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super very basic management of wound.pptx
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- 2. INDEX • Wound management •Classification of suture material • How to read the suture pack • Type of needles-Suturing principle • Armamentarium used for suturing • Types of knots -Types of suturing /techniques • Timing of suture removal • How to remove sutures • Other modalities of wound closure
- 3. Wound management TYPES Open ClosedACUTE Abrasions Lacerations Puncture wounds INCISIONS Burns Avulsions Surgical wounds CHRONIC Pressure injuries Venous Ulcers Non healing surgical wounds Diabetic Ulcers Arterial Ulcers Wound Classification Clean Clean- contaminated Contaminate d Dirty
- 4. Wound Management Wound Evaluation Mechanism and timingof injury Immunization status Presence of foreign body Extent of wound Review allergies Cosmetics/Aesthetics EVALUATION (practical) Extensive or deep lacerations/puncture wounds/animal bites that involve muscle, tendon or fascia (including hands) Neurovascular compromise Fracture, amputation or joint involvement Severe contamination Area where there is significant tissu e loss Phases of Wound Healing Hemostasis Inflammation Proliferation Remodelling
- 5. STEPS OF WOUNDMANAGEMENT Wound Assessment Evaluate the wound's size, depth, location, and appearance. Assess for signs of infection (redness, swelling, pain, pus) and consider factors like patient's overall health and potential barriers to healing. Wound Cleansing Gently clean the wound with saline or a wound cleanser, removing any debris or foreign material. Avoid using harsh antiseptics like hydrogen peroxide or alcohol directly on the wound as they can damage tissue. Debridement Remove any dead or damaged tissue (necrosis) from the wound. This can be done surgically, with enzymatic agents, or by other methods, depending on the wound's characteristics. Hemostasis Control any active bleeding by applying direct pressure to the wound using a clean cloth or bandage. Wound Dressings Choose the appropriate dressing based on the wound's stage and characteristics. Dressings can help to maintain a moist wound environment, absorb excess drainage, and protect the wound from further trauma. Infection Management If signs of infection are present, antibiotic therapy (topical or systemic) may be necessary, following local guidelines. Pain Management Pain control is essential. Analgesics can be used to manage pain associated with the wound and dressing changes. Monitoring and Evaluation Regularly monitor the wound for signs of healing or complications. Dressings should be changed as needed, and the treatment plan adjusted as necessary.
- 6. Laceration/ Wound Repair Timing PRIMARY CLOSURE 12-18 Hours– caused by clean/sharp objects Up to 24 Hours – Wounds of head and neck– SECONDARY INTENTION Presenting after the times above Contaminated wounds Deep stab/puncture wounds Non-cosmetic animal bites Which wounds should NOT be sutured? Animal bites – unless on face Human bites Lacerations older than 24 hrs (unless on face) Lacerations overlying infected tissue Deep puncture wounds
- 7. PRINCIPLES OF SUTURINGAND SUTURING TECHNIQUES
- 8. PRINCIPLES OF SUTURING 1.The needle holder should grasp the needle at 2/3rd of the distance from the point.
- 9. 2. The needleshould enter the tissue perpendicular to the surface 3. The needle should be passed through the tissue following the curve of the needle PRINCIPLES OF SUTURING
- 10. 4. The sutureshould be placed at an equal distance from the incision on both sides and at equal depth. PRINCIPLES OF SUTURING
- 11. 5. The needleshould be passed from the free to the fixed flap. 6. If one tissue side is thinner than the other, the needle should be passed from the thinner to the thicker side. 7. If one tissue plane is deeper than the other, the needle should be passed from the deeper to the superficial side. PRINCIPLES OF SUTURING
- 12. 8. The distancethe needle passes in to the tissue should be greater than the distance from the tissue edge. 9.The tissues should not be closed under tension - tear or necrose around the suture. 10. The tissue should be tied so the tissue is merely approximated, not blanched. 11. The knot should not be placed over the incision line. 12. The sutures should be placed approximately 3-4 mm apart. PRINCIPLES OF SUTURING
- 13. ARMAMANTARIUM Suture appropriate for location Lidocaine– syringe, 18g needle to draw, 23g needle to infiltrate area Saline/Flushes 4x4 pads Needle Drivers Forceps Scissors Suture size Suture Material Classification Absorbable vs Non- absorbable Monofilament vs Braided Tensile strength, handling, tissue reactivity Needle Parts Tip/Point, Body, Swage/EYE Needle Types Cutting • Reverse- cutting • Tapered
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- 15. Armamentarium Suture appropriate for location Lidocaine– syringe, 18g needle to draw, 23g needle to infiltrate area Saline/Flushes 4x4 pads Needle Drivers Forceps Scissors
- 17. TYPES OF SUTUREMATERIALS
- 18. KNOTS Different types ofknots include: 1. Secure/Square knot 2. Surgeon's or Friction knot 3. Granny Knot
- 19. The easiest andmost reliable for tying most suture materials. Formed by wrapping once in opposite direction between the ties. It may be used to tie surgical gut, virgin silk, surgical cotton, and surgical stainless steel SQUARE KNOT
- 20. SURGEON'S OR FRICTIONKNOT • Formed by two throws of suture around the needle holder on the first tie and one throw in the opposite direction in the second tie • A third tie squared on the second tie used for security.
- 21. GRANNY KNOT • Involvestie in one direction followed by single tie in the same direction as the first. • A third tie squared on the second tie used for security.
- 22. 1. Interrupted suture 2.Continuous suture 3. Continuous Locking suture 4. Mattress suture 5. Figure-of-8 suture 6. Subcuticular suture SUTURE TECHNIQUES
- 23. Technique Recommendations Simple InterruptedTissue approximation; can be used for most wounds Simple Running LONG lacerations; all sutures lost if one is accidentally cut Horizontal Mattress Suture Everting wound edges; can cause necrosis/scarring Vertical Mattress Suture Most effective for everting wound edges; can cause necrosis/scarring Half-buried Mattress Suture Triangular wound edges – FLAP repair Staples Fast; Unclean wounds; Avoid in cosmetic concern areas Adhesive Strips Fast, no anesthesia required; approximate simple/small lacerations – low tensile areas with no bleeding Tissue Adhesive Fast, no anesthesia required; approximate small/ simple lacerations – low tensile areas with no bleeding
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- 31. LATEST WOUND CLOSURE •Ligating clips • Surgical staples • Tissue adhesives
- 32. Key Take-Home Messages Match sutureto wound & tissue Maintain atraumatic technique & tension Prioritize wound hygiene & follow- up
Editor's Notes
- #6 Primary closure SUTURE, STAPLES, TISSUE ADHESIVE, ADHESIVE STRIPS
- #8 Grasping the suture end will result in at least bent needle if not a broken one.
- #9 If the needle peirces obliquely a tear may develop If we treat the curved needle like a straight one the flap will tear
- #10 Equal thickness but one side is elevated – tie the knot on the lower side Unequal thickness 1. farther from the incision line on thinner side 2. deeper penetration in the thinner side.
- #11 8. To ensures some degree of tissue eversion in anticipation of scar contracture. 9. Undermining by either blunt or sharp dissection to relieve the tension
- #12 12. The closeness of sutures depends on anticipated tension across the suture line. Closely spaced sutures are indicated in areas with heavy underlying muscle activity as in tongue
- #23 How do you choose which closure technique is best? Tissue adhesives can be applied more quickly, require no anesthesia, and eliminate the need for follow-up because they slough off spontaneously within five to 10 days. They form a protective barrier to promote wound healing and may have antimicrobial effects.18 Although tissue adhesives have a higher direct cost per unit than sutures, they are more cost-effective because of quick application and no follow-up.19 Tissue adhesives' low tensile strength makes them inappropriate for high-tension areas, such as over joints, unless the area is immobilized. They may be ideal for simple lacerations under a cast or splint.
- #24 Can be used in areas of stress Strong and the successive sutures can placed to match the individual requirements Each suture independent of the other The loosening of one suture will not produce loosening of other sutures A degree of eversion of incision can be produced. Useful in cases where the wounds become infected or hematoma formation. Removal of a few sutures offers satisfactory relief
- #25 1. Provides a rapid technique for closure. Initially a simple interrupted suture is placed and then the needle is inserted in a continuous fashion so that the suture passes perpendicular to the incision line. 2. Even distribution of tension over the entire suture line. 3. Provides a more watertight closure of the wound. 4. Should not be used in areas of existing tension. 5. But if a knot slips the whole suturing will come undone. Should not be done in places where hematoma or excessive swelling is anticipated
- #26 Similar to continuous suture but locking is done by withdraing the suture through its own loop after every insertion. This ensures that Suture aligns perpendicular to the incision Locking feature prevents the continuous tightening of the sutures as it progresses Individual locks should not be tightened excessively to prevent tissue necrosis. Prevents adjustment of tension over the suture line as the tissue swelling occurs. Disadvantage is same as continuous suturing
- #27 Provides more tissue eversion than the interrupted sutures. Used in areas where tension free flap closure cannot be done. Resists muscle pull, everts wound margins and adapt the tissue flaps tightly to the underlying structures Horizontal – atleast 8 mm from flap edges- provides broad contact of wound margins. For eg – closure of extraction sockets The vertical mattress sutures offer the advantage of running parallel to the blood supply to the edge of the flap and is used for closing deep wounds
- #28 Used for closure of subcuticular layer If individual subcuticular sutures are placed they should be buried with the knot inverted. A continuous subcuticular sutures may be used with no knots having the ends exit only a short distance from the wound. A continuous subcuticular sutures – removed after 7-10 days by un taping both the ends and pulling in one direction.
- #29 Used for closure of subcuticular layer If individual subcuticular sutures are placed they should be buried with the knot inverted. A continuous subcuticular sutures may be used with no knots having the ends exit only a short distance from the wound. A continuous subcuticular sutures – removed after 7-10 days by un taping both the ends and pulling in one direction.
- #30 External wound has healed - no longer needs the support of nonabsorbable suture material The length of time the sutures remain in place depends upon the rate of healing and the nature of the wound Sutures should be removed using aseptic and sterile technique - use a sterile suture removal tray prepared for the procedure
- #31 Ligating clips –steel, tantalum, titanium or polydioxanone Surgical staples- rapid closure of skin provided 5mm distance to underlying bone or vessels Adhesives – n butyl cyanoacrylate, 2 octyl cyanoacrylate