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Page 1: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Wound Care and Repair

By Dr. Kawair

Page 2: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Wound CareLecture Outline

ƒ Proper sequence for routine wound repair

ƒ Options for choices of local anesthetics & types of sutures

ƒ Basic suturing techniquesƒ Options for post-suturing wound

careƒ "Secondary" aspects of wound

care

Page 3: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Objectives of Wound Care

ƒ Lessen painƒ Prevent infectionƒ Enhance healingƒ Achieve best cosmesis

Page 4: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Classification Scheme for Wounds

ƒ Abrasion : tangential, superficial injury to epidermis only

ƒ Simple laceration : linear, short length break in epidermis

ƒ Deep laceration : penetrates to dermis +/- deeper structures

ƒ Complex laceration : irregular edges (nonlinear), +/- deep

ƒ Skin avulsion : complete removal of epidermal +/- dermal tissue

ƒ Crush injury : vertical compression injury to epidermis & dermis

ƒ Burns : thermal or chemical coagulation of epidermis / dermis

ƒ Frostbite : freezing injury to epidermis / dermisƒ Infected : established microbial invasion of tissueƒ Wounds associated with other injuries : open

fractures, etc.

Page 5: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Surgical Wound Types Classification

ƒ Type I : "Clean" ; usual infection risk 1 to 5 %

ƒ Type II : "Clean-contaminated" ; infection risk 5 to 10 %

ƒ Type III : "Contaminated" ; infection risk 10 to 15 %*

ƒ Type IV : "Dirty" ; infection risk 30 to 50 %*

*Most wounds seen in the E.D. are Type III or IV (since they occur through unprepped skin)

Page 6: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Surgical Wound Types Classification (continued)

ƒ Type I ("Clean")–Nontraumatic–No inflammation present–No break in technique–Example : elective groin hernia repair

ƒ Type II ("Clean-contaminated")–Nonsterile body region entered (GI or GU tract, biliary tract, resp. tract, oropharynx, etc. )–Or minor break in technique

Page 7: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Type III : Contaminated Wounds

ƒ Major break in techniqueƒ Gross spillage from GI tractƒ Infected GI, GU, or biliary tract

enteredƒ Fresh traumatic wound

( through unprepped skin)

Note that the overall infection rate in the Type III wounds seen in the E.D. should be only about 3 %

Page 8: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Type IV : Dirty Wounds

ƒ Wounds associated with perforated viscus

ƒ Traumatic wounds with :–Imbedded foreign body–Fecal contamination–Delayed presentationƒ > 12 to 24 hours for face or scalpƒ > 6 hours elsewhere on body

ƒ Crossing clean tissue to drain pus

Page 9: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Proper Sequence of Steps for Routine Wound Care & Repair

ƒ 1. Adequately expose the wound area.–need wide area exposed for adequate prep margins.

ƒ 2. Remove superficial contaminants (gravel, etc.).–leave deeply imbedded objects in place for removal in O.R.

ƒ 3. Cleanse around the wound.–most cleansing agents damage exposed deep tissues.

ƒ 4. Consider local hair removal.–usually do not need to remove hair (can just slick it down with betadine or K-Y jelly).–shaving increases wound infection rates.–local shaving causes temporary cosmetic problem.–NEVER shave an eyebrow (it might not grow back).

Page 10: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Proper Sequence of Steps for Wound Care & Repair (cont.)

ƒ 5. Irrigate the wound : the most important step for reducing bacterial counts in the wound.–18 or 19 gauge needle and 20 to 30 cc. syringe give best irrigation pressure (about 20 psi).

ƒ 6. Reprep wound edges.–need to prep area larger than the drape fenestration.

ƒ 7. Drape the wound.ƒ 8. Locally anesthetize the wound.ƒ 9. Close (suture) the wound.ƒ 10. Dress and bandage the wound.ƒ 11. Instruct the patient in followup wound

care.

Page 11: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Advantages of Locally Anesthetizing Wounds After the Irrigation & Prep

ƒ Can keep sterile syringe on tray for additional later local anesthesia if needed

ƒ Uses only one pair of gloves & one anesthetic syringe (saves money)

ƒ Less risk of introducing infection into tissue adjacent to wound ( by only injecting into wound surface after irrigation and cleansing of wound)

Page 12: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Wound Edge Prepƒ Important to prep a wide area in case the drapes

slipƒ For finger wounds, should at least prep the

adjacent surfaces of the 2 adjacent fingersƒ For very dirty hands, consider placing a sterile

surgical glove on the patient's hand, & then tear off a portion of the glove to expose the wound area

ƒ Should use an agent with a broad antimicrobial spectrum (e.g. Betadine or Hibiclens)–Most agents need to dry on skin to achieve the best antimicrobial effect

ƒ Try to avoid getting the prep agent on the exposed deeper tissue (try to keep it just on the skin surface)

Page 13: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Choices for Wound Irrigation Fluidsƒ Usual choice : normal saline

–Cheap, isotonic ; however, not bacteriacidalƒ Normal saline with 3 ppm iodine (2 to 3 gtts iodine

per liter)–Perhaps best choice–Bacteriacidal but not tissue toxic

ƒ Normal saline with antibiotics ( 1 gram of 1st generation cephalosporin per liter)–Bacteriacidal but expensive–Mild risk of sensitization

ƒ Poloxamer 188 ("Shur-clens")–Surfactant agent ; not bacteriacidal–Expensive compared to normal saline

Page 14: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Poor Choices for Wound Irrigation Fluids

ƒ Sterile water–Hypotonic ; will damage exposed tissue

ƒ Full strength (10 %) povidone iodine (Betadine)–Damages tissue & WBC's

ƒ Full strength clorhexidine gluconate (Hibiclens)–Damages tissue & WBC's–Toxic also to cornea & middle ear

ƒ Hydrogen peroxide 10 to 30 %–Damages tissue & WBC's

ƒ Hexachlorophene 3 % (Phisohex)–Damages tissue & WBC's–Only effective against gram positive bacteria

Page 15: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Local Anesthetic Agentsƒ Lidocaine (Xylocaine)

–0.5 to 2.0 % concentrations–Available with & without 1: 100,000 epinephrine (epi)–Dose limits :

ƒ 5 mg/kg without epiƒ 7 mg/kg with epi

–Topically doesn't work well–Buffering (1 cc of 1 meq/cc or 7.5 % Na HCO3 added to 9 to 10 cc of lidocaine solution) and warming decrease pain of infiltration

ƒ Buffered lidocaine is stable at least one week

Page 16: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Local Anesthetic Agents

ƒ Bupivacaine (Marcaine)–0.25 to 0.75 % concentrations–Available with & without 1 : 200,000 epi–Same local anesthetic class (amide) as lidocaine–Can yield up to 6 to 8 hours of local anesthesia–Can be mixed as 1 : 1 0.5 % Marcaine & 2 % lidocaine for digital or intercostal or wrist blocks–Dose limit is variable

ƒ Usually quoted as 2.0 to 2.5 mg/kg

Page 17: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Allergy to Local Anesthetic Agents

ƒ Allergy to amide local anesthetics is rareƒ Most reactions are actually due to

intravascular injection and vasodilatationƒ Can use cardiac lidocaine (has no

preservative) if allergy to the preservative is suspected

ƒ If allergy to amide local anesthetic is suspected, then options are :–Use an ester class local anesthetic

ƒ Procaine (Novocaine) or tetracaine–Use 1 % diphenhydramine (Benadryl) injection–Use slow injection of normal saline with benzyl alcohol preservative

Page 18: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Local Anesthetic Injection Technique

ƒ Best to use 27 gauge or smaller needleƒ Inject slowlyƒ Inject through wound surface (is more

painful to inject through intact skin next to wound)

ƒ If 1 & 1/2 inch (3 cm) needle is used, can gradually advance a bleb along the entire length of one side of a short wound with just one stick per side

ƒ Do not usually need to pull back on syringe before injecting ; just look for raising of subcutaneous bleb (the area of the bleb should be well anesthetized)

ƒ For digits, inject on proximal side firstƒ Should limit to 3 cc volume per digit

Page 19: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Use of TACƒ TAC = tetracaine (0.5 %), adrenalin (1:2000), &

cocaine (11.8 %)ƒ Excellent topical anesthetic for open woundsƒ Contraindicated for:

–Wounds on or near mucosal surfaces (due to rapid absorption of cocaine)–Areas of body served by end arteries (digits, penis, ear lobes, tip of nose)–Pregnancy–History of high BP or CAD–Allergy to components

ƒ Most useful for scalp or face lacerations in children

Page 20: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Use of TAC (cont.)ƒ Dose limit : 2 cc for adultsƒ Takes 10 to 15 minutes to workƒ Blanching of wound margins confirms

effectƒ Blanched areas are anestheticƒ For small wounds soak cotton-tipped

applicators in TAC & place directly in wound

ƒ For larger wounds place soaked cotton ball or 2x2 inch gauze pad in wound

ƒ Apply gentle continuous pressure also over wound to facilitate TAC entry into tissue

Page 21: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Use of LET (Lidocaine-Epinephrine-Tetracaine)

ƒ Composed of 4 % lidocaine, 1:2000 epi, 0.5 % tetracaine

ƒ Has largely superseded the use of TAC because of its greater safety and lesser cost

ƒ Unlike TAC, it is safe to use on or near mucous membranes

ƒ Other contraindications same as for TACƒ Application technique same as for TAC

Page 22: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Regional Anesthetic Technique"Minidose" Bier Block

ƒ Indications–Multiple or extensive lacerations of hand, wrist, or foot–Fracture or dislocations of hand, wrist, or foot, especially if multiple

ƒ Safer than previously reported (higher dose) Bier block technique since total amount of lidocaine used in the "minidose" block is nontoxic

Page 23: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Minidose Bier BlockProcedural Sequence

ƒ Place double BP cuffs on limbƒ Place IV catheter distally in limbƒ Raise limb +/- Esmarch bandage wrap ( to

exsanguinate the limb)ƒ Inflate proximal BP cuff (> systolic BP)ƒ Infuse 1.5 mg/kg lidocaine in IVƒ Wait 15 minutesƒ Inflate distal cuff & deflate proximal cuffƒ Perform the wound repair or fracture reduction

procedureƒ Deflate distal cuff

Page 24: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Choice of Suture Needle Type

ƒ Cutting needle–triangular in cross section–can punch through tough skin–however can tear delicate tissues–main use : epidermis repair (outer layer)

ƒ Taper needle–round or circular in cross section–does not puncture epidermis well–good for fascia & deep tissues

Page 25: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Cutting and taper needles

Page 26: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Choice of Suture Typeƒ Nonabsorbable

–Indications:ƒskin repairƒfascia under tensionƒvascular (blood vessel) repairs

ƒ Absorbable–Indications:

ƒsubcutaneous layersƒ intraoral mucosa (including tongue)ƒfascia not under tension

Page 27: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Suture Type Comparison

ƒ Monofilament (single strand)–Advantages :ƒ Less reactiveƒ Less likely to become infected

ƒ Braided (multiple strands wound around each other)–Advantages :ƒ Greater tensile strengthƒ Easier to tie knotsƒ Knots hold better

Page 28: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Comparison of Nonabsorbable Sutures

ƒ Nylon (Dermalon) : inexpensive, fine for most skin repairs.

ƒ Polypropylene (Prolene) : smoother & stronger than nylon ; blue color makes it easier to see on dark-haired scalp ; requires 8 knot throws to secure ; is the best pull-out suture.

ƒ Braided nylon (Surgilon) : combines strength of nylon with tying ease of silk ; very expensive.

ƒ Silk : more reactive, more infection risk ; used by some dentists for intraoral suture ; it has no advantages over other better sutures.

ƒ Wire (stainless steel) : least reactive & strongest type of suture ; difficult to tie & uncomfortable for patient ; requires wire cutters for removal.

ƒ Cotton : obsolete (high tissue reactivity & infection potential).

Page 29: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Comparison of Absorbable Sutures

ƒ Plain gut : absorbs in 5 to 10 days (by inflammation).

ƒ Chromic gut : absorbs in 10 to 14 days (by inflammation).

ƒ Polyglycolic acid or polyglactin (Vicryl, Dexon) : absorb in 30 to 90 days (by hydrolysis) ; are braided ; are stronger, less reactive, and last longer than gut sutures.

ƒ Polydioxanone (PDS) : absorbs in 100 to 210 days ; monofilament ; minimally reactive ; smooth to tie.

ƒ Gut type of sutures shown in studies to cause more wound pain.–Also can cause wound redness & swelling simulating wound infection.

Page 30: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Suture Size Guidelines

Wound Location Recommended Suture Size

Scalp 3-0 , 4-0 Face 6-0, 5-0 Chin 6-0, 5-0 (2

layer) Trunk 4-0 Arm 4-0 Hand 5-0 Leg 4-0 Foot 4-0, 3-0

General rule : 6-0 on face, 5-0 on hand, & 4-0 elsewhere on body

Page 31: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Suture Removal Guidelines

Wound Location Suture Removal (Days)Scalp 7

Face 3 to 5 Chin 7 Trunk 7 to 10

Arm 7 to 10

Hand 10 to 14

Leg 10 to 14

Sole of foot 14 to 21

Page 32: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Factors to Consider Leaving Sutures in Longer Than Listed on Previous Slide

ƒ Insulin - dependent diabetesƒ Chronic steroid useƒ Immunosuppressedƒ Poor nutritionƒ Age > 70 years

Page 33: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Cosmetic Wound ClosureAlternative Techniques

ƒ Steri-strips–Good if wound edges not under much tension–Tinture of benzoin helps hold strips–Okay if patient won't get wound wet for 3 days–Start at center of wound & bisect outwards

ƒ Running subcuticular polypropylene suture–Probably best cosmetic suture–Difficult to learn–Can tie knots at both ends to anchor–Helpful to buttress with steri-strips

Page 34: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Method of application of Steri-Strips (apply benzoin to skin first so tape strips adhere better)

Page 35: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Steri strip application technique

Page 36: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 37: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Lines of Least Skin Tension : "Lines of Langer"

ƒ Should perform debridements & elliptical biopsy incisions parallel to the lines of least skin tension to minimize scarring

ƒ Lines of Langer generally run parallel to natural skin folds or perpendicular to the underlying muscle fibers ; for example :–Horizontal on forehead–Circumferencial on forearm or leg

Page 38: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Elective incisions best made parallel to the Lines of Langer

Page 39: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Use of Staples to Close Wounds

ƒ Advantage : speedƒ Disadvantages :

–Uncomfortable for patient–Requires staple remover to remove–Poorer cosmetic result

ƒ Main use in E.D. :–Rapidly close an actively bleeding scalp laceration in the patient who must be rushed off for emergent other diagnostic tests or surgery

Page 40: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Holliman's 3 Rules of Plastic Surgery

ƒ If these are followed, the repair will be of "plastic surgery quality"

ƒ 1. Plan what you're going to do (line up the corresponding skin points on opposite sides of the laceration)

ƒ 2. Take your timeƒ 3. Use a very large number of

little tiny stitches

Page 41: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Basic Suturing Technique

ƒ Grasp needle with needle holder (instrument clamp) at 90 degree angle

ƒ Grasp needle about 1/3 of the way up from the suture end of the needle

ƒ Hold needle holder with thumb in one finger hole, 4th finger in the other finger hole, and second finger extended for stability

ƒ Never grasp the sharp tip of the needle with the needle holder (will dull or break it)

Page 42: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Basic Suturing Technique (cont.)

ƒ Start to puncture the skin vertically with the needle

ƒ If the needle is a small size & the wound is wide, transit the wound in 2 passes (pick the needle up with the needle holder and remount it after pushing it thru just one side first)

ƒ Exit needle on other side same distance from wound edge

ƒ Usually make the needle pass deeper than wide to achieve wound edge eversion

Page 43: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Basic Suturing TechniqueHow to Instrument Tie a Suture Knot

ƒ Grasp needle side of suture with left handƒ Pull suture partway through, leaving a 1

inch (2.5 cm) "tail"ƒ Point needle holder at tail of sutureƒ Use left hand to throw 2 loops of the

suture strand around the end of the needle holder

ƒ Grasp the "tail" suture end with the needle holder

ƒ Pull the tail thru the 2 loops (this actually creates the knot)

Page 44: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Basic Suturing TechniqueHow to Instrument Tie (cont.)

ƒ Cinch the double-throw knot down–Make sure the knot sets down flat (may have to cross hands 90 degrees to do this)

ƒ Use left hand to throw a single loop around the needle holder

ƒ Then grasp tail of suture with needle holder & pull tail thru the loop

ƒ Alternate subsequent throw loops above & below the needle holder (so that square, not granny, knots result, which are less likely to unravel)

Page 45: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Basic Suturing Technique (cont.)

ƒ Space sutures same distance apart & same distance on either side of wound (should be like a "square box") ; examples :–1 mm apart & 1 mm from wound edges for delicate facial lacerations–1 cm apart & 1 cm from wound edge for "cruder" repairs not under tension

ƒ Tie at least 5 to 6 knots (throws) for nylon

ƒ Tie at least 7 to 8 knots (throws) for prolene

ƒ Tie 3 knots for absorbable sutures

Page 46: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Basic Suturing Technique (cont.)ƒ Always be conscious of good sterile techniqueƒ Don't let your jacket sleeve brush the sterile

drapesƒ Don't let the end of the suture flop off the

sterile areaƒ Bring sponges & scissors over to the drapes

where you are working so they are available (so you don't have to keep reaching back to your suture tray for these)

ƒ Dispose of all needles and sharps in proper receptacles

Page 47: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Best wound edge eversion is obtained when you place the sutures deeper than wide, as in the bottom diagram (note the middle diagram shows poor placement with resultant inversion of the wound edges)

Page 48: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

To avoid gaps in the hair after healing, any debridement of tissue where the hair is coming out at an angle should be at the same angle as the hair (not just straight vertical), such as in the eyebrow

Page 49: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Remember the goal of cosmetic wound closure is to try to have the scar be flat with the surrounding skin (if the scar is raised or lowered it causes a noticeable shadow in oblique light)

Page 50: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 51: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 52: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Main Suturing Techniques

ƒ Simple interrupted–OK for most wounds–Quick to place–Easiest to learn–May cause wound edge eversion

ƒ Continuous over & over–Fastest to place–However, if breaks at one point, the whole suture line will far apart–Generally not recommended unless there is a huge time-consuming total laceration length to repair

Page 53: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Subcuticular

Most common suture techniques

Page 54: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 55: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Main Suturing Techniques (cont.)

ƒ Interrupted vertical mattress–Best suture to evert wound edges–Takes longer to place–Can start at center of wound, & once eversion is achieved, finish with simple interrupted

ƒ Interrupted horizontal mattress–Good where skin is thin (back of hand, etc.)–Equivalent to having 2 sutures per knot (so is a quick technique)

ƒ Interrupted half-buried horizontal mattress–Good to elevate a flap or to repair the tip of a T or Z shaped laceration

Page 56: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 57: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 58: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 59: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 60: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 61: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 62: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Use of half-buried horizontal mattress stitch to close V and T shaped lacerations

Page 63: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Use of half-buried horizontal mattress suture to close a Z shaped laceration

Page 64: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Conversion of a V shaped laceration to a Y shaped laceration (V-Y advancement) ; note use of horizontal mattress suture to close the center of the Y

Page 65: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Needle motion sequence for placing a buried (deep) suture with its knot inverted

Page 66: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 67: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

At completion of suturing, pull all the knots over to one side

Page 68: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Undermining of Wound Edges

ƒ Important to reduce tension on wound edges

ƒ Especially important for lacerations on the anterior calf (either horizontal or vertical)

ƒ Best technique is to spread with curved mosquito clamp just below the subcuticular layer ; essentially loosens subcuticular layer from the underlying fatty dermal layer (you can use a knife for undermining but this can stir up more bleeding)

Page 69: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Using a clamp to spread at the junction of the subcuticular layer and the underlying fat rather than a knife can achieve undermining with less potential for bleeding

Page 70: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

One technique for correction of a “dog ear” ; usually a better alternative is to remove the sutures already placed, realign the wound edges, and start suturing again from the center of the wound

Page 71: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Continuous Interlocking Suture ("Baseball Stitch")

ƒ Each loop is partially locked onto next loop

ƒ Can cause tissue necrosisƒ Only useful occasionally in a

patient with a coagulopathy who has continued bleeding from the initially placed interrupted suture sites

Page 72: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 73: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Imbedded Fishhook Removal : 3 Acceptable Techniques

ƒ Local anesthesia, then :–Just rip the hook out (suitable only if small barb hook)–Or, insert 18 gauge needle to cover the barb, and then back the needle & hook out together–Or, punch the barb on through the skin, and then cut the barb off with wire cutters, and then back the shank out

Page 74: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &
Page 75: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Correct Definitions

ƒ Dressing : the covering immediately next to the wound surface

ƒ Bandage : the material holding the dressing in place

Page 76: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

One method of bandaging a finger

Page 77: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Use of Tube-Gauze to bandage a finger

Page 78: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Use of Topical Antimicrobial Agents for Wounds

ƒ Use of topical agents may :–Decrease scarring–Decrease infection–Lessen coagulum encasing the sutures–Prevent dressing from sticking to wound and redamaging the wound when it is removed

Page 79: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Choices of Topical Agents for Wounds

ƒ Polymixin - Bacitracin (Polysporin) : best choice

ƒ Neosporin (Polysporin + Neomycin) : OK but 10 % risk of sensitivity to neomycin

ƒ Bacitracin : only kills gram positive bacteriaƒ Silver sulfadiazine (Silvadene) : bacteriostatic,

expensive, good for burnsƒ Sulfamylon : bacteriostatic, stings on

application, causes metabolic acidosis (carbonic anhydrase inhibitor)

ƒ Povidone-iodine (Betadine) : toxic to exposed tissue, so DON'T use on wounds (OK for IV sites)

ƒ Mupirocin (Bactroban) : good but more expensive than Polysporin

Page 80: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Choices for Wound Dressings

ƒ Dry gauze : suitable for most wounds or if steri-strips used

ƒ Nonadherent dressings : preferred for abrasions, nailbed injuries, skin flaps, or thin skinned elderly–Vaseline gauze–Xeroform gauze–Adaptic gauze : most expensive–Telfa : not really nonadherent

ƒ Can use clear dressings like Op-site for some wounds

ƒ Duoderm commercial dressing also useful for covering some types of chronic open wounds

Page 81: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Immobilization of the Injured Extremity Versus Encouraging Active Motion After Wound Repair

ƒ In general, active motion is better–Prevents need for physical therapy to regain ROM after immobilization–No increase in wound separation problems if sutures left in for at least 14 days (as on the hand)

ƒ Finger splints usually unnecessary for properly repaired finger lacerations

Page 82: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Hand immobilization and bandaging

Page 83: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Further Wound Care

ƒ Don't forget to consider tetanus immunization for all wounds

ƒ Consider antibiotics for :–Bite wounds–Contaminated wounds–Hand or foot wounds–If delayed presentation–Wound already infected–Risk factors for infection ( diabetes, chronic steroids, immunosuppressed, malnutrition, PVD, age > 70)

Page 84: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Lacerations to Refer to Plastic Surgery

ƒ Suspected facial nerve involvement

ƒ Flap required for repairƒ Major cartilage injuryƒ Parotid duct laceration (blood at

Stensen's Duct)ƒ ? if skin graft neededƒ ? if patient asks for plastic

surgeon

Page 85: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Lacerations to Refer to Ophthalmologist

ƒ Lid margin lacerationƒ Medial canthus lacerationƒ Thru & thru lid lacerationƒ Avulsion of lid or periorbital

tissueƒ Ptosisƒ Suspected globe injury

–Proptosis–Hyphema–Lens or retinal detachment

Page 86: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Tetanus Immunization Guidelines

ƒ Every 5 year update for tetanus toxoid is good general rule on all cases

ƒ Also use TIG (tetanus immune globulin) if :–Patient never immunized–Immunosuppressed–Allergic or severe local reaction to toxoid–? if highly tetanus - prone wound & is > 10 years since last toxoid immunization

Page 87: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Beveled laceration best repaired in 2 layers

Page 88: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Wound appearance after placement of subcutaneous absorbable sutures

Page 89: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Wound appearance after outer layer skin repair with 6-0 nylon

Page 90: Wound Care and Repair By Dr. Kawair. Wound Care Lecture Outline ƒProper sequence for routine wound repair ƒOptions for choices of local anesthetics &

Wound CareLecture Summary

ƒ Carefully plan any wound repairƒ Don't forget to inform the

patient what you're doingƒ Follow Holliman's 3 rules of

plastic surgeryƒ Don't forget to consider tetanus

immunization & antibioticsƒ Ensure proper followup care