Gere Ochs RN, AG-ACNP/ANP-BC Wound care and Suturing Workshop 14th Annual St. Louis Nurses in Advanced Practice Annual Symposium Gere Ochs RN, AG-ACNP/ANP-BC

Objectives Review the principles of wound management as they apply to simple lacerations Demonstrate the following suturing techniques: simple, mattress, corner and intradermal. Summarize the pitfalls in wound management.

Physical exam of wound Location (predicts clinical outcome) & size in cm Description in graphic terms (?cosmetic) “questionable viable flap” “multiple ground-in foreign bodies” “severely contused wound edges” Hemostasis (do not close a bleeding wound)epinephrine or Tourniquet –finger tourniquets (< 30 minutes) Integrity of deep structures – tendons, nerves, joint capsule

xrays Failure to dx. A retained foreign body -2nd leading cause of malpractice Radiopague material – metal, glass, gravel Detection rate low – wood and plastic –ultrasound higher sensitivity 87%, ?CT scan (timing, & smaller sizes)

Wound closure Primary intent Within 6-8 hours “golden period”; face and scalp 24 hrs Clean wounds without tissue loss Secondary intent Days to weeks Small partial thickness avulsions & fingertip amputations Tertiary intent (delayed primary closure) saliva, feces, exudate or > 8 hrs 3-4 days after injury Daily wound care Same technique as primary closure

Pitfalls in wound care Failure to recognize underlying deep structure injury or foreign body due to: Unfamiliarity with the anatomy Inadequate or misleading history Inadequate hemostasis Failure to explore the wound (visually and digitally) Failure to obtain ancillary diagnostic studies

Suturing

Wound prep issues Obtain consent – invasive procedure Sterile technique – standard of care Irrigation – solution to pollution is dilution 100cc NS/1 cm of wound (splash guard or 30 mL syringe with an 18 gauge sheath) Chlorhexidine solution (level A) Betadine on surrounding skin only! Hair Removal – 1-2 mm Debridement Remove foreign bodies & devitalize tissue (crushed, torn edges) Excision with a surgical blade/scissors

Anesthesia Lidocaine Lidocaine w/Epinephrine Bupivacaine Dilute lidocaine with sodium bicarbonate 1:10 ( 1 ml bicarb + 9.0 ml lidocaine); shelf life is 7 days Max dose 4-5 mg/kg; duration 2 hrs Lidocaine w/Epinephrine Highly vascular areas; duration 2-6 hrs Bupivacaine 4x duration of lidocaine Max dose 2-3 mg/kg Topicals (LET) pediatrics

Pearls Inject slowly Inject into subcutaneous plane instead of intradermal plane (field block) Clean wounds, insert needle thru the wound edges Contaminated wounds, infiltrate the skin Small needle 27g or 30 g (reduces pain)

Digital Block Equipment Sterile drape & gloves Betadine 10 cc syringe with 25 gauge needle, 1 ½ inch 1% lidocaine (no epinephrine)/Sodium bicarbonate Informed consent

Procedure Introduce needle into dorsal, lateral aspect of proximal phalanx in web space, just distal to the MTP point (small wheal) Advance slowly until touch bone Aspirate and then inject 1 cc Back needle out slightly & then pass closely adjacent bone to the volar surface Aspirate and then inject 1 cc continuously as the needle is withdrawn Repeat procedure on opposite of finger

Transthecal digital block Hand supinated, locate flexor tendon Enter the skin at a 45 degree angle 25-27 gauge 1 inch needle Inject 2 ml into the sheath at the level of the distal palmar crease Resistance to the injection = needle tip is against the flexor tendon, withdraw for free flow

Complications of a digital block Infection Hematoma Gangrene of the digits Nerve injury

Mental nerve block Indications – repair lower lip lacerations without distorting Nerve mental nerve foramen Onset 4-6 minutes

Insert needle at the gingival-buccal margin inferior to the 2nd bicuspid 1-2 ml fan technique

Absorbable sutures Layered closures Plain and chromic “cat gut” not used on skin (severe tissue reaction) Synthetic (Vicryl & Monocryl Decreased infection rates

Synthetic nonabsorbable sutures Superficial lacerations (supple, easy to handle) Silk Nylon (Ethilon, Dermolon) Polypropylene (Prolene)

Principles of suture selection Monofilament (nylon or Prolene)- preferred!! Single smooth strand Less traumatic; better cosmetic results Glide thru tissue with less friction Lower rates of infection 5-6 throws (slipping) Multifilament (silk) Multiple fibers woven together Tends to be easer to handle Knots are less likely to slip; 3 throws

Suture needle size Finest size suture commensurate with the natural strength of the tissue to be sutured The more “O’s” the smaller the size Tensile strength increases as the number of O’s decreases General: 6-0 face 5-0 hand 4-0 trunk/extremities 3-0 or 4-0 over joints

Personal preference His/ her area of specialization Wound closure experience (training) Knowledge of healing characteristics of tissues and organs Knowledge of physical and biological characteristics of various suture materials Patient factors

Let’s do it!

The Anatomy of a needle Needle eye The body The point

Place the needle in the tissue Grip a suture needle with a needle driver (2/3 of the way back from the point) Elevate skin edge with forceps, right hand is pronated to “cock” the needle Penetrate the skin, perpendicularly, 5-10 mm from the edge Rotate needle thru the epidermis and dermis by supinating the right hand

Tip of the needle now should be protruding into the wound from the subq tissue Maintain the position of the skin edge using the forceps, and release the needle from the holder Forceps elevate the opposite side of wound Right hand fully pronated, grasp the needle, “bite” by supinating the right hand to complete the rotation

Loop the suture twice around the needle driver Grab the short end of the suture with the needle driver Lay down 1st loop of a knot, create 2nd single loop in opposite direction (x2) Square knot complete

Knot tying techniques Completed knot must be firm Tie the knot as small as possible & cut the ends, leaving 3 cm “tail” to facilitate removal Avoid friction Avoid excessive tension Do not tie tightly – approximate—do not strangulate

Maintain traction at one end of the strand after the 1st loop is tied Make the final throw – horizontal Extra throws do not add to the strength –only bulk! Space the sutures far enough from each other so that no gap appears The space between sutures is approximately equal to the bite width

Horizontal Mattress Wounds that are under high tension Used as a stay stitch May be left in for a few days Used in calloused skin (palms and soles) and older, thinner skin

Disadvantage High risk of tissue strangulation Wound edge necrosis Suture marks

Vertical Mattress Maximizes wound eversion Reduces dead space Combine deep and percutaneous sutures Minimizes tension across the wound Placing each stitch precisely & taking symmetric bites

Disadvantage Cross hatching (due to increased tension across the wound and 4 entry and exit points)

Buried Intradermal sutures Subcuticular Best cosmetic results Dermis plane (do not strangle) Do not cause crosshatching Best internal splinting Monofilament sutures

Corner sutures Half-buried horizontal mattress suture Positions corners and tips of flaps

Pearls Use instruments not fingers Take equal “bites” for both sides Evert the wound edges & minimize tension on the wound Face : 2-3 mm from skin edge and 3 mm apart Elsewhere 3-4 mm from skin edge, no closer than 2 mm apart. Each suture strand is passed thru the skin only once

Dressing and splinting Area should be cleansed with NS Antibiotic ointment (?efficacy) for 3-5 days Dressing - cover for 24-48 hours and be non occlusive Tension wounds should be splinted for 1-2 weeks

Antibiotics Cephalexin 500 mg QID for 7-10 days; Dicloxacillin 250 mg QID 7-10 days; Trimethoprim-sulfamethoxazole; doxycycline Wounds > 8-12 hrs old, especially on the hands and lower extremities Crushing injuries (compression) mechanism, devitalization, or extensive revisions Contaminated wounds (fresh water or plantar wounds) covere for pseudomonas Violation of the ear or nose cartilage Involvement of a joint space, tendon, bone Mammalian & human bites Valvular diseases or immunosuppression

Wound After Care All wounds will heal with a scar Daily cleansing Signs & symptoms of infection Suture removal Face: 5-7 days Scalp 7-10 days Trunk/Extremities/digits: 10 – 14 days (may be up to 21 days) Sunscreen to scar for at least 6 – 12 months

Documentation (support the CPT code) H & P with careful attention to neuromuscular and motor function Must document that all wounds were explored (foreign bodies) Site of repair Length of repair in cm. Medium used (sutures, staples, tissue adhesive) Type of anesthesia

Type of wound repair Simple: superficial, requires on layer of closure, epidermis, dermis Intermediate: layered closure or single layer of heavily contaminated wound Complex : layered suturing of torn, crushed or deeply lacerated tissue (debridement, undermining, retention) Nature of the wound irrigation After care instructions

Referral Guidelines When in doubt refer it out! Deep wound on face Inside the mouth Around the eyes Into the joint Ligament or tendon guidelines Finger tip with tissue loss You’re not comfortable!

Questions??