Chris Giaquinto, PA-C Doctors for Emergency Service Christiana Care Health System

Transcription

1 Chris Giaquinto, PA-C Doctors for Emergency Service Christiana Care Health System

2 This program was sponsored by an educational grant from Ethicon. DAPA would like to thank Doctors for Emergency Service for their support.

3 Wound repair resource website Lacerationrepair.com

4 Wound Healing Why close a wound? Optimal healing Better aesthetics Easier to manage

5 Types of Wound Healing Primary Intention Surgical wound closure sutures, staples, wound adhesive, sterile tape Helps prevent additional scar tissue Eliminate dead space Atraumatic handling of tissue Eversion of skin edges

6 Types of Wound Healing Secondary Intention Wound left open and allowed to contract and heal Delayed Primary Closure or Third/Tertiary Intention Delayed primary closure Wound left open due to contamination Usually closed 4-5 days later

7 Indications for wound closure Open wound after traumatic event Almost every wound would benefit from closure

8 Contraindications for Primary Closure Heavily contaminated wounds or deeply embedded debris (grass, dirt) Wound with large amount tension or swelling results in tight closure Wound with a lot of SubQ dead space

9 Contraindications for Primary Closure Animal Bites on the hands and feet Foreign body in the wound (unable to remove) Concave surfaces may better benefit from secondary intention Nasal alar crease Preauricular sulcus Conchal bowl inside the ear

10 Risk Factors for Complications Size - >5cm in length Location extremities higher then Head or Trunk Contamination dirtier the wound, higher the complication Time Not definitive for all wounds (6, 12, 24 hrs?) Longer time until closure, higher the risk of infection Patient s history Higher risk Diabetics, Immunocompromised or Malnourished

11 What to use? Sutures Staples Glue Sterile Tape Nothing

12 Staples Stainless steel Lower infection rate Faster Great for scalp wounds Must assure skin edges are everted More expensive

13 Tissue Adhesive Cyanoacrylate (Dermabond, Indermil, SurgiSeal) Small wounds < 2 cm, clean and linear Contraindicated Stellate injury, bites, diabetic wounds, allergy to cyanoacrylate Use Caution Fingers, Toes, Joints, around eyes Periorbital lacerations With eye close place antibiotic ointment over eyelashes Glue won t adhere

14 Sterile Tape closure Porous paper tape (Steri-Strips) Use alone or with sutures Use skin adhesive Mastisol or Tincture of Benzoin Allows skin to be more adhesive Cheaper Generally not appropriate for large or gaping wounds

15 Not closing wound Wound beginning to heal Clot formed in wound Wound edges immobile No active bleeding in a small wound Signs of infection

16 Local anesthetics Lidocaine 1% or 2% - plain or with epinephrine Adding Bicarb can help lessen the acidity and burning 1 part Bicarb to 10 parts Lidocaine Onset is immediate and last 1-2 hours Bupivicaine 0.25% or 0.5% - plain or with epinephrine Onset can be immediate, but can take 3-5 minutes Lasts 6-8 hours, can have longer analgesic effects after return of sensation

17 Topical Anesthetics Advantages No tissue distortion No Needles Gives you time to do other tasks Disadvantages Takes longer to work May still need to use needle if analgesia not achieved

18 Topical Anesthetics EMLA Lidocaine 2.5% and Prilocaine 2.5% Best if used with occlusive dressing 1 hour to achieve analgesia LET Lidocaine 4%, Epinephrine 0.5%, Tetracaine 0.5% Topical anesthetic gel apply around wound Use cotton ball, absorbs gel less than gauze Can take up to 30 minutes to work

19 Wound cleaning Irrigation of wound best way to prevent infection The Solution to Pollution is Dilution Approx ml solution per 1 cm wound Irrigate with more volume and pressure in more contaminated wounds Irrigate with pressure Syringe with catheter (18/20g) Sterile Saline Tap water just as effective Use splash guard if available

20 Wound Cleaning Heavily contaminated Consider calling surgeon Can use pulse irrigation evacuation if available Battery operated Uses pulse irrigation and suction simultaneously

21 Suction irrigator

22 Tetanus prophylaxis Tdap Tetanus, Diphtheria, acellular Pertussis 0.5 ml IM Consider for all wounds Prophylaxis If >5 years since last tetanus booster in tetanus prone wound update patient > 10 years in all wounds update patient Routine administration is every 10 years if no injury

23 Prophylactic antibiotics Clean Wounds Generally do not need antibiotics Antibiotics usually required Bite wounds (Human or animal) Puncture wounds Open fractures Old wounds (>6 hrs) that are closed Tendon or joint involvement Immunocompromised patients

24 Antibiotic selection Wound contamination, Open fx, tendons involved Cephalexin 500 mg QID (can be dosed TID and BID) Clindamycin if allergy to cephalexin or cephalosporins Can also use dicloxacillin, TMP-SMZ, doxycylcine

25 Antibiotic selection Bites Wounds Cats and Dogs Amoxicillin/Clavulanate Doxycycline Clindamycin plus Ciprofloxacin or TMP-SMZ Human Bite Wounds Amoxicillin/Clavulanate Clindamycin plus Ciprofloxacin or TMP-SMZ

26 Referring to specialist Joint Concern for wound extending into join capsule, consult or refer to orthopedics, hand, or podiatry as appropriate ENT or OMFS (Oral Maxillofacial Surgery) Facial wounds involving mucosa, facial fx and teeth Tendon Partial or complete tear in the hand or feet Contact Hand surgeon or Podiatrist Cosmetics I want a Plastic Surgeon Contact surgeon Simple wounds generally closed with steri-strips and follow up in office later that day or next day Complex wounds may require immediate action

27 When to use certain suture material and needles Skin Nylon or Prolene Face use 5-0 or 6-0 Rest of Body 4-0 If under tension may need 3-0 Sucutaneous Vicryl, Monocryl, or Gut (plain or chromic) 3-0, 4-0 or 5-0 Buccal Mucosa Fast Absorbing gut 5-0 or 6-0

28 Suturing Technique Enter skin at 90 degrees Evert skin edges

29 Suturing Techniques Simple interrupted and continuous Mattress Vertical and Horizontal Subcutaneous sutures Subcuticular Corner stitch for V, Y, X and stellate wounds Half buried Horizontal Mattress Nail bed and Ear lobe Through and through - mouth Dog ear repair Fingertip Avulsion

30 Undermining Helps free skin under tension for better closure Done at either dermal/subcutaneous or dermal/epidermal junctions Can be done blunting or sharply (blunt preferred) Instruments that can be used Scissors Hemostat Electrocautery handheld Scalpel

31 Undermining

32 Simple Interrupted

33 Simple Continuous

34 Mattress Stitches Good eversion of skin edges Does not compromise blood supply Vertical Far-Far, Near-Near Good wound edge approximation Horizontal Box shape Gives added strength to closure Good for calloused skin, palms and soles

35 Vertical Mattress

36 Horizontal Mattress

37 Subcutaneous stitch Allows closure of dead space Takes tension off skin Stitch technique Deep to superficial, then superficial to deep Keeps knot buried

38 Subcutaneous stitch

39 Corner Stitch Half buried horizontal mattress Used for Stellate wounds, X, Y, and V shaped wounds Same concept as horizontal mattress Partially buried

40 Corner Stitch Half buried horizontal mattress

41 Length of time for sutures Face 3-5 days Scalp 5 days Trunk 7-10 days Arm or Legs 10 days Feet days

42 Subcuticular Stitch More cosmetic closure Best for clean, uncomplicated linear wounds Advanced technique Can be done with or without knots No sutures to remove

43 Subcuticular Stitch Bury initial knot Start in corner of wound Stitch runs parallel to wound in Dermal/Epidermal junction Run stitch on alternate sides of wound until wound closed Finish with Aberdeen knot or no knot If using no knots secure with Steri-strips or Wound adhesive

44 Subcuticular stitch

45 Aberdeen Knot

46 Through and through

47 Through and through Lacerations that go through skin of face into buccal mucosa Usually around lip Related to facial trauma in which tooth usually pierces skin Evaluate for damage to facial structures Salivary glands and ducts Teeth Tongue

48 Through and through Irrigate then repair mucosa side first If wound is >2 cm prevents food entrapment Irrigate again after mucosa closed Then close skin +/- Penicillin

49 Dog ear repair

50 Dog ear repair

51 Dog ear repair Extend incision on side of wound with excess tissue at 45 degree angle Use sharp scissors or scalpel Once skin is freed up, excise excess tissue Usually a triangular shape Finish repair of wound

52 Dog ear repair

53 Dog Ear repair

54 Ear lacerations

55 Ear laceration repair

56 Ear laceration repair Does it involve cartilage or not? Anesthesia Field block of the ear preferred Local injection can disrupt borders

57 Ear laceration repair Field Block

58 Ear laceration repair Cartilage involved Repair posterior and anterior portion of skin overlying the cartilage Cartilage does not hold suture well Cartilage should come together with this approach Can excise up to 5mm of cartilage if needed

59 Ear laceration repair Minimal excision of cartilage

60 Ear laceration repair No Cartilage involved Involves Helix or lobe only Simple interrupted repair Small bites of about 1-2 mm with 6-0 nylon Helps prevent inversion

61 Nail bed injuries

62 Fingertip Anatomy

63 Nail bed repair Perform digital block of affected digit Remove nail if needed and explore wound Clean wound Repair nail bed laceration if present Use 6-0 absorbable suture plain or chromic gut preferred

64 Nail bed repair Replace nail if intact to use as stent If nail not usable, use other material as stent Nonadherent dressing Telfa,Adaptic, Xeroform Aluminum from suture package Stent prevents adherence of germinal matrix to eponychium Adherence can cause scarring and granulation tissue buildup Scarring can prevent new nail regrowth

65 Nail bed repair Suture stent in place with nonabsorbable suture Picture shows aluminum from suture packaging Refer to Hand surgeon for follow up

66 Fingertip Avulsion Repair

67 Fingertip Avulsion Simple uncomplicated fingertip avulsions No bone involved and about 1 cm in size Anesthesia Dip finger in ml 1% Lidocaine w/epi for 5-10 minutes gives analgesia Can perform digital block if dip unsuccessful

68 Fingertip Avulsion Tourniquet Shortened IV tourniquet cut in half length wise Use needle driver and twist 5-10 times until bleeding stops

69 Fingertip Avulsion Milk finger to exsanguinate blood Fingertip must be completely dry Apply tissue adhesive Allow to completely dry May used compressed air to help dry Example Nasal Cannula or Suction tubing hooked up to compressed air or oxygen supply Remove tourniquet

70 Documentation of wound closure Wound History MOI, age of wound, associated sx Patient Hx, Allergies Last Tetanus, Handedness Physical Wound description, location, length, condition (clean, contaminated), exam findings

71 Documentation of wound closure Procedure Anesthesia, wound cleansing, exploration, debridement, undermining, foreign bodies, Suture type, size and number (eg. #5, 4-0 nylon, simple interrupted superficially) Dressing and wound care instructions Timing for removal

72 Thank You Questions??