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Wound Care Part II Repair of Simple Lacerations

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Subcuticular running. 3 pt or buried mattress. Dog ear repairs ... Use scapel or scissors. Remove gravel, asphalt etc. (Vaseline gauze) Excise devitalized tissue ... – PowerPoint PPT presentation

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Title: Wound Care Part II Repair of Simple Lacerations


1
Wound Care Part IIRepair of Simple Lacerations
  • Sarah Lowenthal, M.D.
  • UCSF Family Practice Residency

2
Normal Wound Healing
  • Three Phases
  • Inflammation (Day 0-5)
  • Fibroplasia (Day 5-14)
  • Remodeling (Day 14 ?)

3
Phase I Inflammation
4
Phase II Fibroplasia
5
Phase III Maturation/remodeling
6
Goals of Closure
  • Hemostasis
  • Prevent Infection
  • Preserve Function
  • Cosmetic Result

7
Contraindications to Closure
  • Open gt8 hrs ext/torso gt24 hrs face
  • Bites (except face, large dog bites)
  • Puncture wounds
  • Foreign bodies

8
Consent
  • Bleeding
  • Dehiscence
  • Infection
  • Scarring

9
Evaluate Laceration
  • Neurovascular fxn
  • Depth
  • Foreign bodies
  • Anatomy

10
Anesthesia
  • Lidocaine 50ml vial (0.5,1,2)
  • Onset 5 mins, duration 90-200 mins
  • Toxic Dose of 1 lido (10mg/ml) is 5.0 mg/kg in
    adults
  • Signs of toxicity n/v, headache, apprehension,
    convulsions, irreg. pulse hypotension

11
Anesthesia
  • Lido Epi 1100,000
  • Always has RED label
  • Prolonged duration of action
  • Cleaner field
  • Never use in terminal digits
  • (fingers, toes, ears, nose and penis )

12
Injecting Anesthetic
  • Use small needle (27g) and small syringe (3-5cc)
  • Inject into dermis through open wound
  • Inject, advance, aspirate
  • Do not go through intact skin

13
Cleansing
  • 30-35ml syringe with 18g needle (8-15 psi)
  • Use 50-100ml per cm of laceration
  • No betadine, hibiclens etc inside wound

14
Suture Selection
  • Construction
  • Monofilament
  • Multifilament
  • Composition
  • Absorbable/Nonabsorbable
  • Synthetic/Organic

15
Suture Construction
  • Monofilament
  • knots less dependable
  • lower infection rate
  • Multifilament
  • stronger
  • better knotting
  • increased risk of infection

16
Suture Composition
  • Non-absorbable left in, for deep, layers, to
    close dead space and reduce tension
  • Absorbable taken out, seen coming out of
    epidermis
  • Synthetic Broken down by hydrolysis
  • Organic Broken down by proteolysis

17
Absorbable Sutures
  • Synthetics
  • Polyglycolic Acid (Dexon)
  • Polyglactin (Vicryl)
  • Polydioxone (PDS)
  • Organics
  • Gut (beef, sheep)
  • Chromic Gut

18
Nonabsorbable Sutures
  • Nylon (Ethilon)
  • good tensile strength
  • min. tissue reactivity
  • low cost
  • Needs 5 knots (monofilament)
  • Polypropolene (Prolene) similar to Nylon
  • Silk, Dacron, Cotton (dated) all braided

19
Bottom Line Suture Selection
  • No one type is always correct

20
Needle Selection
  • Anatomy of a needle

21
Needle Types
  • Taper
  • Cutting
  • Conventional
  • Reverse

22
Needle Selection
  • Purpose
  • Thick skin FS, CE
  • Cosmetic P, PS, PRE, PC
  • Curvature
  • 3/8 for most cutaneous procedures
  • Size
  • 2 and 3 good for skin closures

23
Sterile Prep and Drape
  • Mask and non-sterile gloves
  • Open your own tray
  • Arrange light, table etc
  • Prep skin (Betadine)
  • Sterile gown and gloves
  • Set up instruments
  • Drape

24
Principles of Closure
  • Control bleeding
  • Eliminate dead space
  • Evert edges
  • Approximate dont strangulate

25
Many Closure Techniques
  • Simple Interrupted
  • Simple Running
  • Vertical Mattress
  • Horizontal Mattress
  • Subcuticular running
  • 3 pt or ½ buried mattress
  • Dog ear repairs

26
Most Useful Techniques for Primary Care
  • Simple (and buried) interrupted
  • Simple running
  • Vertical Mattress
  • Subcuticular running

27
Simple Interrupted
28
Buried Interrupted
29
Simple Running
30
Vertical Mattress
  • Far/far, turn needle, backhand near/near

31
Subcuticular Running
  • Dermal/epidermal junction
  • Advancement and button-hole

32
Instrument Tying
  • 2 loops wrapped around needle end
  • Grab free end with needle holder
  • Keep free tails short
  • Next loop wrapped in opposite direction as the
    first ? square knot
  • Repeat three more times ? 5 knots
  • Pull completed knot to the side

33
Dressings
  • Dress your own wound
  • Remove your own sharps
  • Apply dressing sterilely
  • Clean off blood etc.
  • Bacitracin (face/scalp)
  • Tube gauze fingers and toes

34
Post Procedure
  • Keep dressing clean/dry
  • Remove in 24 hrs (face) or 48 hrs
  • Wash with gentile soap
  • Redress QD
  • No swimming or soaking
  • Return in x days for wound check and approx. 2x
    for suture removal

35
Suture Removal Times
  • Face 3-4 days
  • Scalp 5-10 days
  • Trunk 7-10 days
  • Arm or leg 7-10 days
  • Foot 10-14 days
  • Over Joint 14-21 days

36
Suture Removal Technique
37
Resources
  • Pfenninger JL, Fowler GC. Procedures for Primary
    Care 2nd Edition. 2003
  • Mendez, Roberto. Evaluation, Management and
    Closure of Simple Laceration.
  • The Surgical Residents TrainingHome Page. The
    University of Washington School of Medicine.

38
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39
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40
Debriding
  • Use scapel or scissors
  • Remove gravel, asphalt etc. (Vaseline gauze)
  • Excise devitalized tissue
  • Convert jagged contaminated ? clean surgical

41
Antibiotics?
  • High/mod SBE risk
  • Animal bites
  • Cat/dog Pasturella multocida
  • Human Eikenella corrodens and Staph. Aureus
  • Augmentin

42
Blades
43
Undermining
  • Avoid in dirty wounds
  • Use scapel or scissors
  • Cut at dermal/adipose jxn

44
Other Techniques
  • Tapes/Strips
  • Tissue Adhesive (Dermabond)
  • DPC (Tertiary Intent)

45
Amboise Pare (1520-1590)
Rejected boiling oil treatment in favor of salve
Wound tissue should be treated gently
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