Sutures, Wound Care

Question 1

Direction that wounds heal and direction that epithelial tissue heals

Answer 1

wound bottom to top

skin side to side

Question 2

Primary vs secondary vs tertiary intention in wound closure

Answer 2

primary: clean incision, early suture, minor hairline scar forms
secondary: gaping wound with blood clot, no suture so granulation tissue fills in wound, larger scar
tertiary: allow wound to fill with granulation, late suturing, wide scar

Question 3

How to treat wound infection that has been sutured?

Answer 3

open and drain

Question 4

6 steps on how to approach fresh, uncomplicated wound

Answer 4

1. Consent to treat / procedural consent
2. Tetanus prophylaxis
3. Anesthesia
4. Hemostasis
5. Cleaning and debridement
6. Wound closure

Question 5

PARQA format of informed consent

Answer 5

Procedure
Alternatives
Risks
Questions
Answers

Question 6

Methods to achieve hemostasis

Answer 6

Direct Pressure!
Electrocautery
Chemical cautery (silver nitrate)
Suture ligation

Question 7

Cleaning and debridement of wound

Answer 7

Copious saline, LR, or water
Scrub wound
J&J Baby wash
Remove foreign bodies

*anti-microbial soaps not beneficial

Question 8

Where should staples NOT be used?

Answer 8

hands, feet, neck, face

Question 9

Edges of skin should be in what position for best epithelialization?

Answer 9

everted

Question 10

Which basic appositional suture pattern has least chance of dehiscence?

Answer 10

simple interrupted

Question 11

Best suture pattern for wounds under tension

Answer 11

vertical mattress

Question 12

Where do you avoid suturing in V-shaped wound?

Answer 12

tip of flap because it is likely to become necrotic

Question 13

When should patient f/u for sutures to be removed?

Answer 13

depends on location:
Face: 3 to 5 days
Scalp: 7 to 10 days
Neck: 5 to 7 days
Extremities: 10 to 14 days / 14 to 28 days under tension (joints)
Back: 10 to 14 days
Abdomen: 7 to 10 days

Question 14

What is most commonly used needle point for suturing?

Answer 14

reverse cutting

Question 15

Most common absorbable sutures

Answer 15

Vicryl; strength for 2-3 wks, reabsorbs in 50-75 days

chromic gut; strength for 7 days, reabsorbs in few days

Question 16

Types of non-absorbable sutures

Answer 16

silk, polypropylene, stainless steel, nylon, polyester

Question 17

What should you always do before anesthetizing a wound?

Answer 17

check distal sensation and motor function

Question 18

Local anesthetics for wounds - short and longer acting?

Answer 18

Lidocaine (short-acting)

Bupivacaine (3-6 hrs)

Question 19

Where do you inject local anesthetics for wound?

Answer 19

clean (surgical procedure) - you can inject inside of wound

dirty - edge of wound

Question 20

When do you use epinephrine for local anesthetic and when should you avoid it?

Answer 20

• Can’t achieve hemostasis

- Need anesthesia more long-lasting than Lidocaine (+30 min)

Question 21

6 phases of wound healing

Answer 21

1. Hemostasis
2. Inflammation
3. Epithelialization
4. Collagen synthesis
5. Scar maturation
6. Scar remodeling

Question 22

______ begin the task of removing cellular debris, bacteria, and foreign bodies during inflammatory healing phase.

Answer 22

PMN leukocytes

Question 23

What occurs during hemostasis phase of healing?

Answer 23

Vasoconstriction
Platelets clump
Thrombin and fibrin strands
Clotting cascade initiated to form clot

Question 24

During which phase of healing does neo-vascularization occur? Why is neo-vascularization important?

Answer 24

Epithelialization

replaces injured BV network and brings oxygen and nutrients to healing wound

Question 25

Why do wound edges normally become more erythematous and raised?

Answer 25

area abundant with new collagen and capillaries bed

Question 26

What is the purpose of fibroblast proliferation?

Answer 26

secrete tons of collagen around wound

Question 27

What is scarring composed of?

Answer 27

collagen

Question 28

Three D's of wound cleaning

Answer 28

Remove debris Debride the wound Excise devitalized tissue

Question 29

What should wound ideally be washed with?

Answer 29

normal saline

Question 30

Best hemorrhage control

Answer 30

direct pressure and elevation

Question 31

Which intention healing should gun shot wound be treated with?

Answer 31

tertiary intention (delay primary suture)

Question 32

Timeframe of primary intention

Answer 32

usually suture if injury within 8 hrs | face, scalp, and neck wounds within 24 hrs

Question 33

Reasons for secondary intention

Answer 33

``` Old wound Any infected, open wound Contamination Open wound with large tissue defect Abrasions Penetrating wounds (bites, stab) ```

Question 34

Of non-absorbable sutures, _______ which are least reactive and result in least amount of scarring.

Answer 34

monofilament nylon

Question 35

Prophylactic antibiotics for wounds

Answer 35

IM or IV 1st generation cephalosporin or penicillinase-resistant penicillin if allergic Erythromycin or Cipro

Question 36

When are antibiotics indicated for wound?

Answer 36

Lacerations with bone, cartilage, tendon, or joint injuries Animal or human bites Patients with artificial valves or other prosthetic devices (joint replacement)