laceration repair terren trott & nick chien. objectives basic protocol for laceration repair...

Laceration RepairTerren Trott & Nick Chien

Objectives

• Basic Protocol for Laceration Repair• Simple Uninterrupted Suture• Anesthesia• Materials and Preparation• Suturing Techniques

Suture, Dermabond, or Staple?SutureDermabond Staple

• Superficial lacerations

• Facial lacerations

• Scalp or huge lacerations

• Faster, lower infection, reduced inflammation

• Greater tensile strength

• Most lacerations….

Inquire about tetanus

• Clostridium tetani

• Rigidity/spasms of voluntary muscles and autonomic hyperactivity (sympathetic)

• Usual source: wound**Tetanus booster

-Clean Lac: 10+ yrs-High-risk wound: 5+ yrs

AnestheticName Onset Duration Max Dosing

Lidocaine 1 – 5 minutes 1.5 – 2 hours 4mg/kg

Lidocaine with Epi 1 – 5 minutes 2 – 3 hours 7mg/kg

Mepivacaine 1 – 5 minutes 3 hours 5mg/kg

Mepivacaine with Epi 1 – 5 minutes 4 – 5 hours 7mg/kg

Bupivacaine 10 – 15 minutes ~4 hours 2.5mg/kg

Bupivacaine with Epi 10 – 15 minutes ~8 hours 3mg/kg

Anesthetic PearlsEpinephrine vasoconstricts

Amides: have two ‘I’s in the name, esters have one ‘I’Infiltrate with anesthetic slowly to reduce the burn

Consider digital blocksBicarb can be used to buffer lidocaine and reduce burning

Withdraw on the syringe to make sure you’re not in a vessel

What does lidocaine toxicity look like?

• Early symtoms– Headache, nausea/vomiting, AMS

• Late Symptoms– Seizures– Cardiac Arrythmias: PEA, vtach, torsades

• Tx: Sodium Bicarb, IV Lipids

Maintain Sterile Technique

• Gloves

• Drapes

• Sterile Prep

• Topical Antibiotic Ointment• Iodine + Hydrogen Peroxide

can be toxic

• Remove hair• Scissors > Razor

REDUCE RISK OF INFECTION + PROTECT YOURSELF!

Irrigation

COPIOUS IRRIGATION!-- 0.9% normal saline --

IRRIGATION is… mechanical wound cleaningIRRIGATION removes… bacteria + debris

Selecting Instruments

Needle Driver w/ Tripod Grip

ESSENTIALS: 1. Needle Driver/Holder2. Suture Scissors3. Surgical Forceps or Pickups w/

teeth

Foreceps w/ Writing GripNever handle sutures with fingers

Selecting Instruments

Anatomic Site Skin Deep Duration

Scalp 5-0, 4-0 Monofilament 4-0 Absorbable 6–8 days

Ear 6-0 Monofilament N/A 4–5 days

Eyelid 7-0, 6-0 Monofilament N/A 4–5 days

Eyebrow 6-0, 5-0 Monofilament 5-0 Absorbable 4–5 days

Nose 6-0 Monofilament 5-0 Absorbable 4–5 days

Lip 6-0 Monofilament 5-0 Absorbable 4–5 days

Face/forehead 6-0 Monofilament 5-0 Absorbable 4–5 days

Chest/abdomen 5-0, 4-0 Monofilament 3-0 Absorbable 8–10 days

Back 5-0, 4-0 Monofilament 3-0 Absorbable 12–14 days

Arm/leg 5-0, 4-0 Monofilament 4-0 Absorbable 8–10 days

Hand 5-0 Monofilament 5-0 Absorbable 8–10 daysb

Extensor tendon 4-0 Monofilament N/A N/A

Foot/sole 4-0, 3-0 Monofilament 4-0 Absorbable 12–14 days

Picking up the needle

*Grab just behind midpoint

How to enter wound?

• Needle tip perpendicular to skin• Bite no closer than 0.5cm• Equal bites on either side of wound• Twist wrist & follow curvature of needle

• Needle passes Epidermis SubQ Tissue SubQ Tissue Epidermis• Skin edges should evert for better healing

Instrument Tie

Knot Tying Pearls• Knot throwing: throw as many knows as size

suture material• 6-0 throw 6 knots• Minimum 3 knots

• Knots are tied in opposite directions, should lie flat

• Hand tie vs. instrument tie

Simple Interrupted• Most commonly used technique to

close skin• Enter ≥ 0.5cm from wound edge• Sutures are equidistant from each

other as wound edge• Leave ≥ 0.5cm of tail

Removal and return precautions

• Low tension or highly cosmetic– Face, hands 5-7 days

• High tension– 7-10 days

• Wound dehiscence or infection