Basic techniques

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Basic techniques

• That somehow everyone doesnt know

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Wound care priorities

• Discover and treat injuries to critical deep
  structure
• Cover critical structures with skin
• Maintain function without contracture
• Prevent infection
• Cosmesis is a distant fifth priority

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Basic techniques

• Managing contaminated wounds
• Wound eversion
• Inverted dermal sutures as primary closure
• Instrument tying

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Managing contaminated wounds

• Never close an infected wound
• If wound merely contaminated, clean it up and
  then make a decision for primary, secondary or
  tertiary (delayed primary closure)

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Timing of delayed closure in contaminated wound
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Managing contaminated wounds

• Debride all dead or marginal tissue (if unsure
  cut a little, does it bleed?)
• Remove all foreign debris
• When irrigation needed use either a hydrostatic
  irrigator or a 10 cc syringe with an 18 ga
  angicath or Zerowet

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Klenzalac irrigation tray
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Managing contaminated wounds

• If wound is over 6 hours old and exudative, prep
  it, then gram stain it for white cells and/or
  bacteria
• Frequently, where there are no important
  structures and skin is loose enough to avoid
  tension, better simply to excise a dirty wound,
  then close it

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Wound excisionScore skin in ellipse
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Excise wound with scissors or scalpel
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Undermine excised wound to allow eversion on
closure
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Evert to allow flat scar after healing
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Use dermal stitches as primary closure

• allows natural eversion from technique
• tissue 1/2 life of about a month allows for far
  longer support for healing than skin sutures
• after dermal layer placed, often can close skin
  with rapid techniques (tapes, running suture,
  glue)

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Wound is weakest when skin sutures are removed
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Use dermal stitches as primary closure

• Wound must be clean
• Technically a little more difficult than skin
  sutures

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Instrument tie

• Surgeons knot
• Follow with at least three square throws
• Granny knots will lead to untieing

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Driver in middle, two overhand throws
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Grab loose tail
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Cross hands to lay flat
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Finish by

• Placing needle driver between tails
• single overhand throw, grasp loose tail
• cross hands to lay flat
• at least 3 more throws