2/19/2015...2/19/2015 1 wound care and suturing workshop st. louis university gere ochs rn,...
TRANSCRIPT
2/19/2015
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Wound Care and Suturing Workshop
St. Louis University
Gere Ochs RN, ACNP/ANP-BC
Coordinator of the ACNP track
Objectives
• Understand the principles of wound
management as they apply to simple
lacerations.
• Identify the different methods of wound
closure and appropriate use for each.
• Demonstrate the following suturing
techniques: simple, mattress, corner,
intradermal.
• Discuss the pitfalls in wound management
Major components of the skin
• Epidermis
• Dermis
• Subcutaneous tissue
• Deep fascia
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Wound healing
Goal of proper wound closure
• Elimination of dead space (serum & blood = infection)
• Accurate approximation of deep tissue layers to each other
(minimal tension)
• Avoidance of tissue ischemia and strangulation (sutures too
tight)
• Decrease risk of infection –close wound within 3-8 hrs
History
• Allergies (anesthetic agents,
antibiotics, latex)
• Tetanus ?
• Mechanism of injury –shearing,
tension, compression, puncture
• Type of force –crush vs. shearing
• Time
• Intentional or unintentional act
• Any home remedies or treatments of
the wound
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Factors that affect wound healing
Patient characteristics
• Advanced age
• Malnourished, Poor hygiene
• Alcoholism, AODM, PVD
• Uremia , Liver disease, Connective tissue
diseases
• Hypoxia
• Anemia
• Multiple trauma
Technical characteristics
• Use of tissue-toxic wound prep solutions
• Use of detergent scrub solutions
• Inadequate cleansing and irrigation
• Anesthetics containing epinephrine
• Inadequate hemostasis, wound hematoma
• Reactive suture material
• Excessive suture tension
• Tincture of benzoin
• More concentrated anesthetics ( 2%)
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Drugs
• Corticosteroids
• NSAIDS
• Colchicines
• Anticoagulants
• Antineoplastic agents
• Penicillamine
• Pigmented skin & Oily skin
Physical exam of wound
• Location (predicts clinical outcome) & size in cm
• Description in graphic terms (?cosmetic)
• “questionable viable flap”
• “multiple ground-in foreign bodies”
• “severely contused wound edges”
• Hemostasis (do not close a bleeding wound)epinephrine or Tourniquet –finger tourniquets (< 30 minutes)
• Integrity of deep structures – tendons, nerves, joint capsule
xrays
• Failure to dx. A retained foreign body -2nd leading
cause of malpractice
• Radiopague material – metal, glass, gravel
• Detection rate low – wood and plastic –ultrasound
higher sensitivity 87%, ?CT scan (timing, &
smaller sizes)
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Wound closure
• Primary intent
• Within 6-8 hours “golden period”; face and scalp 24 hrs
• Clean wounds without tissue loss
• Secondary intent
• Days to weeks
• Small partial thickness avulsions & fingertip amputations
• Tertiary intent (delayed primary closure) saliva, feces, exudate or > 8 hrs
• 3-4 days after injury
• Daily wound care
• Same technique as primary closure
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Pitfalls in wound care
• Failure to recognize underlying deep structure injury or
foreign body due to:
• Unfamiliarity with the anatomy
• Inadequate or misleading history
• Inadequate hemostasis
• Failure to explore the wound (visually and digitally)
• Failure to obtain ancillary diagnostic studies
Wound Closure
Adhesive tape
• Superficial, no tension
• Conjunction with deep sutures
• Thin skin
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Tissue adhesive
Dermabond
• Facial & torso
• Extremities – minimal
tension
Staples
• Scalp & torso
• Multiple trauma
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Suturing
Wound prep issues
• Obtain consent – invasive procedure
• Sterile technique – standard of care
• Irrigation – solution to pollution is dilution
• 100cc NS/1 cm of wound (splash guard or 30 mL syringe with an 18 gauge sheath)
• Chlorhexidine solution (level A)
• Betadine on surrounding skin only!
• Hair Removal – 1-2 mm
• Debridement
• Remove foreign bodies & devitalize tissue (crushed, torn edges)
• Excision with a surgical blade/scissors
Anesthesia
• Lidocaine • Dilute lidocaine with sodium bicarbonate 1:10 ( 1 ml
bicarb + 9.0 ml lidocaine); shelf life is 7 days
• Max dose 4-5 mg/kg; duration 2 hrs
• Lidocaine w/Epinephrine • Highly vascular areas; duration 2-6 hrs
• Bupivacaine • 4x duration of lidocaine
• Max dose 2-3 mg/kg
• Topicals (LET) pediatrics
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Pearls
• Inject slowly
• Inject into subcutaneous plane instead of
intradermal plane (field block)
• Clean wounds, insert needle thru the wound
edges
• Contaminated wounds, infiltrate the skin
• Small needle 27g or 30 g (reduces pain)
Digital Block
Equipment
• Sterile drape & gloves
• Betadine
• 10 cc syringe with 25 gauge needle, 1 ½ inch
• 1% lidocaine (no epinephrine)/Sodium
bicarbonate
• Informed consent
Procedure
• Introduce needle into dorsal, lateral aspect of
proximal phalanx in web space, just distal to the
MTP point (small wheal)
• Advance slowly until touch bone
• Aspirate and then inject 1 cc
• Back needle out slightly & then pass closely
adjacent bone to the volar surface
• Aspirate and then inject 1 cc continuously as the
needle is withdrawn
• Repeat procedure on opposite of finger
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Transthecal digital block
• Hand supinated, locate
flexor tendon
• Enter the skin at a 45
degree angle
• 25-27 gauge 1 inch
needle
• Inject 2 ml into the sheath
at the level of the distal
palmar crease
• Resistance to the
injection = needle tip is
against the flexor tendon,
withdraw for free flow
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Complications of a digital block
• Infection
• Hematoma
• Gangrene of the digits
• Nerve injury
Direct Wound infiltration
• Inject immediately beneath the dermis at the junction of
the superficial fascia
Absorbable sutures
• Layered closures
• Plain and chromic
“cat gut”
• not used on skin (severe
tissue reaction)
• Synthetic (Vicryl & Monocryl
• Decreased infection rates
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Synthetic nonabsorbable sutures
• Superficial lacerations (supple, easy to handle)
• Silk
• Nylon (Ethilon, Dermolon)
• Polypropylene (Prolene)
• Dacron (Mersilene)
• Polybutester (Novafil)
Principles of suture selection
Monofilament (nylon or Prolene)- preferred!!
• Single smooth strand
• Less traumatic; better cosmetic results
• Glide thru tissue with less friction
• Lower rates of infection
• 5-6 throws (slipping)
Multifilament (silk)
• Multiple fibers woven together
• Tends to be easer to handle
• Knots are less likely to slip; 3 throws
• Suture needle size
• Finest size suture commensurate with the natural strength of the tissue to be sutured
• The more “O’s” the smaller the size
• Tensile strength increases as the number of O’s decreases
• General:
• 6-0 face
• 5-0 hand
• 4-0 trunk/extremities
• 3-0 or 4-0 over joints
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Personal preference
• His/ her area of specialization
• Wound closure experience (training)
• Knowledge of healing characteristics of tissues and
organs
• Knowledge of physical and biological characteristics of
various suture materials
• Patient factors
LET’S DO IT!
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The Anatomy of a needle
• Needle eye
• The body
• The point
Place the needle in the tissue
• Grip a suture needle with a needle driver (2/3 of the way back from the point)
• Elevate skin edge with forceps, right hand is pronated to “cock” the needle
• Penetrate the skin, perpendicularly,1-2 mm from the edge
• Rotate needle thru the epidermis and dermis by supinating the right hand
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• Tip of the needle now should be protruding into the wound
from the subq tissue
• Maintain the position of the skin edge using the forceps, and
release the needle from the holder
• Forceps elevate the opposite side of wound
• Right hand fully pronated, grasp the needle, “bite” by
supinating the right hand to complete the rotation
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• Loop the suture twice around the needle driver
• Grab the short end of the suture with the needle driver
• Lay down 1st loop of a knot, create 2nd single loop in
opposite direction (x2)
• Square knot complete
Knot tying techniques
• Completed knot must be firm
• Tie the knot as small as possible & cut the ends, leaving
1/2 cm “tail” to facilitate removal
• Avoid friction
• Avoid excessive tension
• Do not tie tightly – approximate—do not strangulate
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• Maintain traction at one end of the strand after the 1st
loop is tied
• Make the final throw – horizontal
• Extra throws do not add to the strength –only bulk!
• Space the sutures far enough from each other so that no
gap appears
• The space between sutures is approximately equal to
the bite width
Horizontal Mattress
• Wounds that are under high tension
• Used as a stay stitch
• May be left in for a few days
• Used in calloused skin (palms and soles) and
older, thinner skin
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Disadvantage
• High risk of tissue strangulation
• Wound edge necrosis
• Suture marks
Vertical Mattress
• Maximizes wound eversion
• Reduces dead space
• Combine deep and percutaneous sutures
• Minimizes tension across the wound
• Placing each stitch precisely & taking symmetric bites
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Disadvantage
• Cross hatching (due to increased tension across
the wound and 4 entry and exit points)
Buried Intradermal sutures
• Subcuticular
• Best cosmetic results
• Dermis plane (do not strangle)
• Do not cause crosshatching
• Best internal splinting
• Monofilament sutures
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Corner sutures
• Half-buried horizontal mattress suture
• Positions corners and tips of flaps
Pearls
• Use instruments not fingers
• Take equal “bites” for both sides Evert the wound edges &
minimize tension on the wound
• Face : 2-3 mm from skin edge and 3 mm apart
• Elsewhere 3-4 mm from skin edge, no closer than 2 mm
apart.
• Each suture strand is passed thru the skin only once
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Dressing and splinting
• Area should be cleansed with NS
• Antibiotic ointment (?efficacy) for 3-5 days
• Dressing - cover for 24-48 hours and be non occlusive
• Tension wounds should be splinted for 1-2 weeks
Antibiotics
• Cephalexin 500 mg QID for 7-10 days; Dicloxacillin 250 mg QID 7-10 days; Trimethoprim-sulfamethoxazole; doxycycline
• Wounds > 8-12 hrs old, especially on the hands and lower extremities
• Crushing injuries (compression) mechanism, devitalization, or extensive revisions
• Contaminated wounds
• Violation of the ear or nose cartilage
• Involvement of a joint space, tendon, bone
• Mammalian bites
• Valvular diseases or immunosuppression
Wound After Care
• All wounds will heal with a scar
• Daily cleansing
• Signs & symptoms of infection
• Suture removal • Face: 5-7 days
• Scalp 7-10 days
• Trunk/Extremities/digits: 10 – 14 days (may be up to 21 days)
• Sunscreen to scar for at least 6 – 12 months
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Documentation (support the CPT code)
• H & P with careful attention to neuromuscular and motor function
• Must document that all wounds were explored (foreign bodies)
• Site of repair
• Length of repair in cm. Medium used (sutures, staples, tissue adhesive)
• Type of anesthesia
• Type of wound repair
• Simple: superficial, requires on layer of closure, epidermis, dermis
• Intermediate: layered closure or single layer of heavily contaminated wound
• Complex : layered suturing of torn, crushed or deeply lacerated tissue (debridement, undermining, retention)
• Nature of the wound irrigation
• After care instructions
Referral Guidelines
• When in doubt refer it out!
• Deep wound on face
• Inside the mouth
• Around the eyes
• Into the joint
• Ligament or tendon guidelines
• Finger tip with tissue loss
• You’re not comfortable!
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Questions??