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Advanced Wound

Closure

• Michael Hazel, DNP, RN, FNP-BC

• Steve Branham, PhD, RN, FNP, ACNP

What to expect today..

• Discuss different types of wound healing techniques and assessments

• Identify different suture types and uses in the clinical setting

• Discuss several wound considerations and/or complications that can arise during healing process

• Practice, practice, practice

Types of Sutures

• Absorbable or non-absorbable (natural or synthetic)

• Monofilament or multifilament (braided)

• Dyed or undyed

• Sizes 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0

indicate progressively smaller)

• New antibacterial sutures

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Suture

Natural Suture• Biological

• Cause inflammatory

reaction

–Catgut (connective from cow or sheep)

–Silk (from silkworm fibers)

–Chromic catgut

Synthetic• Synthetic polymers

• Do not cause inflammatory response

–Nylon

–Vicryl

–Monocryl

–PDS

–Prolene

Suture

Monofilament• Single strand of suture material

• Minimal tissue trauma

• Smooth tying but more knots needed

• Harder to handle due to memory

• Examples: nylon, monocryl, prolene, PDS

Multifilament (braided)• Fibers are braided or twisted

together

• More tissue resistance

• Easier to handle

• Fewer knots needed

• Examples: vicryl, silk, chromic

Suture

Absorbable

• Not biodegradable and permanent

–Nylon

–Prolene

–Stainless steel

–Silk (natural, can break down over years)

Non-Absorbable

• Degraded via inflammatory response

–Vicryl

–Monocryl

–PDS

–Chromic

–Cat gut (natural)

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Suture Materials

Suture Sizes

Surgical Needles

• Wide variety with different company’s naming systems

• 2 basic configurations for curved needles

Cutting: cutting edge can cut through tough tissue, such as skin

Tapered: no cutting edge. For softer tissue inside the body

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Surgical Needles

Surgical Instruments

Scalpel Blades

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Wound Evaluation

• Time of incident

• Size of wound

• Depth of wound

• Tendon / nerve involvement

• Bleeding at site

When to Refer

• Deep wounds of hands or feet, or unknown depth of penetration

• Full thickness lacerations of eyelids, lips or ears

• Injuries involving nerves, larger arteries, bones, joints or tendons

• Crush injuries

• Markedly contaminated wounds requiring drainage

• Concern about cosmesis

Contraindications to Suturing

• Redness

• Edema of the wound margins

• Infection

• Fever

• Puncture wounds

• Animal bites

• Tendon, verve, or vessel involvement

• Wound more than 12 hours old (body) and 24 hrs (face)

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Wound Cleaning

• Consider…

– Hand washing

– Personnel precautions

– Hair removal

– Anesthesia

– Foreign material

– Wound soaking

Wound Cleaning

• Hand washing (after patient contact before proceeding to the next)

– Nurses 58.2%

– Residents 18.6%

– Faculty 17%

Wound Preparation

• Most important step for reducing the risk of wound infection.

• Remove all contaminants and devitalized tissue before wound closure.

– IRRIGATE w/ NS or TAP WATER (AVOID H2O2, POVIDONE-IODINE)

– CUT OUT DEAD, FRAGMENTED TISSUE

• If not, the risk of infection and of a cosmetically poor scar are greatly increased

• Personal Precautions

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Anesthetic Solutions

• Lidocaine (Xylocaine®)

– Most commonly used

– Rapid onset

– Strength: 0.5%, 1.0%, & 2.0%

– Maximum dose:

• 5 mg / kg, or

• 300 mg

– 1.0% lidocaine = 1 g lidocaine / 100 cc

= 1,000mg/100cc

– 300 mg = 0.03 liter = 30 ml

• Lidocaine (Xylocaine®) with epinephrine

– Vasoconstriction

– Decreased bleeding

– Prolongs duration

– Strength: 0.5% & 1.0%

– Maximum individual dose:

• 7mg/kg, or

• 500mg

Anesthetic Solutions

• CAUTIONS: due to its vasoconstriction properties never

use Lidocaine with epinephrine on: – Eyes, Ears, Nose

– Fingers, Toes

– Penis, Scrotum

Anesthetic Solutions

• BUPIVACAINE (MARCAINE):

– Slow onset

– Long duration

– Strength: 0.25%

– DOSE: maximum individual dose 3mg/kg

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Local Anesthetics

Injection Techniques

• 25, 27, or 30-gauge needle

• 6 or 10 cc syringe

• Check for allergies

• Insert the needle at the inner wound

edge

• Aspirate

• Inject agent into tissue SLOWLY

• Wait…

• After anesthesia has taken effect,

suturing may begin

Closure Types

• Primary closure (primary intention)

– Wound edges are brought together so that they are adjacent to each other (re-approximated)

– Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery

• Secondary closure (secondary intention)

– Wound is left open and closes naturally (granulation)

– Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly reduced fractures

• Tertiary closure (delayed primary closure)

– Wound is left open for a number of days and then closed if it is found to be clean

– Examples: healing of wounds by use of tissue grafts.

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Vertical Mattress

Good for everting wound edges

(neck, forehead creases, concave surfaces)

http://www.youtube.com/watch?v=824FhFUJ6wc

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Vertical Mattress Suture

Horizontal Mattress

Good for closing wound edges under high tension,

and for hemostasis.

Horizontal Mattress

http://www.youtube.com/watch?v=9DdaooEXshk

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Subcuticular Suture

http://www.youtube.com/watch?v=I7C7nsl5Tuk

The trick to an instrument tie

• Always place the suture holder parallel to the wound’s direction.

• Hold the longer side of the suture (with the needle) and wrap OVER the suture holder.

• With each tie, move your suture-holding hand to the

OTHER side.

• By always wrapping OVER and moving the hand to the OTHER side = square knots!!

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Suturing - finishing

• After sutures placed, clean the site with normal saline.

• Apply a small amount of Bacitracin or white petroleum and cover with a sterile non-adherent compression dressing (Tefla).

Suturing - before you go…• Need for tetanus globulin and/or vaccine?

– Dirty (playground nail) vs clean (kitchen knife)

– Immunization history (>10 yrs need booster or >5 yrs if contaminated)

• Tell pt to return in one day for recheck, for signs of infection (redness, heat, pain, puss, etc), inadequate analgesia, or suture complications (suture strangulation or knot failure with possible wound dehiscence)

• It should be emphasized to patients that they return at the appropriate time for suture removal or complications may arise leading to further scarring or subsequent surgical removal of buried sutures.

Patient instructions and follow up care

• Wound care

– After the first 24-48 hours, patients should gently wash the wound with soap and water, dry it

carefully, apply topical antibiotic ointment, and replace the dressing/bandages.

– Facial wounds generally only need topical antibiotic ointment without bandaging.

– Eschar or scab formation should be avoided.

– Sunscreen spf 30 should be applied to the wound to prevent subsequent hyperpigmentation.

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Suture Removal

• Average time frame is 7 – 10 days

– FACE: 3 – 5 d

– NECK: 5 – 7 d

– SCALP: 7 – 12 days

– UPPER EXTREMITY, TRUNK: 10 – 14 days

– LOWER EXTREMITY: 14 – 28 days

– SOLES, PALMS, BACK OR OVER JOINTS: 10 days

• Any suture with pus or signs of infections should be removed immediately.

Suturing

Examples

ThanksPractice, Practice, Practice