care of acute lacerations

CARE OF ACUTE LACERATIONS

Introduction Optimum management knowledge

of wound healing.

Goal of Primary Closure

Stop bleeding

Prevent infection

Preserve functionRestore

appearance

Skin Anatomy

Add. features: Langer’s lines Wrinkle lines

Formed by collagen dermis

Less scarring

Wound HealingPhase 1

Inflammatory phase

First 5-6 days

Leukocytes, histamines, prostaglandins fibrinogens.

Neutralize bacteria and foreign material

Reduce inflammatory response: Debridement Remove foreign material Cleaning Control bleeding Tissue coaptation

Amount of Inflammation

Necrotic

Tissue

Dead

space +

Impaired

Circulation

Wound HealingPhase 2

Fibroblastic/collagen phase

6-20 days

Vascular supply compromise

Inhibit collagen synthesis

Fibroblasts enter wound

Collagen synthesis

Binds wound

Collagen ↑ Wound

strength ↑

Wound HealingPhase 3

Maturation phase

18 – 24 months

Collagen synthesis + retraction

Scar softer + less conspicuousColor fades + consistent

with skin

Abberation KELOID

Anasthesia

Anesthetize wound prior to closure Inspect wound + assess neurovascular

supply Topical agents:

PAC + TAC Emla Ethyl Chloride

Injectable agents: Lidocaine Additional Agents Diphenhydramine

Methods: Infiltration blocks Field blocks Nerve blocks

Sedation

Ketamine Midazolam (versed) Fentanyl Nitrous oxide

Wound Preparation

Proper prep improves healing Closed ASAP

Steps:1. Anesthesia2. Clean (wipe-scrub-irrigate)

a. Normal saline using syringeb. Antiseptic soaps (hexachlorophene,

chlorhexidine gluconate, povidone-iodine) delay healing!!

c. Scrub brushes

Wound Preparation3. Drape area

explore

Confirm

depth

Underlying tissue injury?

≠ foreign bodies

Adequate anesthesia

4. Debridement• Irregular dirty wound clean smooth• Excise crushed, mangled devitalized edges• Large amount of tissue close w/ loose

suture

• Incision: scalpel scissors• Edges: perpendicular / slightly undercut• Hairy areas: parallel to hair shafts.

5. Approximate skin edges• Undermine skin 1 : to wash away supporting material

from under (http://www.merriam-webster.com/dictionary)

• Hemostasis: • 5-10 minutes pressure• Cauter/ligate hinder healing• Small vessels absorbable suture

Wound Closure

Absorbable materials: Broken down Absorbed by tissue

Non absorbable materials: From chemicals Encapsulated by body Isolated by tissue

Sutures Advantages DisadvantagesAbsorbable

Catgut Inexpensive Low tensile strengthStrength lasts 4-5 daysHigh tissue reactivity

Chromic catgutPolyglycolic acid (Dexon)Polyglactic acid (Vicryl)

InexpensiveLow tissue reactivityEasy handlingGood tensile strength

Moderate tensile strenth and reactivity

Moderately difficult to handleOccasional “spitting” of

suture due to absorption delay

Polyglyconate (Maxon)Easy handlingGood tensile strength

Expensive

Nonabsorbable

SilkHandles wellModerately inexpensive

Low tensile strengthHigh tissue reactivityIncreased infection rate

Nylon (Ethilon, Dermilon)High tensile strengthMinimal tissue reactivityinexpensive

Difficult to handle; slippery, so many knots needed

Polypropylene (Proline SurgiPro)

No tissue reactionStretches, accommodates swelling

Expensive

Braided polyester (Mersilene, Ethiflex)

Handles wellKnots secure

Tissue drag if uncoatedExpensive

Polybutester (Novofil)Elastic, accommodates

swelling and retractionExpensive

Well closed wound:

Margins w/o

tensionAccurately aligned

≠ dead space

Deep stitches:• In layers that hold suture• Buried knot preferrable• Strongest

Skin sutures:• Improve cosmetic result

Suture Techniques

Simple Interrupted stitch

Goal: evert edges of wound Raised scar remodelling smooth scar Correctly approximate asymmetric wound

edges Invert wound

Wider at top Improve cosmetic appearance

First knot 2 loops (“surgeon’s knot”) Second single loop

Vertical / horizontal mattress suture:

• Promotes eversion• Thick layer / tension

•Needs fewer knots to cover same area

Intracuticular running suture:

• Minimal skin tension• Minimal scarring w/o

marks• Difficult controlled

tissue apposition

Three-point mattress suture:

• Minimize vascular necrosis @ tip of V-shaped wound

• For stellate injuries

: resembling a star (as in shape) (http://www.merriam-webster.com/dictionary)

Running / continuous stitch:

• For speed• Good hemostasis• Poor control of

wound margins

Specific Circumstances

Lacerations across a landmark Border of lip / eyebrow Retention stitch approximate border

Beveled lacerations Modify wound margins Edges:

Squared Undermined Closed in layers

Dog ears Sides of lacerations = unequal Correct:Ten

t up

Linear incision on one side

Grasp exces

s triang

le

Second

linear incisi

on

Complex lacerations Combination 4-point technique

Finger injuries Amputated fingertip

< 1 cm2 clean, dress, heal by secondary intention

Bigger wound: Bevel dorsally and distally Conservative approach good healing

Nail bed injuries Save nail: Reapproximate nail matrix Remove nail:

Replace nail as splint

Alternatives to Suturing

Staples For skin Straight line wounds

Adhesives Cyanoacrylate ester (SuperGlue) Advantages: (superficial wounds)

Rapid closure

Minimal physical & emotional trauma

Less expensive

≠ foreign body in wound

Hemostasis first Avoid suture + adhesive bond to

suture material Wound with no tension : face and

forearm

Postrepair Management

Protect 1-2 days after repair Oozing wound pressure dressing

Nonstick gauze

(Adaptic, Telfa, Xeroderm)

Gauze pad (roller gauze, elastic wrap, elastic tape)

Remove & examine dressing 48-72 hours w/ drain: 24-48 hours Tension: add support (Steri-Strips),

splints

WoundLeft open

1st 24-48 hours

Remove wet

dressingsMacerat

ions

Initial epitheliali

zation1st 24 hours

Infection / hematom

a2-3

days

Sutures removal

Based on wound location

Mechanical stress

Tension of closure

Facial suture 3-5 days

≠ highly mobile 7-10 days

Fingers, palms, soles, joints 10-14 days

Steri-Strips: decrease dehiscence

Concurrent Therapy

Antibiotic usage Not really helpful Extensive repair IV antibiotics

during wound closure Bite wounds antibiotic post-closure Amoxicillin-clavunate, doxycycline,

ceftriaxone

Tetanus prophylaxis Crucial ≠ adequately immunized: elderly

patients Passive immunity human TIg Dose: 500 units IM TT & TIg different needle & different

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