principles of wound closure bucky boaz, arnp-c. history of wounds herbal balms and ointments...
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Principles of Wound Closure
Bucky Boaz, ARNP-C
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History of Wounds
Herbal balms and ointments Initially, wounds were left open Oldest suture 1100BC Primary and secondary closure 2000 yrs ago Middle ages: pus thought necessary Recent wound closure less that 200 yrs old
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Physiology of Wound Healing
Blood leaksWound occurs
Wound occurs STOP
Epithelialcells
Scab causes obstruction
Scab causes obstructionThickening and return
to normal state
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Specific Points AffectingWound Healing
Keep wound clean and scab free Keep wound moist Avoid steroid creams Suturing wound splints skin Wounds actually shrinks
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Evaluation of the Patient
Risk of infection or poor wound healing Detailed history of medicinal or latex allergies Immunization status
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Evaluation of the Laceration
History of mechanism Potential for significant injury Potential foreign body Possible rabies exposure Type of force applied to injury Adequate lighting Neurovascular assessment
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Classification of Wounds
Abrasions Lacerations Crush wounds Puncture wounds Avulsions Combination wounds
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Anesthesia of the Laceration
Lidocaine with/out epi, marcaine
TAC Local vs regional Mechanisms to reduce
pain
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Wound Preparation
Removal of hair– Not eyebrow
Scrubbing the wound Irrigation with saline
– Avoid peroxide, betadine, tissue toxic detergents
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Wound Closure Timeframe
Morgan et al– Arm and hand: 4 hours = difference
Baker and Lanuti– Arm and hand: 6 hours = no difference
Jamaica– Face: no time limit– Trunk and extremity: 19 hours = difference
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Ideal Wound Closure
Allow for meticulous wound closure Easily and readily applied Painless low risk to provider Inexpensive Minimal scarring Low infection rate
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Options for Wound Closure
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Sutures
Non-absorbable sutures– Tinsel strength 60 days– Non-reactive– Outermost closure
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Sutures
Absorbable sutures– Synthetic > natural– Synthetic increases
wound tinsel strength– Deeper layers– Avoid in highly
contaminated wounds– Avoid in adipose tissue– Synthetic & monofilament
> natural & braided
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Sutures
Advantages– Time honored– Meticulous closure– Greatest tensile strength– Lowest dehiscence rate
Disadvantages– Requires removal– Requires anesthesia– Greatest tissue reactivity– Highest cost– Slowest application
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Staples
More rapidly placed Less foreign body
reaction Scalp, trunk, extremities Do not allow for
meticulous closure
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Staples
Advantages– Rapid application– Low tissue reactivity
Disadvantages– Less meticulous closure– May interfere with some
older generation imaging techniques (CT, MRI)
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Adhesive Tapes
Less reactive than staples
Use of tissue adhesive adjunct (benzoin)
Poor outcome in areas of tension
Seldom used for primary closure
Use after suture removal
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Adhesive Tapes
Advantages– Least reactive– Lowest infection rate– Rapid application– Patient comfort– Low cost– No risk of needle stick
Disadvantages– Frequently falls off– Lower tensile strength
than sutures– Highest rate of
dehiscence– Requires use of toxic
adjuncts– Cannot be used in areas
of hair– Cannot get wet
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Tissue Adhesives
Dermabond, Ethicon Topical use only Outcome equal to 5-0
and 6-0 facial repairs Less pain and time Slough off in 7-10 days Act as own dressing No antibiotic ointment
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Tissue Adhesives
Advantages– Rapid application– Patient comfort– Resistant to bacterial
growth– No need for removal– Low cost– No risk of needle stick
Disadvantages– Lower tensile strength
than sutures– Dehiscence over high
tension areas (joints)– Not useful on hands– Cannot bathe or swim
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Post-procedural Care
Dressing for 24-48 hours Topical antibiotics Start cleansing in 24 hours Suture/staple removal
– Face 3-5 days– Non-tension areas 7-10 days– Tension areas 10-14 days
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Choosing Your Suture
6-0– Face
5-0– Chin– Low tension/detail
4-0– Large laceration– Moderate tension
3-0– Significant tension
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The Interrupted Stitch
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The Interrupted Stitch
Instrumentation– Hemostat– Scissors– Forceps with teeth– Plain forceps– Control syringe– Tub for saline– Gauze– Sterile towels– Syringe and splash shield
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The Interrupted Stitch
Finger tip grip Palm grip Grip needle one-third of
way from thread
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The Interrupted Stitch
Curl needle into dermis of 1st side
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The Interrupted Stitch
Curl needle into dermis of 1st side
Curl needle trough parallel opposite subcutaneous side
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The Interrupted Stitch
Curl needle into dermis of 1st side
Curl needle trough parallel opposite subcutaneous side
Tie square knot with at least two braids
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The Interrupted Stitch
Curl needle into dermis of 1st side
Curl needle trough parallel opposite subcutaneous side
Tie square knot with at least two braids
Repeat three to four throws
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Procedure Note
6cm right upper arm laceration repair– 1% lido c/ epi, irrigated c/ NS, betadine prep and
sterile drape. Explored: no vascular involvement, barely into muscle body of triceps. Closed with 4.0 monosoft interrupted sutures. Good wound edge approximation. Topical antibiotics and dressing. Tolerated procedure well.
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Points to Remember
Specific points affecting wound healing
Evaluation of laceration and neurovascular assessment
Types of sutures Staples Adhesive tapes Tissue adhesives
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Points to Remember
Advantages vs disadvantages
Post procedure care Choosing your suture Instruments Be able to perform
interrupted suture for lab final
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Questions?