Suturing, Knot tying, and Local Anesthesia

What are the components of neurovascular testing during wound assessment?

- distal pulses

- sensation: two-point discrimination

- pain rating

What are the components of MSK testing during wound assessment?

Observe wound while testing muscle and tendon function

What is considered a clean wound?

surgical incision not involving GI, respiratory, or GU tracts

What is considered a clean-contaminated wound?

surgical incision involving GI, respiratory, or GU tracts

What is considered a contaminated wound?

surgical incision involving gross spillage, fresh, accidental wounds

What is considered an infected wound?

established infection before wound is made or heavily contaminated wounds

What are indications for wound intervention?

- decrease time required to heal

- reduce likelihood of infection

- decrease amount of scar tissue

- repair loss of form and function

- improve cosmetic appearance

What are the (relative) contraindications to wound intervention?

- location of wound (delayed closure)

- presence of foreign body

- extensive wounds with nerve, tendon, or muscle involvement

- bleeding disorder

- contaminated

- avulsion injury

What are the complications to wound intervention?

- infection

- scarring

- loss of form and function

- loss of cosmetically desired appearance

- wound dehiscence

- tetanus

What are the three kinda of wound closure classification?

- primary intention

- secondary intention

- third intention (delayed primary)

What is primary intention wound closure?

- all layers are closed

- best chance for minimal scarring

- clean and clean-contaminated wounds

What is secondary intention wound closure?

- deep layers are closed, superficial layers are left open to granulate

- Prolonged process often leaving wide scar and requiring frequent care

- utilized when there is infection or extensive tissue loss

What is third-intention wound closure?

- deep layers closed primarily, superficial layers left open until reassessed

- On reassessment: irrigated and closed if clean appearing with granulation tissue; left open if it appears infected

- these wounds often arise from contaminated wounds

What is povidone-iodine surgical scrub (betadine scrub) as a skin cleansing agent?

- strongly bactericidal against Gram-positive and Gram-negative bacteria

- detergent can be toxic to wound tissues

- painful to open wounds

- Uses: Hand cleanser or presurgical cleanse

What is povidone iodine solution (betadine solution, duraprep) as a skin cleansing agent?

- Strongly bactericidal against gram positive and negative bacteria

- minimally toxic to wound tissue

- systemic toxicity is extremely rare

- Uses: Wound periphery cleanse or pre-surgical cleanse

What is chlorhexidine (hibiclens, chloraprep) as a skin cleansing agent?

- Strongly bactericidal against gram positive bacteria, and less strong against negative bacteria

- systemic toxicity is extremely rare

- uses: Hand cleanser, an alternative wound periphery cleanse, or pre-surgical cleanse

What is hydrogen peroxide as a skin cleansing agent?

- Very weak antibacterial agent

- toxic to red cells

- Systemic toxicity is extremely rare

- Uses: Wound cleanser adjunct

What agent is used for wound cleansing?

10% betadine solution

What is the technique for wound cleansing?

Spiral technique: start in the center and swirl outward from the wound and do not return to the center

What are the considerations for local anesthetics?

- Onset and duration of action

- Addition of epinephrine

- Local anesthetic buffering

- Toxicity of local anesthetic

- Allergies

- Contraindications and Complications

- Local anesthesia techniques

What are the three local anesthetics?

- lidocaine

- mepivivaine

- bupivicaine

What is epinephrine in term of local anethetic use?

- a vasoconstricting agent used to decrease blood flow, reduce systemic absorption, shorten onset, and extends duration of action

- more effective with less lipid-soluble agents

- allows larger doses of anesthetic to be provided by decreasing the toxic potential

- Use caution (don't use) in body regions supplied by single vascular source because it may cause tissue necrosis

What is sodium bicarbonate used for for local anesthetic?

- a buffer used to eliminate the burning sensation of an anesthetic

- increases onset and duration, but decreases shelf-life

When is the topical anesthesia technique used?

- For intact skin, and generally not used on mucous membranes --> leads to systemic toxicity

- Typically used for uncomplicated lacerations (<5cm) and pediatric patients

What do you always need to do prior to injecting the local anesthetic?

aspirate: flashback indicates you are in a vessel and need to reposition before administering an anesthetic

When is the direct infiltration technique used?

Recommended in most minimally contaminated wounds

Procedure:

1. Initiate injection on side where sensory innervation originates

2. Aspirate, reposition, if necessary, aspirate and inject if no blood is drawn

3. Continue to repeat steps above until all wound edges are anesthetized

direct infiltration

When is the infiltration of intact skin technique used?

typically used for lesion removal and punch biopsy

When is the field block technique used?

recommended for larger wounds and contaminated wounds

When is the digital block technique used?

- recommended for procedures distal to the midproximal phalanx

- no epinephrine

how much pressure is needed for wound irrigation?

>5psi

What is usually used for wound irrigation?

Normal saline (NS)

What are the types of wound closures?

- Skin adhesives

- Tapes

- Staples

- Sutures

What influences the selection of suture material?

anatomic location and healing potential

What are the absorbable sutures?

- surgical gut (plain or chromic

- polyglactin

What are the non-absorbable sutures?

- silk

- stainless steel

- nylon

- polypropylene

- polyester

What are monofilament/single-stranded sutures?

passes through tissue easily but has less tensile strength

What are multifilamine/multistranded/braided sutures?

stronger but increases potential to harbor organisms

Where should the needle be located in relation to the driver?

- loaded at tip of driver

- perpendicular to driver

Where should the driver be placed on the needle?

in the proximal third (swage) of the needle approximately where the swage and body meet

needle should penetrate the skin at what angle?

90-degree

bites on either side of the wound should be:

equal in distance from wound edge

depth of suture placement should be:

the same on either side of the wound

how should stitches be distributed on the wound?

equally distributed across length of laceration/incision

What is the most common stitch used for closing lacerations?

simple interrupted

What is used to evert wound edges, in areas of increased tension, and to close wound at two levels?

vertical mattress

What is used to close flap tissue or where tension is needed on one side of wound/incision?

horizontal mattress

What percutaneous running stitch that may or may not be locked, is quick to perform but can easily come undone and cannot be partially removed?

simple running (baseball)

What is a running stitch under the skin, and often used for surgical incision?

subcuticular running

What interrupted stitches is placed in the dermis to decrease tension on surgical incision and/or to close dead space?

dermal interrupted (buried)

What a knot that is formed when the loop and tail exit on the same side of the knot?

square knot

What is a knot that is formed when the loop and tail exit on the opposite side of the knot and is not recommended?

granny knot

What is a type of square knot in which the first knot is created with two turns through the first loop, and one turn through the second loop squaring the knot?

surgeon's knot (friction knot)

What is created with any of the above knots when unequal tension is placed on the suture, and is not recommended?

slip knot (half hitch)

What is ytilized to decrease overall tension on the wound, when suturing delicate structures, or when the suture is too short to hand tie?

instrument tie

What is utilized when working in a small space, or when an instrument or needle is attached to the suture?

one-handed tie

What is utilized when closing an area under tension (typically used in surgery, not so much for skin wound closure), and utilizes both hands to apply equal and opposite tension?

two-handed tie

List four wound characteristics that would contraindicate use of wound adhesives?

- Skin creases

- areas of movement

- long lacerations

- hand injuries

A patient comes into the emergency department for a laceration of the eyebrow occurring just prior to arrival. The mechanism of injury involved a clean razor blade. What suture size should be used for this percutaneous repair?

5/0 suture

3 multiple choice options

What are three skin locations that, due to their highly vascular composition, can be closed up to 24 hours following the injury?

face, neck, and scalp