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