4 lin, michelle wound closure
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This presentation discusses novel approaches and tips for wound closure techniques: It reviews using steristrips to reinforce fragile skin when suturing; the importance of adequate visualization and palpation when examining wounds; using a plaster splint or beanie hat for dressings; a modified Hair Apposition Technique without staples; combining sutures with tissue adhesives or steristrips; and tricks like making a glove ring for hemostasis or using a speculum for finger bandaging. The goal is to provide emergency physicians with practical advice for improving wound repair.
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4 lin, michelle wound closure
- 1. Advanced Wound Closure Techniques Michelle Lin, MD Associate Professor of Clinical Emergency Medicine University of California, San Francisco; San Francisco General Hospital and Trauma Center Michelle.Lin@emergency.ucsf.edu On the front lines: We are the experts in wound closure. Goals of this talk 1. Make life easier for you with “tricks of the trade” in wound closure. 2. Review recent literature in wound care. Case 1 A 78 year old woman sustains an arm laceration. How would you repair this laceration? Case 1 A 78 year old woman sustains an arm laceration. How would you repair this laceration? Use steristrips to strengthen skin wound edges in combination with sutures. Davis M et al. J Emerg Med. 2011, 40(3):322‐3. My alternative trick Case 2 35 y/o man presents after being assaulted to the head
- 2. Case 2 Have I missed any additional scalp lacerations? 1. Adequate visualization using bright LED flashlight Case 2 Have I missed any additional scalp lacerations? 2. Manual palpation of the scalp Case 2 You find and repair 3 scalp lacerations with staples. You suture the ear laceration. How do you prevent an auricular hematoma? Case 2 How do you prevent an auricular hematoma? Traditional teaching: Gauze in antihelix. Case 2 How do you prevent an auricular hematoma? Traditional teaching: Gauze in antihelix + sutures. Case 2 How do you prevent an auricular hematoma? Trick of the trade: Make a plaster splint.
- 3. Case 2 How do you prevent an auricular hematoma? Trick of the trade: Make a plaster splint. Case 2 How do you prevent an auricular hematoma? Trick of the trade: Make a plaster splint. Case 2 How do you prevent an auricular hematoma? Trick of the trade: Make a plaster splint. Case 2 How do you prevent an auricular hematoma? Trick of the trade: Make a plaster splint. Case 2 How do you apply a pressure dressing on the head? Traditional teaching Case 2 How do you apply a pressure dressing on the head? Trick of the trade: Beanie hat Thanks to Dr. Eric Silman (Chief resident, UCSF-SFGH)
- 4. Case 2 How do you apply a pressure dressing on the head? Trick of the trade: Beanie hat Case 2 How do you apply a pressure dressing on the head? Trick of the trade: Beanie hat Case 2 How do you apply a pressure dressing on the head? Trick of the trade: Beanie hat Case 2 How do you apply a pressure dressing on the head? Trick of the trade: Beanie hat Case 2 How do you apply a pressure dressing on the head? Trick of the trade: Beanie hat Thanks to Dr. Eric Silman (Chief resident, UCSF-SFGH) Case 2 Can I close scalp lacerations without staples?
- 5. Case 2 Can I close scalp lacerations without staples? Modified Hair Apposition Technique (HAT trick) * Uses opposing hair strands & adhesive * One full 360o revolution twist of hair * Apply adhesive at twisting point * Repeat this along length of wound * Do NOT over‐twist the hair. * Do NOT tie a knot. 1. Ong et al, Annals of EM, 2005 2. Hock et al, Annals of EM, 2002 Case 2 Can I close scalp lacerations without staples? Contraindications to the HAT trick: ‐ Laceration >10 cm long ‐ Grossly contaminated wounds ‐ Active bleeding from the laceration ‐ Significant wound tension ‐ Hair strands <3 cm long Case 2 Speaking of tissue adhesives, how can I prevent tissue adhesives from “running” into undesired areas? Use Trendelenberg or reverse Trendelenberg Case 2 Speaking of tissue adhesives, how can I prevent tissue adhesives from “running” into undesired areas? Use petroleum-based gel as a barrier. Case 2 Speaking of tissue adhesives, how can I prevent tissue adhesives from “running” into undesired areas? Use a tegaderm tape as a barrier. Thanks to Dr. Hagop Afarian (Fresno-Community Regional Medical Ctr) Case 2 Speaking of tissue adhesives, how can I prevent tissue adhesives from “running” into undesired areas?
- 6. Use a tegaderm tape as a barrier. Case 2 Speaking of tissue adhesives, how can I prevent tissue adhesives from “running” into undesired areas? Case 2 What are other uses of tissue adhesives? Securing an avulsed fingernail or toenail. Thanks to Dr. David Carr (University Health Network in Toronto) Case 2 What are other uses of tissue adhesives? Securing an avulsed fingernail or toenail. Case 2 What are other uses of tissue adhesives? In combination with steristrip tapes, can close wounds under slight tension Case 2 What are other uses of tissue adhesives? In combination with absorbable sutures, can close wounds under slight tension or inverted Trick by Dr. Jonathan Davis and Dr. Matt Borloz (Georgetown/ Washington Hospital) Case 2 Which kind of absorbable sutures?
- 7. Case 3 25 y/o man presents with a forearm laceration. How would you close the wound? Case 3 25 y/o man presents with a forearm laceration. How would you close the wound? Horizontal mattress sutures for wounds under tension Case 3 25 y/o man presents with a forearm laceration. How would you close the wound? For LONG wounds under tension, steristrip rest of wound to temporarily relieve tension while suturing
- 8. Case 3 25 y/o man presents with a forearm laceration. How would you close the wound? A bit too much tension! Case 3 25 y/o man presents with a forearm laceration. How would you close the wound? Trick: Alternate horizontals with simple interrupted sutures Case 4 15 y/o boy presents with a forehead laceration. How would you close the wound? Case 4 15 y/o boy presents with a forehead laceration. How would you close the wound? Use corner sutures whenever possible Case 4 15 y/o boy presents with a forehead laceration. How would you close the wound? Use corner sutures whenever possible Case 5 40 y/o man crashes his motorcycle and injures his hand My alternative trick How would you check for non-radioopaque foreign bodies?
- 9. Case 5 40 y/o man crashes his motorcycle and injures his hand My alternative trick How would you check for non-radioopaque foreign bodies? Use the ultrasound water bath technique Blaivas M et al. Amer J Emerg Med. 2004; 22(7):589‐93. Case 5 40 y/o man crashes his motorcycle and injures his hand My alternative trick How would you check for non-radioopaque foreign bodies? Use the ultrasound water bath technique Blaivas M et al. Amer J Emerg Med. 2004; 22(7):589‐93. Case 5 40 y/o man crashes his motorcycle and injures his hand His index finger laceration keeps oozing. How can you achieve better hemostasis? Case 5 40 y/o man crashes his motorcycle and injures his hand His index finger laceration keeps oozing. How can you achieve better hemostasis? Make a glove “ring” Transfer to patient’s finger Case 5 40 y/o man crashes his motorcycle and injures his hand How would you bandage the finger? Finger applicator Cotton tubular gauze Case 5 40 y/o man crashes his motorcycle and injures his hand How would you bandage the finger? “The Digi-Spec” Wrap finger with cotton tubular gauze using pelvic speculum. Thanks to Tina King, NP (SFGH).