Laceration Repar

restore function

repair tissue integrity

optimize cosmetic appearance

minimize risk of infection

Wound care goals?

primary intention

for simply, relatively clean wounds

variety of methods - suture, staples, commercial adhesive, steri-strips

secondary intention

letting the body heat it up by itself

for infected wounds, ulcerations, abscesses, abrasions, animal/human bites

allows skin to heal via granulation tissue, contraction & epithelialization

tertiary intention

delayed primary intention

for wounds too contaminated with soil, feces, saliva

irrigation and debridement and observe it for 5 days before closure

MOI, golden hour, anatomic locaiton, if worker’s compensation, tetanus status

hx questions for a patient

3

Within ___ hours after injury, bacteria growth at a level to cuase infection

12 hours

Acceptable golden hour for body/extremities?

24 hours

Acceptable golden hour for face and scalp?

indicated

If non-tetanus prone and last shot >10 years…

indicated

if tetanus prone and last shot >5 years….

any patient without tetanus vaccination hx or cannot differentiate td vs tdap

What patients should always get tetanus?

>6h old

>1 cm deep

stellate or avulsion configuration

devitalized tissue

contaminated

from a missile

puncture or crush

associated w/ burn

associated w/ frostbite

tetanus prone wounds?

nylon, porlene

What are the two non-absorbable sutures?

nylon

black, most commonly used, ties well, little tissue

prolene

blue, good for hairy areas, slippery

2-6 weeks

absorbable sutures are all biodegrade within _____ weeks

layered closures, lip/mouth lacs

absorbable sutures are best for what?

gut, chromic, synthetic

What are the 3 types of absorbable sutures?

gut

from cows/sheep submucosa, varied knot holding

chromic

gut with chromium salts, doubles life suture

synthetic

minimal tissue reaction, knot hold can be tough

polyglycolic acid

smaller

smaller or larger suture material as the number increases?

1-0 and 2-0

high stress areas requiring strong retention, i.e. deep fascia repair

3-0

areas requiring good retention, i.e. torso, extremities, joints, gaping wounds

4-0

Trunk or extremities where more strength of retention is needed, scalp

5-0

areas involving the face with more tension, ears, digits, palms, soles, scalp

6-0

areas requiring little or no retention, face, esp eyelid, vermillion border, cosmetic concerns

bigger

bigger bites, _____ needles

¼ circle

this needle has shallow curvature

used on easily accessible convex surfaces

typically used for ophthalmic and microsurgical procedures

3/8 circle

MOST COMMONLY USED NEEDLE

curvature makes it easy to manipulate in large and superficial wounds

difficult to use in deep cavities due to the large arc of manipulation needed

½ circle

this needle is to be used in confined locations

requires more pronation and supination of wrists

5/8 circle

this needle is ideal for deep, confined hole

often used by rotating the wrist with little to no lateral movement

simple, interrupted suture

most common outpatient/ED

simple running suture

most commonly used to close fascia

simple buried suture

layered closure

subcuticular running suture

best cosmetic outcome when done well

vertical mattress suture

decrease dead spaced and increase eversion

horizontal mattress suture

evenly distribute tension along edges

figure 8 suture

for vascular procedures and for hemostasis, used for fascia also, can be for quick suturing

halves

if simple laceration close the wounds in ______

all

instrument tie how many knots?

one

bring knots to two or one side?

pencil

when holding forceps how should they be held?

approximation without strangulation

equidistant placement

strategies

evert edges

Suturing principles?

for consistency

Why do we need equidistant placement?

rule of 5

sutures placed 5mm from would edge and 5mm apart

50% rule

taking laceration and dividing it in half and putting a suture there then dividing each half in half until the wound is closed

tournicot or inflated BP cuff to create bloodless field

What to do when you can’t see the wound because of blood?

supinate

When we drive the needle into the wound should we push or supinate?

90 degree

What degree should we introduce the needle to the skin?

1 knot

2 throws = ___ kknot

square

opposing throws = ____ knot

slip

throws in same direction = ____ knot

surgeon

double wrap throw + opposing throw = ___ knot

2 more

Follow surgeon’s knot with at least ___ more throws

smaller stitch or greater tension

When should we more knots?

take it out

What should you do if you don’t like how the stitch looks

langerhans (tension) lines

result of collagen fibers

tension varies on location

must be a consideration in how you decide to repair the wound

surface area

jagged/uneven wounds have a greater ____ ____

defect & worse outcome

the greater the tension, the greater the ….

cutting the skin

convert a jagged wound to a linear one how?

nylon

For vermillion borders, you can use what non-absorbable for the skin?

vicryl

For vermillion borders, you can use what absorbable for the subdermal?

occlusive dressings

What decreases the rate of infection?

clean the area with mild soap and water 2x a day

antibiotics if indicated

non-purulent drainage is okay

What should you tell the patient about aftercare?

can slow healing, will probably be painful

Why should we avoid hydrogen peroxide, iodine-based solutions or alcohol for aftercare of a wound?

scarring, infection

What are the most common adverse outcomes?

rushing, inverted or uneven wound edges, poor technique

What are some things we can control when suturing to prevent adverse outcomes?

redness, swelling, purulent drainage, severe pain, loss of function, streaking up the arm, fever >102.4, when in doubt come back

Red flags for sutures?

plastics, orthopedics

Who should you consult?

dermabond, steristrips, staples, healing by secondary intention

What are some alternatives to sutures?

skin glue

synthetic adhesives that polymerize on contact, exothermic reaction forms strong wound closure

sloughs off in 7-10 days

can get wet

not for deep wounds or high tension, usually wounds with little tension like on the face

Wound selection for skin glue?

steri-strips

aka paper tape or butterfly sutures

benzoin

For steri-strips what must you apply to the skin before putting it on?

no

Can you expose steri-strips to water?

acute care and operating too

scalpe lacerations

poor comesis

When are staples used?

no, can increase infection risk instead trim or slick it back w/ vaseline

Should we shave hair?