primary wound closure?
- used for clean/uncontaminated lacerations w/ minimal tissue loss
- repair within 6-8 hours from time of injury
- MUST aggressively clean, irrigate, debride wound before closure
Secondary wound closure?
- used for skin infections, ulcerations, abscesses, punctures, small animal bites, partial thickness abrasions, 2nd degree burns
- consists of thorough cleaning, irrigation, and debridement; leave wound open to heal on its own
Tertiary wound closure?
- include bite wounds and lacerations beyond the 6-8 hour window
- high bacteria count, antibiotics can be helpful
- can be converted to ‘fresh’ wounds by I&D and closure; once wound appears clean and uninfected, may be closed
When do you close up a wound from a human bite?
NEVER
3 goals of quality closures?
- Eliminate complications
- Restore function
- Reduce scarring
What are Langer’s lines?
helpful guidelines when closing a wound; correspond to natural collagen fibers in the dermis
What are 3 techniques to help reduce tension and improve wound healing?
- Follow Langer’s lines
- Undermine when necessary
- Use layered closure technique when possible/as needed
What is useful about undermining?
- creates “free” tissue under wound edges
- used for clean wounds only
Generally, you use a ____ size suture for more cosmetically important areas
smaller
2 different types of needles?
- Cutting (most often)
- Tapering
Where should you NEVER grab the tip of the needle to pull it through a bite?
The tip - it will dull it!
What do occlusive, dry dressings help with in wound healing?
- Decrease inflammation
- Increase reepithelialization
layering of wound dressings?
- non-adherent/permeable first layer
- absorbant second layer
- pressure top layer (as needed)
- Gauze with tegaderm or band-aid
When to use steri-strips for wound closure?
- superficial, straight lacs under little tension
- flaps where sutures may compromise vascular supply
- lacs with greater than normal potential for infection
- lacs in elderly/steroid-dependent patient
- support for lacs after suture removal
Advantages of steri-strips?
- easy application
- even distribution of tension
- no suture marks
- application by non-providers
Disadvantages of steri-strips?
don’t work well on oily surfaces, hair, joints, lax skin, gaping wounds, wounds under tension, young or uncooperative patients
Where do tapes not work well?
-irregular surfaces, bloody/wet/secreting wounds, hair, scalp, joints, or intertriginous areas
When to use stapling for wound closure?
- linear, sharp lacs of scalp, forehead, neck, trunk, buttocks, and extremities
- temporary, rapid closure of extensive superficial lacs in patients requiring immediate surgery
Advantages of staples
- quick
- tolerated well once placed
- lower infection rates than suture
When should you NOT use staples?
In areas that are going to be studied by CT or MRI
When to use tissue adhesives (such as Dermabond) for wound closure?
- fresh lac within ‘golden period’
- lacs under low tension & easy to approximate
- edges of wound clean & even
- dry wounds with little to no bleeding
Where should you NEVER use tissue adhesives?
Near the eyes!
Advantages of tissue adhesives?
- flexible
- bacterial barrier
- high breaking strength
- espesh good for the face
- no need for anesthesia
- can shower normally
- peels off spontaneously in 5-10 days (no follow-up needed)
3 Key principles of suture care and wound aftercare?
- Protection
- Elevation
- Cleanliness
3 main things involved in wound aftercare?
- Scheduling for suture removal
- aftercare instructions
- info on what to expect as wound heals
Generally, timeline before suture removal in trunk/extremities?
10-14 days
Generally, timeline before suture removal in face?
3-5 days
Generally, timeline before sutural removal in scalp?
6-8 days
Technique used for suture removal?
Cut under the knot, close to the skin surface
When do most wound infections appear?
Within 4-5 days
Signs of wound infection?
- Excessive discomfort
- Mucopurulent discharge
- Erythema
- Lymphangitic streaks
- Fever
Simple interrupted stitch?
- single sutures, tied separately
- deep or percutaneous
- MOST common suture used
Continuous closure/running simple stitch?
- taking several full length bites of wound without tying individual knots
- knots tied only at beginning and end of closure
- deep or percutaneous
Vertical mattress suture?
- ‘far far near near’ stitch
- take a large bite 1-1.5 cm away from wound edge, coming out equal distance on other side
- needle reversed and returned for a smaller bite at the epidermal/dermal edge
- acts as deep and superficial closure all in one
Horizontal mattress suture?
- used to achieve wound edge eversion
- normal bite taken through both sides of wound, then second bite is taken adjacent to first exit and brought back to the original starting edge, ~0.5 cm from initial entry point
- knot is then tied
Subcuticular running closure?
- often used to close straight incisions
- use non-absorbable suture material
- one strand used, without interruption, for entire laceration
- choose a plane of skin (dermis, superficial cutaneous fascia) and take ‘mirror image’ bites horizontally the full length of the wound
V-Y closure? (corner stitch)
- often used with flaps with damaged, non-viable edges
- edges can be excised to make a smaller, more viable flap
- closes the wound as a “Y” rather than original “V” config.
Bite?
- amount of tissue taken when placing the suture needle in skin or fascia
- includes both depth and width from wound edge
Throw?
each suture knot consists of a series of throws; each throw is a pass through the skin
Knot?
used to tie sutures during wound closure
Most common knot?
Surgeon’s knot
If you don’t like the way a particular suture looks, what should you do?
-Cut it out and START OVER
