Wound Care & Suturing

Question 1

list stable vs unstable knots

Answer 1

Stable - square, surgeons

unstable - simple, granny

Question 2

the ideal surgical knot should???

Answer 2

1. minimize contact b/w suture & tissue - DEC inflammation and scar formation
2. _ensure stable configuratio_n to avoid suture disruption which may cause dehiscence (wound rupture along surgical incision)
3. ensure proper amount of tension -

too much = strangulation or weakened suture material

too little = improper wound healing

Question 3

indications for one and two handed surgical knot tying

Answer 3

repair incisions in deeper structures

multi-layer incisions

Question 4

list 4 phaes of wound healing

Answer 4

1. hemostasis
2. inflammation
3. proliferation
4. remodeling

HIP R

Question 5

describe hemostasis

Answer 5

step 1

immediately after wounding

1. platelet plug forms & blood vessels vasoconstrict
2. thrombus develops to seal the wound

Question 6

describe inflammation

Answer 6

step 2

occurs in the first 2-3 days after injury

WBC remove necrotic tissue and control infection

Question 7

describe proliferation

Answer 7

step 3

begins on the 2nd or 3rd day after injury & lasts for 2-4 weeks

1. Fibroblasts proliferate –> produce structural proteins (glycosaminoglycans, collagen & elastin)
2. new capillaries form and epithelial cells migrate across the top of the wound- known as granulation tissue

Question 8

describe remodeling

Answer 8

step 4

1. new capillaries atrophy and c_ollagen changes from type III to type I_ to give the best tensile strength
2. myofibroblasts cause scar contracture - scar reinforcement
3. uniaxial forces acting on the wound shape the remodeling process a

Question 9

what are the 4 phases of wound healing

Answer 9

Hemostasis (immediately after wounding)

1. platelet plug forms and blood vessels vasoconstrict
2. thrombus develops to seal the wound

Inflammation (2-3 days after injury)

WBCs remove necrotic tissue and control infection

Proliferation (begins on the 2nd or 3rd day after injury & lasts for 2-4 weeks)

1. f_ibroblasts proliferate_ into the wound, and produce structural proteins such as glycosaminoglycans, collagen and elastin
2. Angiogenesis = new capillaries form and epithelial cells migrate across the top of the wound- known as granulation tissue

Remodeling

1. new capillaries atrophy and collagen changes from type III -> type I and is rearranged to give the best tensile strength
2. myofibroblasts cause scar contracture.
3. uniaxial forces acting on the wound shape the remodeling process

Question 10

describe primary clouse

Answer 10

•Best utilized within 6-12 hours

wound edges are neatly approximated

• rapid return to function
• good cosmetic outcome (cosmesis)

NO: infection, severely contaminated

Question 11

when would primary closure be CI

Answer 11

infected, severely contaminated

Question 12

Describe Delayed Primary Closure

Answer 12

close after 48-96 hours

used in situations where early primary closure is inappropriate

• infected
• severely contaminated)

allows for a period of secondary healing to occur before the wound is closed

Question 13

define primary vs delayed closure

indications?

timeframe?

Answer 13

Primary closure (6-12 hours)

• wound edges are neatly approximated
• rapid return to function
• good cosmetic outcome (cosmesis)

NO: infected, severely contaminated

Delayed/ Secondary closure (48-96hrs)

• used in situations where early primary closure is inappropriate, i.e. infected, severely contaminated
• allows for a period of secondary healing to occur before the wound is closed

Question 14

indications for delayed primary closure

Answer 14

infection

severe contamination

Question 15

what are the suture removal guidelines

time (days)?

Answer 15

neck down - 7-10 days

Question 16

define the vertical mattress technique

Answer 16

to evert skin edges

used where wound edges tend to invert (i.e. posterior neck) or wounds on concave surfaces

Question 17

define horizontal mattress

Answer 17

• everting technique that spreads tension along wound edge; commonly used to pull wound edges together over a distance
• good for vascular tissue like scalp, thin skin finger and toe web spaces and eyelid

Question 18

name indications / tissues where you would use horizontal mattress

Answer 18

vascular tissue -

1. scalp
2. thin skin finger and toe web spaces
3. eyelid

can serve as an initial suture to hold skin flaps

effective in _holding fragile skin togethe_r (i.e. elderly patient on chronic steroid therapy

Question 19

indications / tissues for vertical mattress

Answer 19

posterior neck) or wounds on concave surfaces

Question 20

define Frankenstein marks”.

what suture technique are they assoc w/?

Answer 20

Vertical Mattress

Natural process wound inflammation and scar retraction will pull loops of suture that lie on the skin surface downward

Question 21

closure technique for strength and distribution??

Answer 21

vertical mattress

Question 22

“fa, far, near, near” is what technique

Answer 22

vertical mattress

Question 23

name some alternatives to sutures

Answer 23

staples

skin adhesives

steri-strips

Question 24

what wound should staples be used?

where should we avoid use?

Answer 24

used in linear lacerations that have straight, sharp edges which are well aligned

good for scalp

AVOID

cosmetic areas ->

• hand
• face
• legs
• neck;

if patient will be needing CT or MRI -> cause artifact or may be avulsed by magnetic fields

Question 25

what areas can we use Skin adhesives? contraindications?

Answer 25

_face, extremities and torso_ -\> but should be used with subcutaneous sutures in high tension area •splinting may be required **contraindications:** * stellate lacerations * bite, puncture or infected wound * mucosal surfaces * Perineum * over joints

Question 26

what is the ingredient in skin adhesive

Answer 26

Dermabond (2-octylcyanoacrylate)

Question 27

T/F: skin adhesives ## Footnote 1. use topical anesthetic such as lidocaine 2. sets in 2.5 minutes, use bacitracin or Vaseline around

Answer 27

F - no need for topical anesthetic T

Question 28

indications for steri-strips areas to avoid?

Answer 28

used for superficial, linear straight clean edges •benzoin tincture helps provide additional adhesion AVOID over joints areas prone to getting wet

Question 29

T/F steri strips ## Footnote no damage to nerves, vessels, tendons can be used as reinforcement over sutures

Answer 29

true

Question 30

when using steri-strips what helps provide additional adhesion?

Answer 30

benzoin tincture helps provide additional adhesion

Question 31

contraindications to skin adhesives

Answer 31

* stellate lacerations * bite, puncture or infected wound * mucosal surfaces * Perineum * over joints

Question 32

when using skin adhesive in high tension areas you should ...?

Answer 32

use in conjunction w/ subcutaneous sutures and consider splinting

Question 33

describe the difference b/w 1% lidocaine 2% lidocaine

Answer 33

_1% lidocaine_ - blocks pain stimuli (pressure & touch remain in tact) _2% lidocaine_ - blocks ALL timuli

Question 34

lidocaine: max dose? how much fluid will an average finger take?

Answer 34

maximum dose _4mg/kg_ an average finger will take no more than _5cc_ of total fluid

Question 35

name examples of topical anesthesia

Answer 35

**TAC**-0.5% tetracaine, 1:2,000 epinephrine, 11.8% cocaine **LET**- 4% lidocaine, 1:2,000 epinephrine, 0.5% tetracaine **EMLA**- eutectic mixture of local anesthetics 2.5% lidocaine and 2.5% prilocaine

Question 36

topical anesthesia is used mostly in..?

Answer 36

pediatrics

Question 37

uses of: TAC LET EMLA

Answer 37

**TAC** - face or scalp – as effective as lidocaine **LET** - most commonly used, safe on face or scalp **EMLA** - approved only for use on intact non-mucosal skin (slower onset than LET)

Question 38

Rare severe toxicity -\> seizures, sudden cardiac death seen w/ what type of anesthesia

Answer 38

topical TAC

Question 39

complciatiosn of EMLA

Answer 39

Contact dermatitis Methhemoglobinemia

Question 40

onset time of TAC LET

Answer 40

TAC - 10-30mins LET - 20-30mins

Question 41

name types of local anesthesia

Answer 41

lidocaine epi

Question 42

Etiology of epi in local anesthesia

Answer 42

potent vasoconstrictive properties-\> aids in hemostasis when mixed with local anesthetics : * decreases clearance time --\> * increasing duration of action

Question 43

avoid Epi in..?

Answer 43

digits Penis ear nose D PEN

Question 44

describe local infiltration

Answer 44

injecting a small skin wheal near the edge of the wound or directly into the wound with the smallest gague needle available then advancing slowly ensuring that each increment of tissue is anesthetized

Question 45

describe tetanus prone wounds

Answer 45

Open wounds over 6 hours \> 1cm deep •stellate lacerations **•soiled with feces, saliva, gunshot** **puncture, burn, frostbite**

Question 46

indications for tetanus booster

Answer 46

\>10 yrs since last vaccine tetanus prone wound & \>5 yrs since last vaccine unconcious patient

Question 47

compare and contrast Dtap vs Tdap age indications?

Answer 47

Dtap- 6wks - 6 yrs, children who cannot have pertussis vaccine Tdap- 11yrs or older

Question 48

name solutions used for wound cleaning and when they are apprioproate saline idodine hibicens peroxide alcohol

Answer 48

_•Saline_- for high pressure irrigation _•Iodine_- anti-septic, best for cleaning skin around wound, can damage cells _•Hibiclens_- anti-septic, good for cleaning wounds * _Peroxide_- anti-septic, not very good for cleaning wounds, best for removing blood from clothing * _Alcohol_- anti-septic but burns, good for intact skin cleaning

Question 49

names 2 categories of anesthehia and how they work

Answer 49

Two categories which both work by reversibly blocking Na+ gated channels, both are weak bases with lipophilic properties Amides & esters amides - Less likely to cause allergic response – less antigenicity

Question 50

define Langer’s Lines and their significance

Answer 50

* Also known as cleavage lines * Correspond to natural orientation of collagen fibers in the dermis * Generally parallel to underlying muscle fibers * Important for improved cosmetic outcomes

Question 51

T/F The bigger the number, the smaller the size of the sutur

Answer 51

true

Question 52

name 3 types of sutures and when they are used monofil dermal and fascial mucosal & scrotal

Answer 52

**Non-absorbable monofilaments** nylon (_Ethilon_, Dermalon polypropylene (_Prolene_) polybutester **Absorbable sutures for dermal and fascial closure:** polyglycolic acid, polyglactin 910 (_Vicryl_ polyioxanone (PDS) polyglyconate **Absorbable sutures for mucosal and scrotal closure:** chromic gut, polyglactin 910 (Vicryl)

Question 53

Do not tie too tightly or too loosely (‘approximate, don’t strangulate’) what is the exception to this rule ??

Answer 53

deep knots MUST be tight