2/19/2015...2/19/2015 1 Wound Care and Suturing Workshop St. Louis University Gere Ochs RN,...

2/19/2015

1

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

2/19/2015

2

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

2/19/2015

3

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%)

2/19/2015

4

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)

2/19/2015

5

2/19/2015

6

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

2/19/2015

7

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

2/19/2015

8

Tissue adhesive

Dermabond

• Facial & torso

• Extremities – minimal

tension

Staples

• Scalp & torso

• Multiple trauma

2/19/2015

9

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

2/19/2015

10

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

2/19/2015

11

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

2/19/2015

12

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

2/19/2015

13

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

2/19/2015

14

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!

2/19/2015

15

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

2/19/2015

16

• 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

2/19/2015

17

• 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

2/19/2015

18

• 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

2/19/2015

19

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

2/19/2015

20

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

2/19/2015

21

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

2/19/2015

22

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

2/19/2015

23

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!

2/19/2015

24

Questions??