Suturing, knot tying, local anesthesia

Mechanism of injury

Site of injury

Time and place of injury

Contamination status/foreign body

Allergies, current medications, tetanus status, implants

Risk factors for healing

components of history during a wound assessment

What does it look like?

Measurements: length, width, depth

Are deep structures involved? (Neurovascular compromise, tendon or muscle involvement)

What does the wound bed look like? (Necrotic, granular, associated exudate)

Is there evidence of contamination or foreign body?

What does the surrounding skin look like?

what should you be looking for on exam of the wound?

Distal pulses

Sensation: two-point discrimination

Pain rating

components of neurovascular testing during wound assessment

Observe wound while testing muscle and tendon function

component of MSK testing during wound assessment

clean

surgical incision not involving GI, respiratory, or GU tracts

clean-contaminated

surgical incision involving GI, respiratory, or GU tracts

contaminated

surgical incision involving gross spillage; fresh, accidental wounds

infected

Established infection before wound is made or heavily contaminated wounds

Does the wound need to be closed?

Can the wound be closed in the office, ER, OR?

Is there a contraindication to closing the wound, or a reason to delay closure?

considerations 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

indications for wound intervention

Location of wound (delayed closure)

Presence of foreign body

Extensive wounds (nerve, tendon, muscle involvement)

Bleeding disorder

Contaminated

Avulsion injury

(relative) contraindications to wound intervention

Infection

Scarring

Loss of form and function

Loss of cosmetically desired appearance

wound dehiscence

Tetanus

complications to wound intervention

primary intention

all layers are closed

best chance for minimal scarring

clean and clean-contaminated wounds

secondary intention

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

Prolonged process often leaving wide scar are requiring frequent care

utilized when there is infection or extensive tissue loss

third intention (delayed primary)

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

povidone-iodine surgical scrub (betadine scrub)

Strongly bactericidal against gram positive and negative bacteria

Detergent can be toxic to wound tissues

Painful to open wounds. Other reactions extremely rare

Uses: Hand cleanser; presurgical cleanse

povidone iodine solution (betadine solution, duraprep)

contains isopropyl alcohol

Strongly bactericidal against gram positive and negative bacteria

Minimally toxic to wound tissue

Systemic toxicity Extremely rare

Uses: Wound periphery cleanse; pre-surgical cleanse

chlorhexidine (hibiclens, chloraprep)

contains isopropyl alcohol

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

systemic toxicity Extremely rare

uses: Hand cleanser. Alternative wound periphery cleanse; pre-surgical cleanse

hydrogen peroxide

Very weak antibacterial agent

Toxic to red cells

Systemic toxicity Extremely rare

Uses: Wound cleanser adjunct

• 10% betadine solution (diluted 10:1)

what agent is used for wound cleansing

Spiral technique: start in the center and swirl outward from the wound. Do not return to the center!

Debate over whether the wound itself should be cleansed and irrigated vs. irrigated only

technique for wound cleansing

• Onset and duration of action

• Addition of epinephrine

• Local anesthetic buffering

• Toxicity of local anesthetic

• Allergies

• Contraindications and Complications

• Local anesthesia techniques

considerations for local anesthetics

epinephrine

a vasoconstricting agent used to decrease blood flow, reduce systemic absorption, shorten onset, and extends duration of action (~doubles)

More effective with less lipid-soluble agents

Allows larger doses of anesthetic to be provided by decreasing toxic potential

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

sodium bicarbonate

a buffer used to eliminate burning sensation of anesthetic

Increases onset and duration, but decreases shelf-life

topical anesthesia

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

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

Procedure:

1. Select anesthetic

2. Remove clots from area

3. Saturate gauze with anesthetic

4. Fold sponge into and around wound, tape into place

5. Hold gentle pressure for 15-20 minutes

aspirate- indicates you are in a vessel and need to reposition before administering anesthetic

what do you always need to do prior to injecting the local anesthetic

direct infiltration

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

infiltration of intact skin

Typically used for lesion removal and punch biopsy

Procedure

1. Clean intended site

2. angle needle at 90 degrees to inject

3. Infiltrate at the junction of the dermis and subcutaneous fat

4. Reposition to level of epidermis and inject small amount (creates bleb)

field block

Recommended for larger wounds and contaminated wounds

procedure

1. periphery cleanse

2. start injection in subcutaneous layer

3. Insert needle into skin and advance to hub parallel to the dermis and subQ fat

4. Reinsert needle at end of first track and repeat above steps until wall of anesthesia surrounds working area

digital block

Recommended for procedures distal to the midproximal phalanx. *No epinephrine

.Procedure

1. Cleanse intended site

2. Infiltrate just distal to web space of digit

3. After aspirating, inject 0.1ml into the epidermis

4. Advance needle to the bone, withdraw slightly, then move dorsally and inject 0.5-1ml anesthetic after aspiration

5. Withdraw needle to midline, advance to bone, and move ventrally, where another 0.5-1ml is injected after aspiration

6. Withdraw needle and repeat on other side of digit

>5psi

how much pressure is needed for wound irrigation

Normal saline (NS) is most used. In the surgical setting, may be mixed with antibiotic.

what is usually used for wound irrigation

a 35ml syringe with 19-G needle and splash guard are used. This setup allows 7- 8psi, which achieves a high enough pressure to irrigate organisms out of wound.

what equipment is used in most outpatient settings for wound irrigation

lavage with basins of warm NS or use pulsatile lavage (50-70psi).

what may be done for wound irrigation in surgery

Skin adhesives, Tapes, Staples, Sutures

types of wound closures

anatomic location and healing potential

what influences the selection of suture material

surgical gut (plain or chromic), polyglactin

absorbable sutures

silk, stainless steel, nylon, polypropylene, polyester

non-absorbable sutures

monofilament/single stranded sutures

passes through tissue easily but has less tensile strength

multifilamine/multistranded/braided sutures

Stronger but increases potential to harbor organisms

different shaped needles that serve different purposes

different sutures are attached to:

at tip of driver and perpendicular to driver.

where should the needle be located in relation to the driver

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

where should the driver be placed on the needle

90-degree

needle should penetrate the skin at what angle

equal in distance from wound edge

bites on either side of the wound should be:

the same on either side of the wound

depth of suture placement should be:

equally distributed across length of laceration/incision

how should stitches be distributed

simple interrupted

most common stitch used for closing lacerations.

vertical mattress

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

horizontal mattress

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

simple running (baseball)

percutaneous running stitch that may or may not be locked. Quick to perform but can easily come undone and cannot be partially removed.

subcuticular running

running stitch under the skin, often used for surgical incision.

dermal interrupted (buried)

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

square knot

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

granny knot

a knot that is formed when the loop and tail exit on the opposite side of the knot. Not recommended.

surgeon's knot (friction knot)

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.

slip knot (half hitch)

Created with any of the above knots when unequal tension is placed on the suture. Not recommended.

instrument tie

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

one-handed tie

Utilized when working in a small space, or when an instrument or needle is attached to the suture.

two-handed tie

Utilized when closing an area under tension (typically used in surgery, not so much for skin wound closure). Utilizes both hands to apply equal and opposite tension.

Skin creases, areas of movement, long lacerations, hand injuries

List four wound characteristics that would contraindicate use of wound adhesives

D. 5/0 suture

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?

A. 2/0 suture

B. 3/0 suture

C. 4/0 suture

D. 5/0 suture

5-0/4-0 monofilament*

4-0 absorbable

suture size for scalp

6-0 monofilament

suture size for ear

7-0/6-0 monofilament

suture size for eyelid

6-0/5-0 monofilament

5-0 absorbable

suture size for eyebrow

6-0 monofilament

5-0 absorbable

suture size for nose

6-0 monofilament

5-0 absorbable

suture size for lip

5-0 absorbable‡

suture size for oral mucosa

6-0 monofilament

5-0 absorbable

suture size for other parts of face/forehead

5-0/4-0 monofilament

3-0 absorbable

suture size for trunk

5-0/4-0 monofilament

4-0 absorbable

suture size for extremities

5-0 monofilament

5-0 absorbable

suture size for hand

4-0 monofilament

suture size for extensor tendon

4-0/3-0 monofilament

4-0 absorbable

suture size for foot/sole

4-0 absorbable

suture size for vagina

5-0 absorbable‡

suture size for scrotum

5-0 monofilament

suture size for penis

6-8 days

days to removal for scalp

4-5 days

days to removal for face

4-5 days

days to removal for ear

8-10 days

days to removal for chest/abdomen

12-14 days

days to removal for back

8-10 days

days to removal for arm/leg

8-10 days

days to removal for hand

8-12 days

days to removal for fingertip

12-14 days

days to removal for foot

face, neck, scalp

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