Wound Closure and Suture Techniques

imagesGoals are to optimize wound strength, reduce inflammation, avoid infection, and minimize scar formation


   imagesTime to wound cleaning is the most important factor


   imagesTo preserve viable tissue and restore continuity and function of tissue


CONTRAINDICATIONS



imagesHeavily contaminated wounds


imagesPresentation time for primary closure is after 12 hours for standard lacerations


imagesPresentation time for primary closure is after 24 hours for lacerations of the face, scalp, or other highly vascular areas


imagesWounds under high tension should not be closed by skin adhesives alone


imagesAnimal or human bite and most puncture wounds should not be closed on initial presentation


RISK/CONSENT ISSUES



imagesCleaning and repair of wounds cause pain


   imagesLocal anesthetics are indicated for all wound repairs in conscious, alert patients


imagesInfection is always a risk in wound repair


imagesWound repair always results in some scarring and can affect cosmetic appearance permanently


imagesTendon, nerve, and vascular injuries can occur at time of initial injury or at time of repair


imagesRisk of retained foreign body exists despite best methods of foreign body identification and removal, such as local exploration, radiographs, ultrasonography, and irrigation


   imagesThorough exploration for foreign bodies must be performed and documented



imagesGeneral Basic Steps


   imagesAnesthetize wound


   imagesClean wound


   imagesExplore wound


   imagesConsider radiography


   imagesRepair wound


TECHNIQUE



imagesPatient and Wound Preparation


   imagesPosition the patient to prevent falling or fainting during wound repair


   imagesPractice universal precautions


   imagesPrepare the surrounding skin with povidone–iodine solution and cover with sterile drapes before manipulation of any kind


imagesLocal Anesthesia: Lidocaine (1% or 2%) with or without epinephrine


   imagesEpinephrine is contraindicated in areas of high risk for ischemia, such as fingers, ears, nose, toes, and penis


   imagesUse small-gauge needle (25 or 27 gauge) to directly inject into subcutaneous (SQ) tissue within the laceration


   imagesTo decrease pain, inject through the wound and not through the skin


   imagesUse adequate amount for anesthesia but avoid high volumes that will lead to significant tissue distortion, possible cosmetic embarrassment, or systemic toxicity


      imagesMaximum dose: 3 to 5 mg/kg 1% lidocaine, 7 mg/kg 1% lidocaine with epinephrine.


   imagesConsider regional blocks for repairs in cosmetically important areas (face, hands, etc.) to avoid distortion of tissue


imagesWound Cleansing


   imagesCopious amounts of sterile water or sterile saline via high-power irrigation with a large syringe and splatter shield or an 18-gauge catheter. Tap water equally effective.


imagesWound Exploration


   imagesAfter cleansing, the true depth of the wound is appreciated


   imagesLook for deeper tissue involvement and explore the wound


   imagesIf tendon or vascular structures are visualized, inspect through full range of motion, test for state of function, and document findings


imagesRadiography and/or Sonography


   imagesIf the possibility of underlying fracture and/or foreign body exists, image the affected area and document


imagesSelect Method of Repair


   images2-Octyl cyanoacrylate


   imagesStaples


   imagesSutures


DERMABOND (LIQUID ADHESIVE)



imagesIndicated for simple wounds under low tension


imagesAdvantages


   imagesEase of use, speed, and safety


   imagesNo return visit necessary (sloughs off in 5 to 10 days and serves as own dressing)


   imagesMuch less painful


imagesDisadvantages


   imagesModerate closure strength—cannot be used on joints or areas with high tension


   imagesCannot be used in areas with excessive hair


imagesCaution when using around eyes to prevent accidental runoff into eyes


imagesEquivalent tensile strength at 7 days when compared to sutures


imagesProcedure


   imagesClean the wound


   imagesApproximate wound edges with forceps or fingers


   imagesApply three to four layers along the wound length or perpendicularly to it (as strips)


   imagesMaintain manual support for 60 seconds


STAPLES



imagesIndicated for superficial scalp lacerations, linear lacerations on extremities, trunk, and wounds under low tension


imagesAdvantages


   imagesEase of use, speed, and safety


   imagesEasily removed and excellent tensile strength


imagesDisadvantages


   imagesLess refined closure


   imagesPossible greater scarring


   imagesUncomfortable removal (TABLE 69.1)


imagesNo significant differences found with infection, healing, or patient acceptance when compared to suturing










TABLE 69.1.


SUTURE SIZE AND LOCATION
































Size


Superficial (nonabsorbable)


Deep (absorbable)


2-0


Suture chest tube


 


3-0


Foot


Chest, abdomen, back


4-0


Scalp, chest, abdomen, foot, extremity


Scalp, extremity, foot


5-0


Scalp, brow, mouth, chest, abdomen, hand


Brow, nose, lip, face, hand


6-0


Ear, lid, brow, face, mouth, nose


 


imagesProcedure


   imagesAnesthetize, clean, and debride wound as necessary


   imagesIf necessary, close deep fascia with absorbable sutures with a buried knot


   imagesEvert wound edges before placing staple, if possible utilizing the services of an assistant with forceps. Do not press too hard.


   imagesAllow the staple crossbar to sit 1 to 2 mm above wound edge


   imagesPlace enough staples to adequately appose tissue edges


SUTURES



imagesGeneral Rules


   imagesDeep stitches require 3-0 or 4-0 absorbable sutures


   imagesSkin closure requires 4-0 or 5-0 nonabsorbable sutures


   imagesFace, lips, and eyelid wounds: Consider 6-0 sutures


   imagesHigh skin tension areas: Consider 3-0 or 4-0 sutures


   imagesAlways select the smallest size that will hold the skin edges together


imagesNonabsorbable Sutures


   imagesSilk: Has the best knot security, the best tie ability, the least tensile strength, and causes significant tissue reactivity. Used in intraoral mucosa.


   imagesEthilon: Has good knot security, good tensile strength, minimal tissue reactivity, and good tie ability. Best suited suture material for typical wound closure.


   imagesProlene: Poorest knot security, best tensile strength, least tissue reactivity, and fair tie ability


imagesAbsorbable Sutures


   imagesVicryl: Good knot security, good tensile strength, minimal tissue reactivity, best tie ability, and 30-day suture duration. Used for deep repair to reduce wound tension.


   imagesSurgical and chromic gut: Fair knot security, fair tensile strength, greatest tissue reactivity, poor tie ability, and 5- to 7-day suture duration. Used for intraoral wounds.


imagesProcedure


   imagesAnesthetize, clean, and debride wound as necessary


   imagesPrepare the skin with povidone–iodine or chlorhexidine solution


   imagesMinimize trauma by handling skin with toothed forceps and by using small sutures


   imagesRelieve tension by undermining with a scissor and by using layered sutures (FIGURE 69.1)


   imagesSubcutaneous Layer Closure


      imagesReapproximate fascia as needed


      imagesClose the SQ layer in sections, starting in the middle and then bisecting adjacent sections until adequate tension has been relieved from the skin edges


      imagesInsert the suture at the bottom of the layer and draw it through to just beneath the dermis on the same side of the wound


      imagesReenter beneath the dermis on the adjacent side and draw through to the bottom of the SQ layer


      imagesTie the knot such that it remains at the bottom of the wound, thereby preventing a palpable knot near the skin surface


   imagesInterrupted Stitch


      imagesMost commonly used stitch. If one fails, the rest will maintain closure.


      imagesInsert the needle at 90 degrees to the skin surface and include sufficient SQ tissue in the bite and carry the suture through to the opposite side



images


FIGURE 69.1 Undermining a wound reduces the degree of tension present after the repair. (From McNamara R, Loiselle J. Laceration repair. In: Henretig FM, King C, eds. Textbook of Pediatric Emergency Procedures. Philadelphia, PA: Williams & Wilkins; 1997:1152, with permission.)

Only gold members can continue reading. Log In or Register to continue

Aug 9, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Wound Closure and Suture Techniques
Premium Wordpress Themes by UFO Themes