Laceration Repair (Skills)

Goals of Wound Care

Restore function

Repair tissue intergity

Optimize cosmetic apperance

Minimize infection risk

What are the types of wound clousre

Primary Intenion

Secondary Intenion

Teritary Intention

Primary Intention

Means of closing the skin ourselves (suture, staples etc.)

When is primary intention used

Simple clean wound

Secondary intention

Letting the body itslef heal via granulation tissue, contractrion, and epithelialization

When is secondary intention used

Infected wounds

Ulcerations

Abscesses

Abrasions

Bites

Teritary Intention

Delaying primary intention by I&D and observing for 5 days before closing

when is teritary intention used

Contamined wounds

Crush injuries have a potential for

Compartment syndromeI

Important hx for laceration repair

MOI

Golden Hour

Anatomic Location

Worker’s Compensation

Tetatnus status

How long after an injury does bacteria grow to infectious level

3 hours

What is the acceptable timing for wound care

Body / Extermity = 12 hour

Face / Scalp = 24 hour

Face Wound = 72 hour

Who shoud get a tetanus shot for wound care?

Non-tetanous prone + > 10 years for last shot

Tetanus prone and > 5 years for last shot

Not hx of shor or differeniated between Td or Tdap

What makes a wound tetanus prone

> 6 hours old

> 1 cm deep

Stellate or Avlusion

Devitalized tissue

Contaminated

From a missile (GSW)

Puncture or Crush

Associated burn

Associated frostbite

What should be done for PE of a laceration

Clean it

Measure

Foreign Body Asssess

Depth and Tendon Involvement

NV status

Fractures

What are components of NV status

Circulation

Motor

Sensory

What is most commonly used suture

Nylon

When is prolene preferred to nylon

Hairy areas

What are the absoble sutures

Gut

Chromic

Synthetic

What are the non-absorbed sutures

Polypropylene

Nylon

Silk

Polyester

Steel

When are absorbable sutures used

Layered closure

Lip Lac

Mouth Lac

What are gut absorable sutures made from

Cow / Sheep submucosa

What are chromic sutures

Gut sutures with chromium salts added to double life

When are synthetic absorb sutures used

SubQ layers

What are the syntehtic absorb sutures

polyglycolic acid (Vicryl) - braided suture

polyglactin 910 (PGLA)- braided suture

poliglecaprone (Monocryl) - monofilament suture

polydioxanone (PDS)- monofilament suture

How are sutures sized

n-0 (1-0 to 6-0)

Bigger number = Smaller material

What determines the size of the suture

Locaiton

Tension

Cosmesis

When should 1-0 and 2-0 sutures be used

High stress areas needing strong retention

What sized suture is best for deep fasica repair

1-0 / 2-0

When are 3-0 sutures used

areas that need good retention but not high stress

What areas do you use 3-0

Torso

Extremity

Joints

Gaping wound

When are 4-0 sutures used

Trunk or extremity where more strength is needed

Scalp

When are 5-0 sutures used

Areas of the face with more tension

Ears

digits

Palms

Soles

Scalp

When are 6-0 sutures used

Areas needing little to no retention

face

eyelid

Vemillion border

Cosmetic Concerns

What are the parts of the needle

Swage

Body

Point

Swage

The press-fit of the thread to the needle

What are the needle sizes

11mm

13mm

16mm

19mm

What are the curves for needles

¼ circle

3/8 circle

½ circle

5/8 circle

What is the most common needle curve

3/8 circle

When are ¼ circles used

Easy access to convex surface

Opthlamic procedure

Microsurgical procedure

When are 3/8 circle used

Large superficial wounds

When are ½ circles used

Confined locations

When are 5/8 needle used

Deep confined holes

What are the stures types

Simple interrupted

Simple running

Simple buried

Subcuticular running

Vertical mattress

Horizontal mattress

Figure 8

What is the most common suture

Simple interrupted

What suture is used to close fascia

Simple running

What suture is used to for layered closure

Simple buried

What suture has the best cosmetic outcome

Subcuticular running

Benefit to a verticular mattress

Decrease dead space

Increase eversion

Benfit to a horizontal mattress

Even tension along edges

What suture is used for vasculature

Figure 8

Uses of Figure 8 sutuire

Vessesl

Hemostatis

Fascia

quick suture

If closing a simple lac with simple interrputed sutures, where do you place the suture

Close in halves

What tie should be done for simple interrputed sutures

Instrument

Where should knots be for simple interrputed sutures

One side

How long are tails for simple interrputed sutures

1/4-1/2 inch

How are scissors and needleholders held

thumb and ring fingers in rings

thumb in ring, no fingers

no thumb in rings, ring finger in rings

no fingers in rings

How are forceps held

Pencil

Rule of 5

sutures placed 5 mm from would edge and 5 mm apart

What should be done with edges when suturing

Evert

How is a needle introduced to the wound

needle to skin at 90-degree angle

Drive the needle in one motion by supinating

What happens if you push the needle while supinating

Bends the needle

How can a bloodless field be created for simple lac

TourniCot or inflated BP cuff

How long can a TourniCot be applied

1-2 hours

What define the approximation of a surgeon’s knot

Opposing throw at the end

Why do we use 3 throws for a surgeon’s knot

Too few = Unravel

Too many = Stitch abscess

Langerhans Lines (Tension Lines)

Natural tension lines in the skin resulting from collagen fibers

How does tension play a role in wound repair

More tension = More defect

Vermillion Borders

The border between lips and skin

What is the first thing to fix with lip lacs

Vermillion Border

What type of dressing decreases infection in sutures

Occlusive

What goes ino after care for sutures

Clean twice per day with mild soap and water

When do we consider Abx for wound care

Bites

Most common adverse oucomes from stures

Scarring

Infection

What causes of adverse outcomes can we control

Rushing

Uneven wound edges

poor technique

What are red flags with sutures

Redness

Swelling

Purulent drainage (clear serous drainage okay)

Severe pain

Loss of function

Streaking up the arm

Fever > 102.4 F

Who can be consulted for sutures

Plastics

Ortho

When would plastics be consulted for suture

Cosmetic concenr

When is ortho consulted on sutures

Tendon involvement

Open Fracture

AMputation

What should you do if consulting for lac repair

Clean wound

Steril dressing

Determine tetanus

Possibly splint

Start Abx

What abx is given for aftercare of lac repair

Triple Abx Ointment

• Bacitracin Zinc

• Neomycin Sulfate

  • Polymixin B

What are alternatives to sutures

Dermabond

Streistreps

Staples

Healing by secondary intention

Skin glue (Dermabond)

synthetic adhesives that polymerize on contact

exothermic reaction forms strong wound closure

When does the skin glue slough off

7-10 daus

What wounds are good for skin glue

1-1.5 cm

Face with little tension

Fingertips

Surgical use

Steps to Applying Dermabond

Clean and irrigate as usual

MUST BE DRY or BLOODLESS

Approximate the edges or have assistant to hold

Crack tube, squeeze tube, and roll on

Apply one layer, wait, apply another. 2-3 layers.

Cover with bandage after complete dry, not tacky

NO antibiotic ointment

Uses of steristrips

Close primary wound

Skin tears

Reinforce layered repairs

Reinforce wound suture removal

What is good practice for applying steri-strips

Can be applied benzoin to both side of dry wound (but can be irritating)

Apply with clean gloves

Steps to Apply Steristrips

Apply benzoin to skin around wound

Open the Steri-strips and cut to length

Grab the Steri-strips using forceps

If needed, have assistant approximate edges

Apply Steri-strips

When are staples used in place of sutrues

acute care and operating room (OR)

Scalp lacerations

When do face sutures come out

3-5 days

When do scalp sutures come out

6-8 days

When do chest sutures come out

8-10 days

When do UE sutures come out

7-10 days

When do LE sutures come out

10-14 days

When do back sutures come out

10-14 days