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WOUND CARE “ the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions f...
GOALS of wound care <ul><li>Facilitate hemostasis </li></ul><ul><li>Decrease tissue loss </li></ul><ul><li>Promote wound h...
INTRODUCTION
Wound healing : PATHOPHYSIOLOGY <ul><li>1.) Inflammatory Phase </li></ul><ul><li>Initial response (Day 1-4 post injury) </...
<ul><li>2.) Proliferative Phase </li></ul><ul><li>Day 4-42 </li></ul><ul><li>macrophage-released growth factors   Fibrobl...
<ul><li>3.) Remodeling Phase </li></ul><ul><li>6wks-1 year </li></ul><ul><li>Intermolecular cross-linking of collagen via ...
TYPES of Wound Healing <ul><li>1.) Healing by first intention  (aka. primary wound healing or primary closure) </li></ul><...
<ul><li>2.) Healing by second intention   (aka. secondary wound healing or spontaneous healing) </li></ul><ul><li>wound le...
<ul><li>3.) Healing by third intention  (aka. tertiary wound healing or delayed primary closure) </li></ul><ul><li>wounds ...
<ul><li>wound preparation (debridement,cleansing, etc.) </li></ul><ul><li>dress with saline soaked fine mesh gauze </li></...
Factors that affect wound healing <ul><li>Patient factor  : Age   </li></ul><ul><li>Immunocompromising   -DM </li></ul><ul...
Factors that affect wound healing <ul><li>In general, remember “DIDN'T HEAL” </li></ul><ul><li>D =  Diabetes : -diminishin...
DIDN’T HEAL <ul><li>D =  Drugs : Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis. ...
DIDN’T HEAL <ul><li>H =  Hypoxia : -esp the distal extent of the extremities. Blood volume deficit, unrelieved pain, or hy...
DIDN’T HEAL <ul><li>A =  Another wound : Competition for the substrates required for wound healing. </li></ul><ul><li>L = ...
Wound Evaluation -HISTORY <ul><li>identify all extrinsic and intrinsic factors that jeopardize healing and promote infecti...
history <ul><li>Immunocompromised </li></ul><ul><li>Bleeding disorder.Prolonged bleeding-. Hematoma can serve as culture m...
Mechanism of injury FORCE OBJECT DAMAGE WOUND shear Sharp Minimal Linear compression Blunt Right angle Moderate (+) Stella...
TYPES of wound <ul><li>Abrasions  Superficial layer  of tissue is removed </li></ul><ul><li>Avulsions  A section of tissue...
Wound assessment <ul><li>Examine for: </li></ul><ul><li>–  amount of tissue destruction </li></ul><ul><li>–  degree of con...
<ul><li>• Body Location  </li></ul><ul><li>– Proximity to Other Structures  </li></ul><ul><li>– Joints –Nerves –Tendons –V...
Physical examination <ul><li>Wound Location </li></ul><ul><li>–  importance in the risk of infection </li></ul><ul><li>–  ...
WOUND PREPARATION
Wound Preparation - Anesthesia <ul><li>Topical </li></ul><ul><ul><li>Solution or paste </li></ul></ul><ul><ul><li>LET </li...
Topical anesthesia <ul><li>Solely / with local infiltration </li></ul><ul><li>Most effective :  face and scalp  (high vasc...
Local anesthetic Drug Max Dose Onset Duration Cocaine 6.6 mg/kg Rapid 1 hour Procaine 10-15 mg/kg Rapid 30min-1hr Tetracai...
Epinephrine <ul><li>Vasoconstrictive  </li></ul><ul><li>– Increases Duration of Action </li></ul><ul><li>– Promotes Hemost...
Local infiltration <ul><li>reduce the pain of anesthetic infiltration </li></ul><ul><li>1.  Premedicate   the wound with a...
Wound Preparation - Hemostasis <ul><li>Direct Pressure–Usually best choice  </li></ul><ul><li>Ligatures </li></ul><ul><ul>...
Wound Preparation – Foreign Body Removal <ul><li>Suspect with  point tenderness </li></ul><ul><li>Visual inspection  (to t...
Hair removal <ul><li>Shaving  – Increases risk of infection X 10 ! </li></ul><ul><li>Clip Hair with Scissors  </li></ul><u...
Wound preparation : CLEANING <ul><li>high pressure irrigation (Normal Saline) </li></ul><ul><li>min 100-300 ml with contin...
Wound Preparation – Debridement <ul><li>Removes devitalized tissue </li></ul><ul><li>Creates sharp wound edge </li></ul><u...
Indications for  systemic antibiotic for traumatic wounds <ul><li>•  Injury  6 hours  old on the  extremities </li></ul><u...
“ Prophylactic” Antibiotics  <ul><li>If Prescribed  </li></ul><ul><li>• Duration 3 –7 days </li></ul><ul><li>• Wound Reche...
Wound preparation -Tetanus prophylaxis <ul><li>Clean wounds </li></ul><ul><ul><li>Incompleted immunization   toxoid </li>...
WOUND CLOSURE <ul><li>Undermine the wound edges </li></ul><ul><ul><li>Release tension </li></ul></ul>
Wound closure in relation to time <ul><li>Primary closure </li></ul><ul><ul><li>Suture, staple, adhesive, or tape </li></u...
Suture supply <ul><li>needle drivers … </li></ul><ul><li>tissue forceps (or skin hook) </li></ul><ul><li>Scissors </li></u...
Suture Material <ul><li>Absorbable </li></ul><ul><ul><li>Chromic catgut  ( natural monofilament) </li></ul></ul><ul><ul><l...
Suture size <ul><li>Skin </li></ul><ul><li>Face 5/0 or 6/0 </li></ul><ul><li>Hands and Limbs 3/0 or 4/0 </li></ul><ul><li>...
SUTURE TECHNIQUES <ul><li>Deep layer approximation </li></ul><ul><ul><li>Absorbable sutures </li></ul></ul><ul><ul><li>Bur...
Skin Closure <ul><li>Key – wound edge eversion </li></ul><ul><li>“ Approximate, don’t strangulate” </li></ul><ul><li>Antic...
Suture Techniques <ul><li>Simple Interrupted </li></ul><ul><ul><li>Used on majority of wounds </li></ul></ul><ul><ul><li>E...
Suture Techniques <ul><li>Simple Continuous </li></ul><ul><ul><li>Useful in pediatrics </li></ul></ul><ul><ul><ul><li>Rapi...
Suture Techniques <ul><li>Horizontal Mattress </li></ul><ul><ul><li>Useful for single-layer closure of lacerations under t...
Suture Techniques <ul><li>Vertical Mattress </li></ul><ul><ul><li>Useful for everting skin edges </li></ul></ul><ul><ul><l...
Suture Techniques <ul><li>Purse-string </li></ul><ul><ul><li>Useful for stellate lacerations </li></ul></ul>
Suture Techniques <ul><li>Instrument tie </li></ul>
Other devices in wound closure <ul><li>Staples </li></ul><ul><ul><li>Quick, poor aesthetic result </li></ul></ul><ul><ul><...
After care <ul><li>• Wound Dressings  </li></ul><ul><li>•   Maintain dry  –24 –48 hours </li></ul><ul><li>– Augments reepi...
Suture removal guidelines <ul><li>Anatomic location  Days (average) </li></ul><ul><li>face 3-5 </li></ul><ul><li>arm 7 </l...
Wounds appropriate for consultation/referral <ul><li>•  Primary provider is  unable to perform  optimal repair </li></ul><...
References <ul><li>www.cme-ce-summaries.com/emergency-medicine/em2604.html </li></ul><ul><li>www.medstudentlc.com </li></u...
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Woundcare

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Woundcare

  1. 1. WOUND CARE “ the primary goal of wound care is not the technical repair of the wound; it is providing optimal conditions for the natural reparative processes of the wound to proceed” – Richard L. Lammers (Roberts and Hedges)
  2. 2. GOALS of wound care <ul><li>Facilitate hemostasis </li></ul><ul><li>Decrease tissue loss </li></ul><ul><li>Promote wound healing </li></ul><ul><li>Minimize scar formation </li></ul>
  3. 3. INTRODUCTION
  4. 4. Wound healing : PATHOPHYSIOLOGY <ul><li>1.) Inflammatory Phase </li></ul><ul><li>Initial response (Day 1-4 post injury) </li></ul><ul><li>rubor, tumor, dolor, calor </li></ul><ul><li>Platelet aggregation and activation </li></ul><ul><li>Leukocyte (PMNs, macrophages) migration, phagocytosis and mediator release </li></ul><ul><li>Venule dilation </li></ul><ul><li>Exudative </li></ul><ul><li>a biologic debridement </li></ul><ul><li>In wounds closed by primary intention, lasts 4 days </li></ul>
  5. 5. <ul><li>2.) Proliferative Phase </li></ul><ul><li>Day 4-42 </li></ul><ul><li>macrophage-released growth factors  Fibroblast proliferation  Increased rate of collagen synthesis </li></ul><ul><li>Granulation tissue and neovascularization </li></ul><ul><li>Gain in tensile strength </li></ul>
  6. 6. <ul><li>3.) Remodeling Phase </li></ul><ul><li>6wks-1 year </li></ul><ul><li>Intermolecular cross-linking of collagen via vitamin C-dependent hydroxylation </li></ul><ul><li>Characterized by increase in tensile strength </li></ul><ul><li>Type III collagen replaced with type I </li></ul><ul><li>Scar flattens </li></ul>
  7. 7. TYPES of Wound Healing <ul><li>1.) Healing by first intention (aka. primary wound healing or primary closure) </li></ul><ul><li>wound closed by approximation of wound margins or by placement of a graft or flap , or wounds created and closed in the operating room. </li></ul><ul><li>Best choice for wounds in well-vascularized areas </li></ul><ul><li>Indications -recent (<24h old) </li></ul><ul><li>-clean </li></ul><ul><li>-viable tissue </li></ul><ul><li>-tension-free </li></ul><ul><li>treated within 24 h, prior to development of granulation tissue. </li></ul><ul><li>epithelialize within 24 to 48 h. Water barrier function restored  can shower or wash. </li></ul>
  8. 8. <ul><li>2.) Healing by second intention (aka. secondary wound healing or spontaneous healing) </li></ul><ul><li>wound left open and allowed to close by epithelialization and contraction. </li></ul><ul><li>Commonly : management of contaminated or infected wounds. </li></ul><ul><li>without surgical intervention. </li></ul><ul><li>Unlike primary wounds , approximation of wound margins occurs via reepithelialization and wound contraction by myofibroblasts. </li></ul><ul><li>Presence of granulation tissue. </li></ul><ul><li>Complications -late wound contracture </li></ul><ul><li>-hypertrophic scarring </li></ul>
  9. 9. <ul><li>3.) Healing by third intention (aka. tertiary wound healing or delayed primary closure) </li></ul><ul><li>wounds that are too heavily contaminated for primary closure but appear clean and well vascularized after 4-5 days of open observation . </li></ul><ul><li>Inflammation  reduced bacterial concentration (“debribe”)  allow safe closure. </li></ul><ul><li>Indications :- infected or unhealthy wounds with high bacterial content, </li></ul><ul><li>-wounds with a long time lapse since injury, or -wounds with a severe crush component with significant tissue devitalization. </li></ul><ul><li>Wound edges are approximated within 3-4 days </li></ul><ul><li>tensile strength develops as with primary closure. </li></ul>
  10. 10. <ul><li>wound preparation (debridement,cleansing, etc.) </li></ul><ul><li>dress with saline soaked fine mesh gauze </li></ul><ul><li>follow up in 72-96 hours for debridement </li></ul><ul><li>repeat cleansing and closure if no evidence of infection </li></ul>
  11. 11. Factors that affect wound healing <ul><li>Patient factor : Age </li></ul><ul><li>Immunocompromising -DM </li></ul><ul><li>- renal failure </li></ul><ul><li>- AIDS </li></ul><ul><li>- splenectomy </li></ul><ul><li>Medications –systemic steroids/ other immunocompromising drugs  i ncreased infection rates </li></ul><ul><li>Wound Characteristics   - Time , Location , Etiology , Mechanism of injury , Laceration width </li></ul>
  12. 12. Factors that affect wound healing <ul><li>In general, remember “DIDN'T HEAL” </li></ul><ul><li>D = Diabetes : -diminishing sensation and arterial inflow ++ acute loss of diabetic control  diminished cardiac output, poor peripheral perfusion, and impaired polymorphonuclear leukocyte phagocytosis. </li></ul><ul><li>I = Infection : -potentiates collagen lysis. Bacterial contamination + susceptible host + wound environment = wound infection. Foreign bodies (including sutures) potentiate wound infection. </li></ul>
  13. 13. DIDN’T HEAL <ul><li>D = Drugs : Steroids and antimetabolites impede proliferation of fibroblasts and collagen synthesis. </li></ul><ul><li>N = Nutritional problems: Protein-calorie malnutrition and deficiencies of vitamins A, C, and zinc. </li></ul><ul><li>T = Tissue necrosis , from local or systemic ischemia or radiation injury. Blood supply is important. </li></ul>
  14. 14. DIDN’T HEAL <ul><li>H = Hypoxia : -esp the distal extent of the extremities. Blood volume deficit, unrelieved pain, or hypothermia  sympathetic overactivity  local vasoconstriction  Inadequate tissue oxygenation. </li></ul><ul><li>E = Excessive tension on wound edges  local tissue ischemia and necrosis. </li></ul>
  15. 15. DIDN’T HEAL <ul><li>A = Another wound : Competition for the substrates required for wound healing. </li></ul><ul><li>L = Low temperature : (relatively) distal aspects of the upper and lower extremities (a reduction of 1-1.5°C [2-3°F] from normal core body temperature) is responsible for slower healing of wounds at these sites. </li></ul>
  16. 16. Wound Evaluation -HISTORY <ul><li>identify all extrinsic and intrinsic factors that jeopardize healing and promote infection </li></ul><ul><li>– mechanism of injury </li></ul><ul><li>– time of injury (accelerated growth phase of bacteria starts at 3 hours post wound) </li></ul><ul><li>– environment in which wound occurred </li></ul><ul><ul><ul><li>potential contaminants, foreign bodies </li></ul></ul></ul><ul><li>– species of animal if bite wound </li></ul><ul><li>– pt’s medical problems (allergies to medication) / immune status </li></ul><ul><li>tetanus immunization status </li></ul>
  17. 17. history <ul><li>Immunocompromised </li></ul><ul><li>Bleeding disorder.Prolonged bleeding-. Hematoma can serve as culture medium for wound infection. </li></ul><ul><li>Peripheral vascular disease </li></ul>
  18. 18. Mechanism of injury FORCE OBJECT DAMAGE WOUND shear Sharp Minimal Linear compression Blunt Right angle Moderate (+) Stellate Jagged tensile Blunt Oblique angle Moderate (+) Triangular Flap
  19. 19. TYPES of wound <ul><li>Abrasions Superficial layer of tissue is removed </li></ul><ul><li>Avulsions A section of tissue is torn off (partially or totally) </li></ul><ul><li>Lacerations Ti ssue is cut or torn. Sharply demarcated borders. </li></ul><ul><li>Puncture Small opening and of indeterminate depth. </li></ul><ul><li>Contusion forceful blow, outer layer of skin intact ; minimal wound care ; evaluate for possible hematoma </li></ul><ul><li>Combination wound </li></ul>
  20. 20. Wound assessment <ul><li>Examine for: </li></ul><ul><li>– amount of tissue destruction </li></ul><ul><li>– degree of contamination </li></ul><ul><li>– damage to underlying structures </li></ul>
  21. 21. <ul><li>• Body Location </li></ul><ul><li>– Proximity to Other Structures </li></ul><ul><li>– Joints –Nerves –Tendons –Vasculature </li></ul><ul><li>– Test integrity of each structure </li></ul><ul><li>• Assess laxity/muscle and tendon function </li></ul><ul><li>• Assess 2-point discrimination </li></ul><ul><li>• Assess vascular supply </li></ul>
  22. 22. Physical examination <ul><li>Wound Location </li></ul><ul><li>– importance in the risk of infection </li></ul><ul><li>– high endogenous bacterial counts in hairy </li></ul><ul><li>scalp, forehead, axilla, groin, foreskin of penis, vagina, mouth, nails </li></ul><ul><li>– wounds in areas of high vascularity more </li></ul><ul><li>easily resist infection (scalp, face) </li></ul>
  23. 23. WOUND PREPARATION
  24. 24. Wound Preparation - Anesthesia <ul><li>Topical </li></ul><ul><ul><li>Solution or paste </li></ul></ul><ul><ul><li>LET </li></ul></ul><ul><ul><li>TAC </li></ul></ul><ul><ul><li>EMLA </li></ul></ul><ul><li>Local </li></ul><ul><ul><li>Direct infiltration </li></ul></ul><ul><ul><li>1% lidocaine with or without epinephrine </li></ul></ul><ul><ul><li>Bupivicaine or sensorcaine for longer acting anesthesia </li></ul></ul><ul><li>Regional Block </li></ul><ul><ul><li>Local infiltration proximally in order to avoid tissue disruption </li></ul></ul><ul><ul><li>Smaller amount of anesthesia required </li></ul></ul>
  25. 25. Topical anesthesia <ul><li>Solely / with local infiltration </li></ul><ul><li>Most effective : face and scalp (high vascularity) </li></ul><ul><li>LET ( lidocaine, epinephrine, tetracaine) </li></ul><ul><li>TAC ( tetracaine, adrenaline/epinephrine, cocaine ) </li></ul><ul><li>cotton ball </li></ul><ul><li>soaked with 3–5ml </li></ul><ul><li>applied to the open wound for at least 10 minutes </li></ul>
  26. 26. Local anesthetic Drug Max Dose Onset Duration Cocaine 6.6 mg/kg Rapid 1 hour Procaine 10-15 mg/kg Rapid 30min-1hr Tetracaine 1.5 mg/kg Moderate 2 hours Lidocaine 5 mg/kg 5-30 min 2 hours (with Epi) 7 mg/kg 5-30 min 2-3 hours Bupivacaine 2 mg/kg 7-30 min > 6 hours
  27. 27. Epinephrine <ul><li>Vasoconstrictive </li></ul><ul><li>– Increases Duration of Action </li></ul><ul><li>– Promotes Hemostasis </li></ul><ul><li>– Avoid end-arterial blood supply areas </li></ul><ul><li>– May increase pain (low pH) </li></ul>
  28. 28. Local infiltration <ul><li>reduce the pain of anesthetic infiltration </li></ul><ul><li>1. Premedicate the wound with a topical anesthetic (described above) or ice. </li></ul><ul><li>2. B uffer anesthetic with sodium bicarbonate ( 1 ml/ 10 ml )  less painful anesthetic. </li></ul><ul><li>3. Needle size : smallest diameter needle . A 30-gauge needle is preferred. </li></ul><ul><li>4. Inject slowly (10sec), as pain results when the soft tissue stretches. </li></ul>
  29. 29. Wound Preparation - Hemostasis <ul><li>Direct Pressure–Usually best choice </li></ul><ul><li>Ligatures </li></ul><ul><ul><li>Use a tourniquet </li></ul></ul><ul><li>Chemicals </li></ul><ul><li>– Epinephrine </li></ul><ul><li>– Gelfoam </li></ul><ul><li>– Oxycel </li></ul><ul><li>– Actifoam </li></ul><ul><li>Cautery </li></ul>
  30. 30. Wound Preparation – Foreign Body Removal <ul><li>Suspect with point tenderness </li></ul><ul><li>Visual inspection (to the apex) </li></ul><ul><li>Imaging </li></ul><ul><ul><li>Glass, metal, gravel fragments >1mm should be visible on plain radiographs </li></ul></ul><ul><ul><li>Organic substances and plastics are usually radiolucent </li></ul></ul><ul><li>Always discuss and document possibility of retained foreign body </li></ul>
  31. 31. Hair removal <ul><li>Shaving – Increases risk of infection X 10 ! </li></ul><ul><li>Clip Hair with Scissors </li></ul><ul><li>Matt Hair with Ointment </li></ul><ul><li>Never shave eyebrows ( may not regrow ) </li></ul>
  32. 32. Wound preparation : CLEANING <ul><li>high pressure irrigation (Normal Saline) </li></ul><ul><li>min 100-300 ml with continued irrigation </li></ul><ul><li>at least 8 psi force to the wound  the irrigation fluid dislodges foreign bodies, contaminants, and bacteria. </li></ul><ul><li>A simple device setup </li></ul><ul><li>30-60 ml syringe and an 14-gauge angiocatheter. </li></ul>
  33. 33. Wound Preparation – Debridement <ul><li>Removes devitalized tissue </li></ul><ul><li>Creates sharp wound edge </li></ul><ul><li>Excision with elliptical shape </li></ul><ul><li>Respect skin lines </li></ul>
  34. 34. Indications for systemic antibiotic for traumatic wounds <ul><li>• Injury 6 hours old on the extremities </li></ul><ul><li>Injury 24 hours old on the face and scalp </li></ul><ul><li>Tendon, joint, or bony involvement </li></ul><ul><li>• Cartilage involvement </li></ul><ul><li>• Mammalian bite </li></ul><ul><li>• Co-morbidity (diabetes mellitus, extremes of age, steroid use, morbid obesity) </li></ul><ul><li>Puncture wound </li></ul><ul><li>Complex intraoral wound </li></ul>
  35. 35. “ Prophylactic” Antibiotics <ul><li>If Prescribed </li></ul><ul><li>• Duration 3 –7 days </li></ul><ul><li>• Wound Recheck in 24 –48 hours </li></ul>
  36. 36. Wound preparation -Tetanus prophylaxis <ul><li>Clean wounds </li></ul><ul><ul><li>Incompleted immunization  toxoid </li></ul></ul><ul><ul><li>>10 years, then give toxoid </li></ul></ul><ul><li>Tetanus prone wound </li></ul><ul><ul><li>Incompleted immunization  Toxoid & immunoglobulin </li></ul></ul><ul><ul><li>> 5 years, give toxoid </li></ul></ul>
  37. 37. WOUND CLOSURE <ul><li>Undermine the wound edges </li></ul><ul><ul><li>Release tension </li></ul></ul>
  38. 38. Wound closure in relation to time <ul><li>Primary closure </li></ul><ul><ul><li>Suture, staple, adhesive, or tape </li></ul></ul><ul><ul><li>Performed on recently sustained lacerations: <12 hours generally and <24 hours on face </li></ul></ul><ul><li>Secondary closure </li></ul><ul><ul><li>Secondary intent </li></ul></ul><ul><ul><li>Allowed to granulate </li></ul></ul><ul><li>Tertiary closure </li></ul><ul><ul><li>Delayed primary (observed for 3-4days) </li></ul></ul>
  39. 39. Suture supply <ul><li>needle drivers … </li></ul><ul><li>tissue forceps (or skin hook) </li></ul><ul><li>Scissors </li></ul><ul><li>sterile drapes </li></ul><ul><li>sterile gloves </li></ul><ul><li>suture materials </li></ul><ul><li>sterile gauze </li></ul>
  40. 40. Suture Material <ul><li>Absorbable </li></ul><ul><ul><li>Chromic catgut ( natural monofilament) </li></ul></ul><ul><ul><li>Vicryl (synthetic braided) </li></ul></ul><ul><ul><li>PDS II (synthetic monofilament) </li></ul></ul><ul><li>Non-Absorbable </li></ul><ul><ul><li>Silk (natural braided) </li></ul></ul><ul><ul><li>Ethilon (synthetic monofilament) </li></ul></ul><ul><li>Monofilament (smooth but stiff) vs. Braided (has interstices = haven for bacteria) </li></ul>
  41. 41. Suture size <ul><li>Skin </li></ul><ul><li>Face 5/0 or 6/0 </li></ul><ul><li>Hands and Limbs 3/0 or 4/0 </li></ul><ul><li>Elsewhere 2/0 or 3/0 </li></ul>
  42. 42. SUTURE TECHNIQUES <ul><li>Deep layer approximation </li></ul><ul><ul><li>Absorbable sutures </li></ul></ul><ul><ul><li>Buried knot </li></ul></ul><ul><ul><li>Serves two purposes </li></ul></ul><ul><ul><ul><li>Closes potential spaces </li></ul></ul></ul><ul><ul><ul><li>Minimizes tension on the wound margins </li></ul></ul></ul>
  43. 43. Skin Closure <ul><li>Key – wound edge eversion </li></ul><ul><li>“ Approximate, don’t strangulate” </li></ul><ul><li>Anticipate wound edema </li></ul><ul><li>Choose appropriate size of suture for location of laceration </li></ul>
  44. 44. Suture Techniques <ul><li>Simple Interrupted </li></ul><ul><ul><li>Used on majority of wounds </li></ul></ul><ul><ul><li>Each stitch is independent </li></ul></ul>
  45. 45. Suture Techniques <ul><li>Simple Continuous </li></ul><ul><ul><li>Useful in pediatrics </li></ul></ul><ul><ul><ul><li>Rapid </li></ul></ul></ul><ul><ul><ul><li>Easy removal </li></ul></ul></ul><ul><ul><li>Provides effective hemostasis </li></ul></ul><ul><ul><li>Distributed tension evenly along length </li></ul></ul><ul><ul><li>Can also be locked with each stitch </li></ul></ul>
  46. 46. Suture Techniques <ul><li>Horizontal Mattress </li></ul><ul><ul><li>Useful for single-layer closure of lacerations under tension </li></ul></ul>
  47. 47. Suture Techniques <ul><li>Vertical Mattress </li></ul><ul><ul><li>Useful for everting skin edges </li></ul></ul><ul><ul><li>“ Far-far-near-near” </li></ul></ul>
  48. 48. Suture Techniques <ul><li>Purse-string </li></ul><ul><ul><li>Useful for stellate lacerations </li></ul></ul>
  49. 49. Suture Techniques <ul><li>Instrument tie </li></ul>
  50. 50. Other devices in wound closure <ul><li>Staples </li></ul><ul><ul><li>Quick, poor aesthetic result </li></ul></ul><ul><ul><li>where scar is less of an issue (hairy scalp) </li></ul></ul><ul><li>Adhesives </li></ul><ul><ul><li>Dermabond </li></ul></ul><ul><ul><li>clean, sharp edges, clean nonmobile areas, laceration less than 5 cm in length </li></ul></ul><ul><li>Tape </li></ul><ul><ul><li>Steri-strips </li></ul></ul><ul><ul><li>superficial, straight laceration under little tension </li></ul></ul>
  51. 51. After care <ul><li>• Wound Dressings </li></ul><ul><li>• Maintain dry –24 –48 hours </li></ul><ul><li>– Augments reepithelialization </li></ul><ul><li>•“ Water-Tight” after 48 hours </li></ul><ul><li>• Bandages </li></ul><ul><li>– Soft-splint </li></ul><ul><li>– Absorb exudates </li></ul><ul><li>– Protects Wound </li></ul><ul><li>– Protects knots </li></ul>
  52. 52. Suture removal guidelines <ul><li>Anatomic location Days (average) </li></ul><ul><li>face 3-5 </li></ul><ul><li>arm 7 </li></ul><ul><li>anterior trunk 7 </li></ul><ul><li>back 10-14 </li></ul><ul><li>feet and hand 10-14 </li></ul><ul><li>joint 10-14 </li></ul><ul><li> scalp 10-14 </li></ul>
  53. 53. Wounds appropriate for consultation/referral <ul><li>• Primary provider is unable to perform optimal repair </li></ul><ul><li>– Skill level does not match complexity of wound </li></ul><ul><li>– Practice setting is too busy to allow adequate time for repair </li></ul><ul><li>• Underlying injury </li></ul><ul><li>– Tendon ,Nerve, Vascular,Joint involvement or underlying fracture </li></ul><ul><li>Eyelid : tarsal plate or lacrimal duct involvement </li></ul><ul><li>Patient requests specialist </li></ul><ul><li>• Operative repair necessary </li></ul><ul><li>– Skin grafting </li></ul><ul><li>– Flap creation or rotation </li></ul>
  54. 54. References <ul><li>www.cme-ce-summaries.com/emergency-medicine/em2604.html </li></ul><ul><li>www.medstudentlc.com </li></ul><ul><li>www.emedicine.medscape.com </li></ul><ul><li>www.proceduresconsult.com </li></ul><ul><li>Essential Practice of Surgery : Basic Science and Clinical Evidence;2003;chapter7;pg77-88;H.Peter Lorenzo, Michael T. Longaker. </li></ul><ul><li>Robbins Basic Pathology 8 th edition;chapter3;pg70-8; Kumar, Abbas, Faustro, Mitchell. </li></ul><ul><li>Essential Surgery : Problems, Diagnosis & Management ; chapter11;pg149-58; H.G. Burkitt,C.R.G. Quick, J.B.Reed. </li></ul><ul><li>Wound Management ; powerpoint presentation by UNC emergency medicine (Medical Student Lecture Series). </li></ul><ul><li>Wound Management Principles ; powerpoint presentation by Donald J Sefcik and Nicole Y Ottens, FACOEP. </li></ul><ul><li>Wound Management 2001 ; powerpoint presentation by Gavin Greenfield and Bob Johnston. </li></ul>
  55. 55. Practice Time!

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