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TRANSCRIPT
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Basic Suturing for Family Nurse Practitioners
Wayne McLeod FNPKellie Keel FNPSaguaro Surgical PC.TMC Wound Center andHyperbaric MedicineJuly 30,2017
Wound Evaluation and Preparation
Local Anesthesia
Suture Selection
Suturing Techniques
Staples
Dermabond
Documentation
Overview
The student will be able to:
1. Discuss the principles and management of wound repair
2. Explain local anesthesia concepts, pharmacology, and possible complications
3. Perform simple interrupted suturing technique
4. Discuss suture material choices and wound healing processes
5. Document
Objectives
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Hemostasis
• Blood clots to stop bleeding
Inflammation
• Dilation of capillaries and slight increased erythema around wound but not more than 1‐2 cms may last up to 30 days
Granulation
• Fills in wound when healing by secondary intention
Remodeling
• May take up 9 months
Phases of Wound Healing
• Medical History
• Allergies to tape, Abx, latex
• Tetanus status
• On anti‐coagulation Meds, chemotherapy, RA Medications
• PMHX: DM, HIV, HepC, PAD
• Hx of poor wound healing
Patient Information
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“Assess the whole person not just the hole in the person”(Dr. Gary Sebold)
Types of Lacerations
Simple
Stellate
Avulsed
Complex
Wound Status Wound Status
Foreign Bodies
Wood
Pebbles
Glass
Thorns
Etc.
Associated with Fracture
Onset:
Time from injury
Extremities – 12 hours
Face – 24 hours
Mechanism of Injury:
Clean knife/glass
Trauma
Dog bite
Clean vs Contaminated
Puncture
Basic Principles
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General rule of “6” for acute wounds› Most wounds over 6 hours should not be
closed primarily Exceptions Face and Neck Children have longer safe period If wound is clean with excellent perfusion or can
be aggressively debrided
Basic Principles
The goals of laceration repair are to achieve hemostasis, avoid infection, restore function to the involved tissue, and achieve optimal cosmetic results with minimal scarring.
For any traumatic lesion – Don’t Forget Tetanus
Traumatic› Skin Tears› Abrasions› Lacerations› Punctures
Other wound types› Pressure Ulcers› Arterial Ulcers› Venous Ulcers
Types of wounds
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Viability of tissue Location of laceration
Tissue loss
Necrotic tissue
Depth of injury
Associated injuries
Fractures?
Gross contamination
Foreign Bodies
Wound Evaluation
Foreign Bodies
Anesthesia
Lidocaine with or without Epinephrine
No epi to nose, toes, fingers, hose, or earlobes
Lidocaine 1% (10mg per ml)
Lidocaine 2% (20mg per ml)
Max dose 3 – 5 mg/kg without epinephrine and up to 7mg/kg with epinephrine
May also use Marcaine or Bupivicaine 0.25% on small wounds. 1‐2mg/kg without epinephrine and up to 3mg/kg with epinephrine
Wound Preparation
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1% Lidocaine
• Blocks pain stimulation but leaves pressure and touch sensation intact
2% Lidocaine
• Blocks all awareness of stimuli including pressure and touch
Lidocaine
• Use a small needle for infiltration usually a 25 gauge or even 30 gauge
• May add Bi Carb 1ml of 8.4% solution to 10ml of Lidocaine
• May help to drip a small amount of lidocaine into the wound for 10 – 15 minutes prior to injecting the rest
Reducing pain from local anesthetic
Avoid allowing patient to view injection of local
Aspirate prior to injecting
Drip solution in wound a few minutes before injecting local
Inject within the wound
General Guidelines
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Follows basic principles for all wounds
regardless of location
Wound Preparation
1. Universal Body Fluid Precautions
2. Deep wounds require multiple layer closure with absorbable suture
3. Aseptic Technique
1. Including sterile fields and gloves
› Flush wound out with Normal Saline or tap water› 30 -60 ml syringe with 18
gauge needle or angiocathprovides 5-8 lb per Sq inch of pressure.
› Avoid using full strength betadine or H2O2 directly on wound bed
› Clip any hair around the edges of wound
Wound Preparation
1st and foremost know when to turfLacerations over jointsPossible ligament, tendon, or nerve damageAssociated with fractureGrossly contaminatedRequires precise cosmetic closure
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Needle Holder
Skin Forceps
Scissors
Hemostats
Appropriate Suture
Instruments
Non‐Absorbable
Ethilon
Prolene
Silk
Nylon
Absorbable
Chromic
Vicryl – complete absorption by 42 days – 0% tensile strength at 14 days
Monocryl – approx 60 – 90 days – 20% tensile strength at 21 days
Dexon
They are digested by body enzymes or Hydrolyzed by body fluids
Suture Classifications
Suture
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Suture Needles
Used to close spaces below the skin
Special areas that are hard to get to
ie. Tongue
Situations where future removal is difficult
Eliminates trauma of suture removal
Low skin tension
Absorbable Sutures
Hairy or Keloid prone areas
Requires removal
Silk no longer used for skin closure due to their poor tensile strength and high tissue reactivity
Non‐Absorbable Sutures
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Optimal cosmetic results:
• 5.0 0r 6.0 should be used on face
• 4.0 or 5.0 on the extremities depending on skin thickness and location
• 3.0 or 4.0 on back and trunk
• Consider using blue prolene for scalp wounds to differentiate from hair. Staples commonly used now
General Suture Guidelines
Holding the needle
Suturing
http://search.tb.ask.com/search/video.jhtml?searchfor=simple+suturing&p2=%5EBVB%5Exdm301%5EYYA%5Eus&n=781B3B0B&ss=sub&st=hp&ptb=5D148315‐FE3A‐4FA2‐B997‐70F1FBBCA1DD&si=314029_mysocialviewer&tpr=sbt
Needle should enter skin at 90 degrees
Suturing
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Horizontal Mattress
Stitch
Best for gaping or high tension wounds
Wound edges must be everted for proper healing
Suturing
Running Sub‐cutaneous stitch
Suturing
• Close Wound in segments
• Sutures equidistant from skin edges on either side of wound
• Evert skin edges
• Wound margins loosely approximated
• Repeatedly bisect the wound
Suture Placement
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“Wounds should be approximated, not strangulated”
Too tight = tissue necrosisToo loose = edges not aligned
Key Steps
• Initiate tie with surgeon’s knot
• Tighten knot so it lies flat
• Second throw in opposite direction
• Two additional throws to secure knot
Knot security
Face and Neck – 3‐5 days
Scalp – 7‐10 days
Joints – 10‐14 days
Back and Feet 10 – 14 days
Suture Removal
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• Stainless steel
• Used to close thick skin on extremities, trunk, and scalp
• NEVER on face, neck, hands or feet
Staplers
• Comparable with sutures in cosmetic results, dehiscence rates, and infection
• Can be applied more quickly
• Require no anesthesia
• Eliminate need for follow up
Tissue Adhesives
• Low tensile strength
• Contraindicated in patients at high risk for poor healing
• Should not be used on contaminated, complex, or jagged lacerations
• Avoid in high moisture areas, mucosal surface, groin, axillae
Tissue Adhesives
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• Follow up is similar regardless of technique
• An antibiotic ointment or white petrolatum ointment can be applied daily (do not use if closed with Dermabond)
• Written instructions should be given to all patients
Post Closure Care and follow up care
Post Closure Care and follow up care
Antibiotics?› Never give Rx for Abx
and tell pt to start if looks infected
Follow up?› 1-2 days if concerned
about infection
Billing for laceration repair depends on:
1. Size and location of the laceration
2. Complexity of repair
1. Simple laceration repair includes superficial single layer closures with local anesthesia;
2. Intermediate repairs includes multiple layer closure or extensive cleaning;
3. Complex includes multiple layer closure, debridement, and wound preparation ie: undermining of skin for better closure
Documentation/Billing
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• Suture removal is generally included in laceration repair fee
• However, if sutures placed in ED or elsewhere then can be billed
Documentation/Billing
http://www.youtube.com/watch?feature=player_detailpage&v=PoORW7pQs2M
https://m.youtube.com/watch?v=TFwFMav_cpE
Any Questions