Basic skills in surgery and medicine wound management, cannulation, dressing , intubation\

1. Mohamed Ahmed El-Rouby, MD
Lecturer of Plastic and Reconstructive Surgery
Ain Shams University
http://tajmeel.ohost.de
Dr_mohamed_a@yahoo.com

2.  Sterilization
 Incision
 Management of Wounds
 Wound Closure & Suturing
 Wound Dressing
 Airway Management
 Venous Cannulation
 Arterial Blood Sample
 Catheterization

3. Betadine Scrub Betadine Paint

7. • Initial Examination
• Classification of Injury
• Special Regional Considerations
• Animal and Human Bites
• Tetanus
• Suture Materials
• Wound Healing/Repair
• Wound Closure

8.  Establish airway and control hemorrhage
 Rule out C-Spine Injury
 Rule out facial bone fractures
 Reduce fractures before soft tissue repair
 Keep wounds moist during examination:
• Direct inspection of persistent bleeding
• Copious irrigation with saline
• Direct pressure to control bleeding

9.  Wounds divided into two groups:
 clean and contaminated
 Contamination increases with time
 “The solution to pollution is dilution”
• Anesthetize wound before irrigation
• Remove foreign bodies
• Tetanus prophylaxis as needed

10. Classification of injuries
• Contusion
• Abrasion
• Accidental Tattoo
• Retained Foreign Bodies
• Puncture Wounds
• Simple Laceration
• Avulsion (flap)
• Avulsion (complete)
• Burn

11.  Forehead and Brow
 Hair  Do not shave eyebrow
 Muscles  prevent depression
 Rule out fractures
 Eyelid
 Protects globe and drying of cornea
 Ophthalmology consult mandatory
 Rule out muscle impairment

12.  Nose
 Soft tissue injuries usually simple
 Align nasal structures accurately + casting
 Rule out hematoma
 Reduce fractures first
 Use 6-0 non-absorbable sutures (Nylon or Polypropylene)
 Soft tissue repair in then out

13.  Ear
 Direct blow causes hematoma  “Cauliflower ear”
 Use 6-0 non-absorbable sutures (Nylon or Polypropylene)
 Complex lacerations  ???

14.  Cheek
 Common facial injury
 Superficial injuries  ? simple
 Deeper injuries may involve:
 parotid gland
 facial nerve

15.  Lip
 Vermilion border
 Single suture to reorient
 Close in layers
 Muscle  use chromic or Vicryl
 Mucosa  use chromic or Vicryl
 Skin  use 6-0 Polypropylene or silk sutures

17. • Peak incidence ages 5-9
• 15-20% of dog bites become infected
• 20-50% of cat bites become infected
• Puncture wound highest rate of
infection
• ????????
• Contaminated with oral flora
as well as with Staph, from
the skin of the victim

18. • Irrigation and debridement are
mainstays of treatment
• Loose primary closure of bite wounds
• Antibiotics G+ve, G-ve, anaerobic
• Antitetanic serum
• S. aureus and Pasteurella canis,
multocida and septica are pathogens
• 2nd look and repair after 2 days

19. Clinical Feature Tetanus Prone Clean, minor wound
Age of wound 6 hours + Less than 6 hours
Configuration Stellate, evulsions Linear, abrasion
Mechanism of Injury Missile, crush, heat/cold Sharp surface (knife/glass)
Signs of Infection Present Absent
Devitalized tissue Present Absent
Contaminants (dirt, feces,
soil, saliva)
Present Absent

20. 1. Hemostasis : direct simple pressure
: compressive dressing
: tourniquet
: no blind clamp
: no rubber band
2.Pain control : local anesthesia
: regional anesthesia
: general anesthesia
3.Wound cleansing : scrub
: irrigation
: antiseptic
4.Wound exploration
: control bleeding
: identify injured structures
: debridement
: irrigation
: repair injured structures

22. ‫المظهر‬ ‫حسن‬ ‫و‬ ‫الطبع‬ ‫خير‬ ، ‫الذكاء‬ ‫حسن‬ ، ‫الخلق‬ ‫تام‬ ‫يكون‬ ‫إن‬
‫اللهجة‬ ‫صادق‬ ،‫النظر‬ ‫عفيف‬ ،‫القلب‬ ‫سليم‬ ‫يكون‬ ‫أن‬‫و‬‫المرضى‬ ‫ألسرار‬ ‫كتوما‬
‫الفقراء‬ ‫عالج‬ ‫في‬ ‫ورغبته‬ ،‫األجر‬ ‫في‬ ‫رغبته‬ ‫أكثرمن‬ ‫المرضى‬ ‫عالج‬ ‫في‬ ‫رغبته‬ ‫يكون‬ ‫أن‬‫األ‬ ‫عالج‬ ‫في‬ ‫رغبته‬ ‫من‬ ‫اكثر‬‫غنياء‬
‫الناس‬ ‫منافع‬ ‫في‬ ‫والمبالغة‬ ‫التعليم‬ ‫على‬ ‫حريصا‬ ‫يكون‬ ‫أن‬
‫الواضح‬ ‫اإلهمال‬ ‫من‬ ‫عمله‬ ‫وخال‬ ‫مثله‬ ‫من‬ ‫يرتقب‬ ‫ما‬ ‫وأدى‬ ‫اجتهد‬ ‫فان‬ ‫مريضه‬ ‫عالج‬ ‫فى‬ ‫باالجتهاد‬ ‫مطالب‬ ‫والطبيب‬‫أو‬ ‫عمدا‬
‫على‬ ‫أثم‬ ‫فال‬ ‫المطلوب‬ ‫غير‬ ‫على‬ ‫النتيجة‬ ‫جاءت‬ ‫و‬ ‫أمثاله‬ ‫بها‬ ‫يأخذ‬ ‫أن‬ ‫ينبغي‬ ‫التي‬ ‫باألسباب‬ ‫وأخذ‬ ‫سهوا‬‫ع‬ ‫وال‬ ‫الطبيب‬‫قوبة‬
‫فى‬ ‫المريض‬ ‫وكيل‬ ‫والطبيب‬‫مبدئيا‬ ‫إقرارا‬ ‫معالجا‬ ‫طبيبا‬ ‫له‬ ‫المريض‬ ‫قبول‬ ‫ويعتبر‬ ‫جسمه‬‫يص‬ ‫الذي‬ ‫العالج‬ ‫بقبول‬‫فه‬
‫ه‬ ‫توثيق‬ ‫وجب‬ ‫جراحيا‬ ‫أجراء‬ ‫العالج‬ ‫هذا‬ ‫استدعى‬ ‫فإذا‬‫ذ‬‫للمريض‬ ‫األمر‬ ‫شرح‬ ‫بعد‬ ‫للطبيب‬ ‫وقاية‬ ‫كتابيا‬ ‫القبول‬ ‫ا‬
‫ه‬ ‫يثبت‬ ‫أن‬ ‫ثم‬ ‫له‬ ‫ينصح‬ ‫أن‬ ‫الطبيب‬ ‫على‬ ‫كان‬ ‫العالج‬ ‫المريض‬ ‫رفض‬ ‫فإذا‬‫ذ‬‫بتوقيع‬ ‫أو‬ ‫باإلشهاد‬ ‫أو‬ ‫بالكتابة‬ ‫الرفض‬ ‫ا‬‫المريض‬
‫األحوال‬ ‫وفى‬‫بالتأجيل‬ ‫الوقت‬ ‫يسمح‬ ‫وال‬ ‫حياة‬ ‫إلنقاذ‬ ‫ضروريا‬ ‫الجراحة‬ ‫أو‬ ‫الطبي‬ ‫المدخل‬ ‫فيها‬ ‫يكون‬ ‫التي‬‫الطبي‬ ‫على‬‫يتدخل‬ ‫أن‬ ‫ب‬
‫سليم‬ ‫وبأسلوب‬ ‫المهنة‬ ‫أصول‬ ‫توجبه‬ ‫ما‬ ‫أجرى‬ ‫قد‬ ‫دام‬ ‫ما‬ ‫النتائج‬ ‫كانت‬ ‫مهما‬ ‫عليه‬ ‫وال‬.
‫الشديد‬ ‫األلم‬ ‫بدعوى‬ ‫منها‬ ‫التخليص‬ ‫أو‬ ‫الحياة‬ ‫من‬ ‫التخلص‬‫دعوة‬ ‫شفائها‬ ‫من‬ ‫الميئوس‬ ‫األمراض‬ ‫فى‬‫سندا‬ ‫تجد‬ ‫ال‬‫شرع‬‫ى‬

24.  Inflammatory Phase
 Proliferative Phase
 Remodeling or Maturation Phase

25. •Wound strength gradually increases during the
healing process:
•2 weeks less than 10%.
•3 weeks up to 20%.
•4 weeks up to 50%.
•3-6 months 70-80% of its original strength
(its maximum strength).

26. •The choice of a particular suture material
should be based on
•the patient,
•the wound,
•the tissue characteristics,
•the anatomic location.

27. “There exists the strange belief that a
plastic surgeon can make an incision
and leave no visible scar and that he
can in fact do away with previously
existing scars”

28.  Types of wound closure
 Linear Wounds:
 primary closure
 delayed primary closure
 secondary closure
 Wide Area Wounds:
 Partial-thickness wound closure
 Full-thickness wound closure
 Compound wound closure
 Re-implantation

29. • Basic Principles
 Less scarring by primary intention; open wound granulates
and scars
 debride and close primarily
 Clean wounds can be closed primarily 48 hours after injury
 If delayed primary closure, give systemic antibiotics and
place sterile dressing
 Stabilize first, then treat soft tissue wounds
 We may access fracture through wound
 Closure with minimal tension
 Handle tissue gently
 Use appropriate suture

30.  Monofilament or multifilament strands
 Absorbable or non-absorbable
 Size: Refers to the diameter of the suture
 The more “0’s” in the number, the smaller the suture

31. •The optimal suture is:
•easy to handle
•high tensile strength and knot security.
•good elasticity and plasticity 
accommodate wound swelling.
•resist infection
•tissue reaction minimal,
•low cost.
NB: no one material is ideal

32.  Plain Gut
 submucosa of sheep
intestines
 Not a true monofilament
 Less than 10 day life span in
tissue
 100 times the bacterial
adhesion than that of
Polypropylene

33. • Chromic Gut
 Plain gut tanned with
chromium salts
 Improved strength and
duration
 Duration is 2-3 weeks
 Knot security greater than
plain gut
 Absorption by proteolytic
enzymes

34. • Vicryl
 Copolymer of glycolic and lactic
acid
 Absorbed by hydrolysis of ester
bond
• PDS
• The best but expensive

35. • Dexon

36.  Silk

37.  Polypropylene (Prolene)
 Similar to synthetic
 monofilament polymers
 Knot security and ease of tying
?????
 Non Absorbable
 good for contaminated
wounds

38. Tapered
Cutting
Reversed Cutting
1/4 circle
1/2 circle
3/8 circle
3/4 circle
Curve-ended
straight Straight

41.  Needle Holder

42.  Scalpel

44. 1. SUTURE
2. STAPLES  Stainless steel
3. TAPES  Steri-strips
4. TISSUE ADHESIVES 
Octylcyanoacrylate (Dermabond)

45. • Simple interrupted
 Advantages:
- common, apply rapidly
- can get good eversion of wound edges
 Disadvantages:
- eversion of edges takes practice to master
- does not relieve tension from wound edges
- time consuming

46. • Simple interrupted

47. • Continuous over and over

48. • Running locked stitch

49.  Subcutaneous Sutures (inverted)
1
43
2

50. • Vertical Mattress
 Advantages:
- unsurpassed to provide
eversion of wound edges
- relieves tension from
the skin edges
 Disadvantages:
- takes time to apply
- produces more cross-marks
- caution must be taken not to
place sutures too tight

51.  Vertical mattress stitch

52. • Horizontal mattress
 Advantages:
- reinforces the subcutaneous
tissue
- relieves tension from the skin
edges better
- can be applied quickly
 Disadvantages:
- apposition of wound edges
better with the vertical mattress

53.  Horizontal mattress stitch

54. • Mattress sutures

55. • Half – buried horizontal matress suture

56. • Subcuticular suture

57. • Skin staples

58. • Skin adhesive strips

59. Epidermis
Dermis
Muscle
Submucosa
Mucosal Epithelium

60. 1- flat knots
- square knots
- surgeon's knots.
2- instrumental tie.
3- deep tie.
4- ligation around clamp

61.  Simple Surgeon Knot

62.  Surgeon Knot

63.  Instrumental Knot

64.  Deep structure Knot

65.  Ligation around a clamp

66.  Lumen structure Knot

68.  After wound closure:
 Dressings is applied
 Antibacterial ointment
may be applied
 Remove skin sutures
after ?
 Scar will mature in 8-12
months

69.  the face, 5-7 days.
 the neck, 7 days.
 the scalp, 10 days.
 the trunk 10-14 days.
 The upper extremities, 10-14 days.
 the lower extremities, 14-21 days.

79. • Scar formation
 Foreign material
 Necrosis
 Ischemia
 Wound tension

83.  Goals
: moisture but no maceration
: no infection
: no foreign body
: optimal temperature and pH
 Dry Dressing
1. Non – adherent layer
2. Absorptive and protective layer
3. Immobilization
 Wet Dressing
 0..9% NSS solution is the best one
 Antiseptic cream
 Hydrocolloid
 Calcium alginate

84. So, the ideal wound dressing:
1. Creates ideal microclimate for most rapid and effective
healing (prevents dehydration and is permeable to oxygen)
2. Is sterilisable
3. Provides good absorption of blood and exudates
4. Protects against secondary infection
5. Has sufficient mechanical protection to wound
6. Is non-adherent
7. Is non-toxic
8. Is non-allergenic or sensitizing
9. Does not shed loose material into wound

85. 10. Conforms to anatomical contours
11. Resists tearing
12. Resists soiling
13. Is non-flammable
14. Its properties remain constant in a range of
temperatures and humidities
15. Has a long shelf life
16. Has small bulk (hospital storage problem)
17. Accepts and releases medicaments
18. Is cost effective

86.  Types:
 Biological, synthetic.
 Time:
 Temporary, permanent.
 Technique:
 Dry, wet-to-dry, wet-to-wet
 Method:
 Open, semi-open,
 semi-occlusive, occlusive.
 Chronological
 Conventional
 Membranous.
Types of Wound dressing

87.  Biological:
- Xenografts - Allografts
- Alloderm (Acellular human dermis)

88.  Synthetic:
Telfa (Absorbant) Xeroform (Low adherent)
Opsite (semiperm.film) Tegagerm (semiperm.film)

89.  Synthetic:
Inadine (non-adherent) Intrasite Gel (hydrogel)
Tielle (Hydroplymers) Duoderm (hydrcolloids)

90.  Synthetic:
AquacelAg (Hydrofiber) Kaltostat (Alginates)
LyoFoam (Synth.foam) Actisorb (Charcoal)

91.  Biosynthetic:
BiocCore (Collagen) Integra (tissue eng.)
Biobrane (Synth.derm) Cutured keratinocytes

92.  Debriding agents:
Saline gush Wound
cleansing
Iruxol (Collagenase) Surgical

93. Wound Type Type of Dressing
Dry, necrotic wounds Deriding agent > synthetic
Slough-covered wounds Deriding agent > synthetic
Clean, exuding wounds
(granulating)
Synthetic or biosynthetic

94. Wound Type Type of Dressing
Clean, dry, low exudate wounds
(epithelialising)
Biosynthetic or biological
Clean, medium-to-high exudate
wounds (epithelialising)
Synthetic, biosynthetic or
biological
Cavity e.g bed sore Deriding agent + Vaccum

95. 1- Preparation

96. 2- Remove old dressing

97. 3- Cleansing and wash
 Wound cleansing is a clean - not sterile - procedure
 Before commencing, assess the wound
 Not all wounds require cleaning
 Wound exudate contains anti-microbial substances,
which are natural wound cleansers.
 Reasons to clean a wound Presence of:
 Foreign bodies
 Debris e.g. slough, residue from hydrocolloid dressings
 Purulent exudates i.e. infection

98. 4- Sterilization

99. 5- Dry the wound

100. 6- Application of dressing agent

101. 7- Application of dry gauze

102. 8- Application of dry dressing

103. 9- Bandage

104. 10- Discuss with the patient the wound
progression and add any instruction to
accelerate healing like certain position or avoid
certain movements…etc.