care of acute lacerations
TRANSCRIPT
CARE OF ACUTE LACERATIONS
Introduction Optimum management knowledge
of wound healing.
Goal of Primary Closure
Stop bleeding
Prevent infection
Preserve functionRestore
appearance
Skin Anatomy
Add. features: Langer’s lines Wrinkle lines
Formed by collagen dermis
Less scarring
Wound HealingPhase 1
Inflammatory phase
First 5-6 days
Leukocytes, histamines, prostaglandins fibrinogens.
Neutralize bacteria and foreign material
Reduce inflammatory response: Debridement Remove foreign material Cleaning Control bleeding Tissue coaptation
Amount of Inflammation
Necrotic
Tissue
Dead
space +
Impaired
Circulation
Wound HealingPhase 2
Fibroblastic/collagen phase
6-20 days
Vascular supply compromise
Inhibit collagen synthesis
Fibroblasts enter wound
Collagen synthesis
Binds wound
Collagen ↑ Wound
strength ↑
Wound HealingPhase 3
Maturation phase
18 – 24 months
Collagen synthesis + retraction
Scar softer + less conspicuousColor fades + consistent
with skin
Abberation KELOID
Anasthesia
Anesthetize wound prior to closure Inspect wound + assess neurovascular
supply Topical agents:
PAC + TAC Emla Ethyl Chloride
Injectable agents: Lidocaine Additional Agents Diphenhydramine
Methods: Infiltration blocks Field blocks Nerve blocks
Sedation
Ketamine Midazolam (versed) Fentanyl Nitrous oxide
Wound Preparation
Proper prep improves healing Closed ASAP
Steps:1. Anesthesia2. Clean (wipe-scrub-irrigate)
a. Normal saline using syringeb. Antiseptic soaps (hexachlorophene,
chlorhexidine gluconate, povidone-iodine) delay healing!!
c. Scrub brushes
Wound Preparation3. Drape area
explore
Confirm
depth
Underlying tissue injury?
≠ foreign bodies
Adequate anesthesia
4. Debridement• Irregular dirty wound clean smooth• Excise crushed, mangled devitalized edges• Large amount of tissue close w/ loose
suture
• Incision: scalpel scissors• Edges: perpendicular / slightly undercut• Hairy areas: parallel to hair shafts.
5. Approximate skin edges• Undermine skin 1 : to wash away supporting material
from under (http://www.merriam-webster.com/dictionary)
• Hemostasis: • 5-10 minutes pressure• Cauter/ligate hinder healing• Small vessels absorbable suture
Wound Closure
Absorbable materials: Broken down Absorbed by tissue
Non absorbable materials: From chemicals Encapsulated by body Isolated by tissue
Sutures Advantages DisadvantagesAbsorbable
Catgut Inexpensive Low tensile strengthStrength lasts 4-5 daysHigh tissue reactivity
Chromic catgutPolyglycolic acid (Dexon)Polyglactic acid (Vicryl)
InexpensiveLow tissue reactivityEasy handlingGood tensile strength
Moderate tensile strenth and reactivity
Moderately difficult to handleOccasional “spitting” of
suture due to absorption delay
Polyglyconate (Maxon)Easy handlingGood tensile strength
Expensive
Nonabsorbable
SilkHandles wellModerately inexpensive
Low tensile strengthHigh tissue reactivityIncreased infection rate
Nylon (Ethilon, Dermilon)High tensile strengthMinimal tissue reactivityinexpensive
Difficult to handle; slippery, so many knots needed
Polypropylene (Proline SurgiPro)
No tissue reactionStretches, accommodates swelling
Expensive
Braided polyester (Mersilene, Ethiflex)
Handles wellKnots secure
Tissue drag if uncoatedExpensive
Polybutester (Novofil)Elastic, accommodates
swelling and retractionExpensive
Well closed wound:
Margins w/o
tensionAccurately aligned
≠ dead space
Deep stitches:• In layers that hold suture• Buried knot preferrable• Strongest
Skin sutures:• Improve cosmetic result
Suture Techniques
Simple Interrupted stitch
Goal: evert edges of wound Raised scar remodelling smooth scar Correctly approximate asymmetric wound
edges Invert wound
Wider at top Improve cosmetic appearance
First knot 2 loops (“surgeon’s knot”) Second single loop
Vertical / horizontal mattress suture:
• Promotes eversion• Thick layer / tension
•Needs fewer knots to cover same area
Intracuticular running suture:
• Minimal skin tension• Minimal scarring w/o
marks• Difficult controlled
tissue apposition
Three-point mattress suture:
• Minimize vascular necrosis @ tip of V-shaped wound
• For stellate injuries
: resembling a star (as in shape) (http://www.merriam-webster.com/dictionary)
Running / continuous stitch:
• For speed• Good hemostasis• Poor control of
wound margins
Specific Circumstances
Lacerations across a landmark Border of lip / eyebrow Retention stitch approximate border
Beveled lacerations Modify wound margins Edges:
Squared Undermined Closed in layers
Dog ears Sides of lacerations = unequal Correct:Ten
t up
Linear incision on one side
Grasp exces
s triang
le
Second
linear incisi
on
Complex lacerations Combination 4-point technique
Finger injuries Amputated fingertip
< 1 cm2 clean, dress, heal by secondary intention
Bigger wound: Bevel dorsally and distally Conservative approach good healing
Nail bed injuries Save nail: Reapproximate nail matrix Remove nail:
Replace nail as splint
Alternatives to Suturing
Staples For skin Straight line wounds
Adhesives Cyanoacrylate ester (SuperGlue) Advantages: (superficial wounds)
Rapid closure
Minimal physical & emotional trauma
Less expensive
≠ foreign body in wound
Hemostasis first Avoid suture + adhesive bond to
suture material Wound with no tension : face and
forearm
Postrepair Management
Protect 1-2 days after repair Oozing wound pressure dressing
Nonstick gauze
(Adaptic, Telfa, Xeroderm)
Gauze pad (roller gauze, elastic wrap, elastic tape)
Remove & examine dressing 48-72 hours w/ drain: 24-48 hours Tension: add support (Steri-Strips),
splints
WoundLeft open
1st 24-48 hours
Remove wet
dressingsMacerat
ions
Initial epitheliali
zation1st 24 hours
Infection / hematom
a2-3
days
Sutures removal
Based on wound location
Mechanical stress
Tension of closure
Facial suture 3-5 days
≠ highly mobile 7-10 days
Fingers, palms, soles, joints 10-14 days
Steri-Strips: decrease dehiscence
Concurrent Therapy
Antibiotic usage Not really helpful Extensive repair IV antibiotics
during wound closure Bite wounds antibiotic post-closure Amoxicillin-clavunate, doxycycline,
ceftriaxone
Tetanus prophylaxis Crucial ≠ adequately immunized: elderly
patients Passive immunity human TIg Dose: 500 units IM TT & TIg different needle & different
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