S U T U R E M A T E R I A L S A N D B A S I C S U T U R I N G T E C H N I Q U E S

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SUTURE MATERIALS AND BASIC SUTURING TECHNIQUES PRESENTED IN M.S.RAMAIAH MEDICAL COLLEGE ,AUG 2011 BY DR.L.SIVAKUMARA SENTHIL MURUGAN MODERATED BY DR.PRASHANTH NAGARAJ

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  • Tissue Forceps, Dressing Forceps, Needle Holder (Driver), Iris scissors (debridement/revision), Dissection Scissors (heavier tissue revision, wound undermining), Hemostats (clamping blood vessels, grasping,exploring), Suture Removal Scissors
  • The general course of bundles of connective tissue within the dermis. Wounds that cross these lines tend to be widened by the inherent tension.
  • S U T U R E M A T E R I A L S A N D B A S I C S U T U R I N G T E C H N I Q U E S

    1. 1. SUTURING MATERIALS AND BASIC TECHNIQUES DEPT. OF ORTHOPAEDICS M.S.RAMAIAH MEDICAL COLLEGE AND TEACHING HOSPITAL,BANGALORE 29/08/2011 <ul><li>PRESENTED BY </li></ul><ul><li>DR.L.SIVAKUMARA SENTHILMURUGAN </li></ul>MODERATOR DR.NARESH SHETTY DR.ASHOK
    2. 2. SUTURE <ul><li>The word suture describes any strand of material used to ligate blood vessels or approximate tissues </li></ul><ul><li>Used by egyptians and syrians as far back as 2000 B.C..they used silk,cotton,linen,horse hairs,animal tendons,.. </li></ul>
    3. 3. Objectives <ul><li>types and sizes of suture material. </li></ul><ul><li>Choose the proper instruments for suturing. </li></ul><ul><li>To Describe different types of closure techniques: simple interrupted, continuous, subcuticular, vertical and horizontal mattress, dermal </li></ul><ul><li>To Demonstrate two-handed, one-handed, instrument tie. </li></ul>
    4. 4. Ideal Suture Materials <ul><li>Criteria </li></ul><ul><ul><li>Tensile strength </li></ul></ul><ul><ul><li>Good knot security </li></ul></ul><ul><ul><li>Workability in handling </li></ul></ul><ul><ul><li>Low tissue reactivity </li></ul></ul><ul><ul><li>Ability to resist bacterial infection </li></ul></ul>
    5. 5. Types of Sutures <ul><li>Absorbable or non-absorbable (natural or synthetic) </li></ul><ul><li>Monofilament or multifilament (braided) </li></ul><ul><li>Dyed or undyed </li></ul><ul><li>Sizes 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate progressively smaller) </li></ul><ul><li>New antibacterial sutures </li></ul>
    6. 6. <ul><li>Absorbable </li></ul><ul><li>Degradable </li></ul><ul><ul><li>Vicryl(polygalactin 910) </li></ul></ul><ul><ul><li>Monocryl(polyglecaprone 25) </li></ul></ul><ul><ul><li>PDS </li></ul></ul><ul><ul><li>Chromic Catgut (natural) </li></ul></ul><ul><li>Non-absorbable </li></ul><ul><li>Not biodegradable and permanent </li></ul><ul><ul><li>Nylon </li></ul></ul><ul><ul><li>Prolene </li></ul></ul><ul><ul><li>Stainless steel </li></ul></ul><ul><ul><li>Silk (natural, can break down over years) </li></ul></ul>
    7. 7. <ul><li>ABSORBABLE </li></ul><ul><li>Rapid degradation in tissues losing their tensile strength with in 60 days </li></ul><ul><li>Natural absorbable:digested by body enzymes,more degree of tissue reaction. </li></ul><ul><li>Synthetic absorbable sutures:absorbed because of hydrolysis,lesser degree of tissue reaction. </li></ul><ul><li>NON-ABSORBABLE </li></ul><ul><li>Maintains tensile strength more than 60 days </li></ul><ul><li>Made from non biodegradable materials and are ultimately encapsulated or walled off by bodys fibroblast </li></ul><ul><li>Indications : 1.ext. skin closure </li></ul><ul><li>2.h/o reaction to absorbable sutures , keloid tendency 3.prosthesis attachment </li></ul>
    8. 8. <ul><li>Loss of tensile strength and the rate of absorption are separate phenomenon </li></ul><ul><li>A suture can lose tensile strength rapidly and yet be absorbed slowly </li></ul><ul><li>or </li></ul><ul><li>It can maintain adequate tensile strength throughout wound healing followed by rapid absorption </li></ul><ul><li>LIMITATIONS OF ABSORBABLE SUTURES: if pt. has fever, infection the suture absorption process may accelerate causing too rapid a decline in tensile strength. </li></ul>
    9. 9. <ul><li>NATURAL SUTURE </li></ul><ul><li>Biological </li></ul><ul><li>Cause inflammatory reaction </li></ul><ul><ul><li>Plain Catgut (from cow or sheep) </li></ul></ul><ul><ul><li>Chromic catgut </li></ul></ul><ul><ul><li>Silk (from silkworm fibers) </li></ul></ul><ul><ul><li>Linen </li></ul></ul><ul><ul><li>cotton </li></ul></ul><ul><li>SYNTHETIC </li></ul><ul><li>Synthetic polymers </li></ul><ul><li>Do not cause inflammatory response </li></ul><ul><ul><li>Nylon </li></ul></ul><ul><ul><li>Vicryl </li></ul></ul><ul><ul><li>Monocryl </li></ul></ul><ul><ul><li>PDS </li></ul></ul><ul><ul><li>Prolene </li></ul></ul>
    10. 10. <ul><li>Monofilament </li></ul><ul><li>Single strand of suture material </li></ul><ul><li>Minimal tissue trauma </li></ul><ul><li>Smooth tying but more knots needed </li></ul><ul><li>Harder to handle due to memory </li></ul><ul><li>Resists harbouring org. which may cause infection. </li></ul><ul><li>Examples: nylon, monocryl, prolene, PDS </li></ul><ul><li>Multifilament (braided) </li></ul><ul><li>Fibers are braided or twisted together </li></ul><ul><li>More tissue resistance </li></ul><ul><li>Easier to handle(passes relatively smoothly through tissues) </li></ul><ul><li>Fewer knots needed </li></ul><ul><li>Examples: vicryl, silk, chromic </li></ul>
    11. 11. NATURAL ABSORBABLE SUTURE <ul><li>PLAIN SURGICAL CATGUT </li></ul><ul><li>Rapidly absorbed ,with in 70 days complete absorbtion </li></ul><ul><li>Tensile strength maintained only for 7 to 10 days. </li></ul><ul><li>CHROMIC CATGUT </li></ul><ul><li>Treated with chromium salt solution to resist body enzymes,minimize tissue reaction. </li></ul><ul><li>Tensile strength may be retained for 10 to 14 days </li></ul>
    12. 12. Catgut <ul><li>Absorption in tissues can be delayed by treating with chromic acid. </li></ul><ul><li> </li></ul><ul><li> chromic catgut </li></ul>
    13. 13. Type Degree of Chromicity Approx No.Of days taken for absorption Type A Plain 10 Days Type B Mild chromic 15 Days Type C Medium chromic 20 Days Type D Extra chromic 40 Days
    14. 14. Depending on preservative used, catgut is available either as boilable or non boilable catgut. Boilable catgut is preserved in xylol,toulene-99.75%,phenyl merecuric acetate.025% Non boilable catgut is supplied in tubes containing90-95%alcohol.
    15. 15. SYNTHETIC ABSORBABLE SUTURES <ul><li>COATED VICRYL(POLYGALACTIN 910)RAPIDE:- </li></ul><ul><li>-Braided suture </li></ul><ul><li>-available only as undyed form </li></ul><ul><li>-fastest absorbing suture </li></ul><ul><li>-well suited for skin closure, closure of lacerations under cast, episiotomy tear. </li></ul>
    16. 16. COATED VICRYL(POLYGALACTIN 910) <ul><li>BRAIDED(violet) </li></ul><ul><li>MONOFILAMENT(undyed) </li></ul><ul><li>Copolymer of lactide and glycolide and calcium stearate. </li></ul><ul><li>Absorbed by hydrolysis.absorbtion complete by 56to70 days. </li></ul>
    17. 17. COATED VICRYL PLUS ANTIBACTERIAL SUTURE <ul><li>Equal parts of copolymer of glycolide and lactide and calcium stearate +IRGACARE MP(one of the purest forms of broad spectrum antibacterial agent triclosan). </li></ul><ul><li>Invivo studies has a zone of inhibiton that is effective against the pathogens that most often causes surgical site infection,staph.aures,staph.epidermicus,MRSA,MRSE, </li></ul>
    18. 18. <ul><li>Studies demonstrate that plus sutures has no adverse effect on wound healing. </li></ul><ul><li>Frequently used in bowel closure ,orthopaedics and plastic surgery. </li></ul><ul><li>Retains 75% of original tensile strength at 2 weeks and lost all of the tensile strength by 5wks post implantation </li></ul>
    19. 19. MONOCRYL (POLIGLECAPRONE25) <ul><li>Monofilament, </li></ul><ul><li>Undyed and dyed (violet) </li></ul><ul><li>Copolymer of glycolide and epsilon-caprolactone. </li></ul><ul><li>Absorbed by hydrolysis.absorbtion complete by 90to120 days. </li></ul><ul><li>All of the original tensile strength lost by 21 days post implantation </li></ul>
    20. 20. <ul><li>Surgeons may prefer monocryl sutures for procedures requiring high initial tensile strength dimnishing over 2weeks post operatively like sub cuticular closure and soft tissue approximations and ligations. </li></ul>
    21. 21. PDSII(POLYDIOXANONE) <ul><li>Monofilament suture. </li></ul><ul><li>Polyester polymer </li></ul><ul><li>Slight tissue reaction. </li></ul><ul><li>Absorbed by slow hydrolysis, absorption is minimal until about 90 days. </li></ul><ul><li>Used in pediatric cardiovascular surgery(where growth is expected to occur),orthopaedic, gynecological surgery. </li></ul><ul><li>Useful where combination of an absorbable suture and extented wound support is required. </li></ul>
    22. 22. NON-ABSORBABLE SUTURES <ul><ul><li>U.S.P CLASSIFICATION </li></ul></ul><ul><ul><li>CLASS I:Silk or Synthetic fibres of monofilament,twisted or braided constrution. </li></ul></ul><ul><ul><li>CLASS II:Cotton or linen fibres,or coated naturals or synthetic fibers where the coating contributes to sutures thickness without adding strength. </li></ul></ul><ul><ul><li>CLASS III:Metal wire of monofilament or Multifilament construction. </li></ul></ul>
    23. 23. SURGICAL SILK <ul><li>Twisted/Braided-provides best handling qualities. </li></ul><ul><li>Although silk is classified by U.S.P as non-absorbable,long term invivo studies shown that it loses most or all of its tensile strength in about 1yr and cannot be detected in tissue after 2 yrs. </li></ul><ul><li>In reality it behaves as a very slowly absorbing sutures. </li></ul><ul><li>Acute inflammatory reaction + </li></ul>
    24. 24. <ul><li>Should not be used in pt with known hypersensitivity or allergies to silk. </li></ul>
    25. 25. Surgical stainless steel <ul><li>Monofilament/Multifilament. </li></ul><ul><li>Made of 316L stainless steel. </li></ul><ul><li>Minimal acute inflammatory reaction. </li></ul><ul><li>Used in orthopaedic procedures including cerclage and tendon repair.,sternal closure,hernia repair. </li></ul><ul><li>DISADVANTAGES:Possible cutting,pulling,and tearing of patients tissues,fragmentation,kinking which renders the stainless steel suture useless. </li></ul>
    26. 26. <ul><li>When used in bone approximation and fixation asymmetrical twisting of the wire will lead to potential buckling,wire fracture or subsequent wire fatigue. </li></ul><ul><li>Incomplete wire fixation under these circumstances will permit movement of the wire,resulting in postoperative pain and possible dehiscence. </li></ul><ul><li>Should not be used when prosthesis of another alloy is implanted since an unfavourable electrolytic reaction may occur. </li></ul>
    27. 27. SURGICAL STAINLESS STEEL
    28. 28. NYLON SUTURE <ul><li>Monofilament(ETHILON),Braided (NUROLON) </li></ul><ul><li>Long chain aliphatic polymers nylon 6 or nylon6,6 </li></ul><ul><li>Progressive hydrolysis may result in gradual loss of tensile strength over time. </li></ul><ul><li>Gradual encapsulation by fibrous connective tissue. </li></ul><ul><li>Should not be used where permanent retention of tensile strength is required. </li></ul>
    29. 29. NYLON
    30. 30. MERSILENE <ul><li>Polyester fiber suture </li></ul><ul><li>Derived from polyethylene terephthalate </li></ul><ul><li>Braided/monofilament </li></ul><ul><li>No significant change known to occur in vivo </li></ul><ul><li>Gradual encapsulation by fibrous tissue. </li></ul><ul><li>No contra-indication. </li></ul><ul><li>CALCULI formation in urinary and biliary tracts when prolonged contact with salt solution such as urine. </li></ul>
    31. 31. PROLENE <ul><li>POLYPROPYLENE SUTURE </li></ul><ul><li>Monofilament </li></ul><ul><li>Its an isotactic crystalline stereo isomer of polypropylene </li></ul><ul><li>No change invivo </li></ul><ul><li>No contraindications. </li></ul>
    32. 32. PROLENE
    33. 33. PRONOVA-POLY <ul><li>Polymer blend of poly(vinylidene fluoride) and poly(vinylidene fluoride-cohexafluoro-propylene) </li></ul><ul><li>Monofilament suture </li></ul><ul><li>No contraindications </li></ul><ul><li>Resists infection and has been successfully employed in contaminated and infected wounds to minimize sinus formation and suture extrusion. </li></ul>
    34. 35. SUTURE SELECTION <ul><li>Do not use dyed sutures on the skin </li></ul><ul><li>Use monofilament on the skin as multifilament harbor BACTERIA </li></ul><ul><li>Non-absorbable cause less scarring but must be removed </li></ul><ul><li>Plus sutures (for vicryl staph, monocryl for E. coli, Klebsiella) </li></ul><ul><li>Location and layer, patient factors, strength, healing, site and availability </li></ul>
    35. 36. Cont. <ul><li>Absorbable for GI, urinary or biliary tracts </li></ul><ul><li>Non-absorbable for skin, tendons, fascia </li></ul><ul><li>Cosmetics = monofilament or subcuticular </li></ul>
    36. 37. SUTURE SIZES
    37. 38. SURGICAL NEEDLES <ul><li>Wide variety with different company’s naming systems </li></ul><ul><li>2 basic configurations for curved needles </li></ul><ul><ul><li>Cutting: cutting edge can cut through tough tissue, such as skin </li></ul></ul><ul><ul><li>Tapered: no cutting edge. For softer tissue inside the body </li></ul></ul>
    38. 39. Cont.
    39. 40. Needles <ul><ul><li>Classified according to shape and type of point </li></ul></ul><ul><ul><ul><li>Curved or straight (Keith needle) </li></ul></ul></ul><ul><ul><ul><li>Taper point, cutting, or reverse cutting </li></ul></ul></ul>
    40. 41. <ul><ul><ul><li>Atraumatic needles- to suture delicate tissues like intestine, stomach, bladder, uterus etc. </li></ul></ul></ul><ul><ul><ul><li>Double curved and loopuyt needles -for skin closure of cattle or buffalo and for deeper structures. </li></ul></ul></ul>
    41. 42. Needles <ul><li>Curved </li></ul><ul><ul><li>Designed to be held with a needle holder </li></ul></ul><ul><ul><li>Used for most suturing </li></ul></ul><ul><li>Straight </li></ul><ul><ul><li>Often hand held </li></ul></ul><ul><ul><li>Used to secure percutaneously placed devices (e.g. central and arterial lines) </li></ul></ul>
    42. 43. Needle Curvature
    43. 44. Needle point Geometry Taper-Point <ul><li>Suited to soft tissue </li></ul><ul><li>Dilates rather than cuts </li></ul>Reverse cutting <ul><li>Very sharp </li></ul><ul><li>Ideal for skin </li></ul><ul><li>Cuts rather than dilates </li></ul>Conventional Cutting <ul><li>Very sharp </li></ul><ul><li>Cuts rather than dilates </li></ul><ul><li>Creates weakness allowing suture tearout </li></ul>Taper-cutting <ul><li>Ideal in tough or calcified tissues </li></ul><ul><li>Mainly used in Cardiac & Vascular procedures. </li></ul>
    44. 45. Needle Point Geometry Blunt <ul><li>Also known as “Protect Point” </li></ul><ul><li>Mainly used to prevent needle stick injuries i.e. for abdominal wall closure. </li></ul>Premium point spatula <ul><li>Ophthalmic Surgery </li></ul>Spatula <ul><li>Ophthalmic Surgery </li></ul>DermaX* <ul><li>NEW: ½ The Penetration force </li></ul><ul><li>Superior Cosmetic Effect </li></ul>
    45. 47. Surgical Instruments
    46. 48. Using needle holder, grasp needle about 1/3 rd to 1/2 of the distance from swaged end to the point .
    47. 49. Index finger stabilizes the instrument by resting on the shaft.
    48. 50. FORCEPS <ul><li>Grasp forceps between thumb & middle finger, while index finger is used for stabilization. </li></ul><ul><li>If possible, use forceps to grasp dermis , rather than epidermis or skin surface itself. </li></ul><ul><li>This helps prevent marking & injuring of skin at wound edge. </li></ul>
    49. 51. WOUND EVALUATION <ul><li>Time of incident </li></ul><ul><li>Size of wound </li></ul><ul><li>Depth of wound </li></ul><ul><li>Tendon / nerve involvement </li></ul><ul><li>Bleeding at site </li></ul>
    50. 52. CONTRAINDICATIONS TO SUTURING <ul><li>Redness </li></ul><ul><li>Edema of the wound margins </li></ul><ul><li>Infection </li></ul><ul><li>Fever </li></ul><ul><li>Puncture wounds </li></ul><ul><li>Animal bites </li></ul><ul><li>Tendon, nerve, or vessel involvement </li></ul><ul><li>Wound more than 12 hours old (body) and 24 hrs (face) </li></ul>
    51. 53. CLOSURE TYPES <ul><li>PRIMARY CLOSURE (PRIMARY INTENTION </li></ul><ul><ul><li>Wound edges are brought together so that they are adjacent to each other (re-approximated) </li></ul></ul><ul><ul><li>Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery </li></ul></ul>
    52. 54. SECONDARY CLOSURE (SECONDARY INTENTION) <ul><ul><li>Wound is left open and closes naturally (granulation) </li></ul></ul><ul><ul><li>Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly reduced fractures </li></ul></ul>
    53. 55. Tertiary closure (delayed primary closure) <ul><ul><li>Wound is left open for a number of days and then closed if it is found to be clean </li></ul></ul><ul><ul><li>Examples: healing of wounds by use of tissue grafts. </li></ul></ul>
    54. 56. WOUND PREPARATION <ul><li>Most important step for reducing the risk of wound infection. </li></ul><ul><li>Remove all contaminants and devitalized tissue before wound closure. </li></ul><ul><ul><li>IRRIGATE w/ NS or TAP WATER (AVOID H2O2, POVIDONE-IODINE) </li></ul></ul><ul><ul><li>CUT OUT DEAD, FRAGMENTED TISSUE </li></ul></ul><ul><li>If not, the risk of infection and of a cosmetically poor scar are greatly increased </li></ul><ul><li>Personal Precautions </li></ul>
    55. 57. Basic Laceration Repair Principles And Techniques
    56. 58. Langer’s Lines
    57. 59. Principles And Techniques <ul><li>Minimize trauma in skin handling </li></ul><ul><li>Gentle apposition with slight eversion of wound edges </li></ul><ul><li>Change the laceration </li></ul><ul><ul><li>Debride crushed tissue </li></ul></ul>
    58. 60. TYPES OF CLOSURES <ul><ul><li>Simple interrupted closure – most commonly used, good for shallow wounds without edge tension </li></ul></ul><ul><ul><li>Continuous closure (running sutures) – good for hemostasis (scalp wounds) and long wounds with minimal tension </li></ul></ul><ul><ul><li>Locking continuous - useful in wounds under moderate tension or in those requiring additional hemostasis because of oozing from the skin edges </li></ul></ul><ul><ul><li>Subcuticular – good for cosmetic results </li></ul></ul><ul><ul><li>Vertical mattress – useful in maximizing wound eversion, reducing dead space, and minimizing tension across the wound </li></ul></ul><ul><ul><li>Horizontal mattress – good for fragile skin and high tension wounds </li></ul></ul><ul><ul><li>Percutaneous (deep) closure – good to close dead space and decrease wound tension </li></ul></ul>
    59. 61. SIMPLE INTERRUPTED SUTURING <ul><li>Apply the needle to the needle driver </li></ul><ul><ul><li>Clasp needle 1/2 to 2/3 back from tip </li></ul></ul><ul><li>Rule of halves: </li></ul><ul><ul><li>Matches wound edges better; </li></ul></ul><ul><ul><li>Vary from rule when too much tension across wound </li></ul></ul>
    60. 62. Simple Interrupted Suturing <ul><li>Rule of halves </li></ul>1
    61. 63. Simple Interrupted Suturing <ul><li>Rule of halves </li></ul>1 1 3 2
    62. 64. Suturing <ul><li>The needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees </li></ul><ul><ul><li>Evert wound edges </li></ul></ul><ul><ul><ul><li>Because scars contract over time </li></ul></ul></ul>
    63. 65. Suturing <ul><li>Release the needle from the needle driver, reach into the wound and grasp the needle with the needle driver. Pull it free to give enough suture material to enter the opposite side of the wound. </li></ul><ul><li>Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites. </li></ul><ul><li>Rotate your wrist to follow the arc of the needle. </li></ul><ul><li>Principle: minimize trauma to the skin, and don’t bend the needle. Follow the path of least resistance. </li></ul>
    64. 66. CONT. <ul><li>Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2-inch suture strand protruding form the bites site. </li></ul><ul><li>Release the needle from the needle driver and wrap the suture around the needle driver two times. </li></ul><ul><li>Do not position the knot directly over the wound edge. </li></ul><ul><li>Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap. </li></ul><ul><li>Cut the ends of the suture 1/4-inch from the knot. </li></ul><ul><li>The remaining sutures are inserted in the same manner </li></ul>
    65. 67. Simple, Interrupted http://www.youtube.com/watch?v=PFQ5-tquFqY
    66. 68. THE TRICK TO AN INSTRUMENT TIE <ul><li>Always place the suture holder parallel to the wound’s direction. </li></ul><ul><li>Hold the longer side of the suture (with the needle) and wrap OVER the suture holder. </li></ul><ul><li>With each tie, move your suture-holding hand to the OTHER side. </li></ul><ul><li>always wrapping OVER and moving the hand to the OTHER side = square knots!! </li></ul>
    67. 69. Two Handed Tie
    68. 70. Two Handed Tie
    69. 71. One-Hand Tie
    70. 72. One-Hand Tie
    71. 73. Continuous Locking and Nonlocking Sutures http://www.youtube.com/watch?v=xY4cAqk30K4 http://cal.vet.upenn.edu/projects/surgery/5000.htm
    72. 74. http://www.youtube.com/watch?v=sgOaBojcX-c
    73. 75. Vertical Mattress Good for everting wound edges (neck, forehead creases, concave surfaces)
    74. 76. http://www.youtube.com/watch?v=824FhFUJ6wc
    75. 77. Horizontal Mattress Good for closing wound edges under high tension, and for hemostasis.
    76. 78. Horizontal Mattress http://www.youtube.com/watch?v=9DdaooEXshk
    77. 79. http://www.youtube.com/watch?v=I7C7nsl5Tuk
    78. 80. Suturing - finishing <ul><li>After sutures placed, clean the site with normal saline. </li></ul><ul><li>Apply a small amount of Bacitracin and cover with a sterile non-adherent compression dressing (Tefla). </li></ul>
    79. 81. Suturing - PRECAUTIONS <ul><li>Need for tetanus globulin and/or vaccine? </li></ul><ul><ul><li>Dirty (playground nail) vs clean (kitchen knife) </li></ul></ul><ul><ul><li>Immunization history (>10 yrs need booster or >5 yrs if contaminated) </li></ul></ul><ul><li>Tell pt to return in one day for recheck, for signs of infection (redness, heat, pain, puss, etc), inadequate analgesia, or suture complications (suture strangulation or knot failure with possible wound dehiscence) </li></ul><ul><li>It should be emphasized to patients that they return at the appropriate time for suture removal or complications may arise leading to further scarring or subsequent surgical removal of buried sutures. </li></ul>
    80. 82. Patient instructions and follow up care <ul><li>Wound care </li></ul><ul><ul><li>After the first 24-48 hours, patients should gently wash the wound with soap and water, dry it carefully, apply topical antibiotic ointment, and replace the dressing/bandages. </li></ul></ul><ul><ul><li>Facial wounds generally only need topical antibiotic ointment without bandaging. </li></ul></ul><ul><ul><li>Eschar or scab formation should be avoided. </li></ul></ul>
    81. 83. Suture Removal <ul><li>Average time frame is 7 – 10 days </li></ul><ul><ul><li>FACE: 3 – 5 d </li></ul></ul><ul><ul><li>NECK: 5 – 7 d </li></ul></ul><ul><ul><li>SCALP: 7 – 12 days </li></ul></ul><ul><ul><li>UPPER EXTREMITY, TRUNK: 10 – 14 days </li></ul></ul><ul><ul><li>LOWER EXTREMITY: 14 – 28 days </li></ul></ul><ul><ul><li>SOLES, PALMS, BACK OR OVER JOINTS: 10 days </li></ul></ul><ul><li>Any suture with pus or signs of infections should be removed immediately. </li></ul>
    82. 84. Suture Removal <ul><li>Clean with hydrogen peroxide to remove any crusting or dried blood </li></ul><ul><li>Using the forceps, grasp the knot and snip the suture below the knot, close to the skin </li></ul><ul><li>Pull the suture line through the tissue- in the direction that keeps the wound closed . </li></ul><ul><li>Most wounds have < 15% of final wound strength after 2 wks, so steri-strips can be applied afterwards. </li></ul>
    83. 85. Topical Adhesives <ul><li>Indications: selection of approximated, superficial, clean wounds especially face, limbs. May be used in conjunction with deep sutures </li></ul><ul><li>Benefits: Cosmetic, seals out bacteria, apply in 3 min, holds 7 days (5-10 to slough), seal moisture, faster, clear, convenient, less supplies, no removal, less expensive </li></ul><ul><li>Contraindicated with infection, gangrene, mucosal, damp or hairy areas, allergy to formaldehyde or cyanoacrylate, or high tension areas </li></ul>
    84. 86. Dermabond ® <ul><li>A sterile, liquid topical skin adhesive </li></ul><ul><li>Reacts with moisture on skin surface to form a strong, flexible bond </li></ul><ul><li>Only for easily approximated skin edges of wounds </li></ul><ul><ul><li>punctures from minimally invasive surgery </li></ul></ul><ul><ul><li>simple, thoroughly cleansed, lacerations </li></ul></ul>
    85. 87. Dermabond ® <ul><li>Standard surgical wound prep and dry </li></ul><ul><li>Crack ampule or applicator tip up; invert </li></ul><ul><li>Hold skin edges approximated horizontally </li></ul><ul><li>Gently and evenly apply at least two thin layers on the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky </li></ul><ul><li>Apply dressing </li></ul>http://www.youtube.com/watch?v=oa13wriWTus&feature=related http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1
    86. 88. Follow Up Care with Adhesives <ul><li>No ointments or medications on dressing </li></ul><ul><li>May shower but no swimming or scrubbing </li></ul><ul><li>Sloughs naturally in 5-10 days, but if need to remove use acetone or petroleum jelly to peel but not pull apart skin edges. </li></ul>
    87. 89. <ul><li>THANK U </li></ul>

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