Wound Care Part II Repair of Simple Lacerations

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Wound Care Part IIRepair of Simple Lacerations

• Sarah Lowenthal, M.D.
• UCSF Family Practice Residency

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Normal Wound Healing

• Three Phases
• Inflammation (Day 0-5)
• Fibroplasia (Day 5-14)
• Remodeling (Day 14 ?)

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Phase I Inflammation
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Phase II Fibroplasia
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Phase III Maturation/remodeling
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Goals of Closure

• Hemostasis
• Prevent Infection
• Preserve Function
• Cosmetic Result

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Contraindications to Closure

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

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Consent

• Bleeding
• Dehiscence
• Infection
• Scarring

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Evaluate Laceration

• Neurovascular fxn
• Depth
• Foreign bodies
• Anatomy

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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

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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 )

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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

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Cleansing

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

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Suture Selection

• Construction
• Monofilament
• Multifilament
• Composition
• Absorbable/Nonabsorbable
• Synthetic/Organic

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Suture Construction

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

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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

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Absorbable Sutures

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

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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

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Bottom Line Suture Selection

• No one type is always correct
  

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Needle Selection

• Anatomy of a needle

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Needle Types

• Taper
• Cutting
• Conventional
• Reverse

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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

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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

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Principles of Closure

• Control bleeding
• Eliminate dead space
• Evert edges
• Approximate dont strangulate

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Many Closure Techniques

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

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Most Useful Techniques for Primary Care

• Simple (and buried) interrupted
• Simple running
• Vertical Mattress
• Subcuticular running

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Simple Interrupted
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Buried Interrupted
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Simple Running
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Vertical Mattress

• Far/far, turn needle, backhand near/near

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Subcuticular Running

• Dermal/epidermal junction
• Advancement and button-hole

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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

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Dressings

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

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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

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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

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Suture Removal Technique
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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.

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Debriding

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

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Antibiotics?

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

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Blades
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Undermining

• Avoid in dirty wounds
• Use scapel or scissors
• Cut at dermal/adipose jxn

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Other Techniques

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

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