Wound Management and Suture Skills for the Medical Practitioners
Four Classification of Wounds
Based on the estimation of microbial contamination and risk of infection:
> Clean – surgical
> Clean-contaminated – usually surgical, such as appendicitis
> Contaminated – related to trauma
> Dirty and Infected contaminated – abscesses, FB contamination, surgical wounds that become infected.
Four Major Types of wounds
> Blunt= stab with a dull object
> Sharp= stab with a sharp object
> Foreign Bodies
> Can further be defined as avulsion (partial, complete), abrasion, or deep
> Primary right away
> Secondary intent (inside out)
> Delayed Primary. Closed after some granulation of wound margins
Rules for wound closure
> Do not do a primary closure on dirty wounds
> Do not close wound on extremities or trunk over 12 hours
> Do not close wounds on face over 24 hours old
> Bites - should always avoid closure, if possible
> If mammal, placed on antibiotics
> Augmentin is the first line
> Normal Saline is the best
> Betadine is out
> Hibiclens is questionable
> Peroxide and alcohol products tend to do more tissue damage.
> Shaving is always bad
> Golden rule Clean and irrigate with pressure!
> Always ask tetanus status
> “I don’t know” = today
> Update anyone over the age of 7 who has not been updated in 5 years
> Inject through wound edges not directly into the skin
> Can buffer 10cc of local with 1 cc of NaHCO3
> Can warm in your pocket (the bottle)
Typical Topical Anesthetics
> All local are amides and are alkaline
> The effect depends on the amount of acid in the tissue. PKA is decreased in the acid environment
> No cross-reaction or sensitivity in the group (most are allergic to the preservative methylparaben)
> Lidocaine allergy does not mean marcaine allergy
> Gut last 3-4 days
> Chromic gut 7-10 days
> Vicryl/Ethicon up to 14 days (least reaction)
> Nylon (Ethilon/Prolene) synthetic less reaction harder to tie
> Silk. Biologic and braided, so increased risk of infection.
Suture Technique Guide
> Do the passing technique, two loops around the needle holder, then grab the tail and do the knob.
> Indications: Single tooth extraction, third molar extraction flap, biopsies, implants, ...etc.
> Advantages: It is the most commonly used technique, preferred in urgent situations and it is easy to remove. Failure of one is inconsequential of the others.
> Disadvantages: It does not bring all surfaces into contact and is less supportive for the healing of flap margins.
> Start it with a simple interrupted suture. Practice with Pro-Health best suture pad.
> Then you cut the tail off and leave that last piece loose then you can do your loops.
> Indications: Bone graft, removal of mandibular tori, tuberosity reduction, and where esthetics are not important
> Advantages: It is very easy to produce and offers a more watertight closure
Disadvantages: If you cut one part of it, you lost all of it.
> The needle is introduced 10mm distal to one wound end and taken from alternating sides of the wound working towards the other wound apex.
> Indications: It is used to close the deep portion of surgical defects under moderate tension.
> Advantages: It is minimal epidermal puncture points allowing the suture to be left in place longer without suture-track scarring.
> Disadvantages: The risk of suture breakage and the formation of dead space beneath the skin surface.
> The far, near technique.
> Indications: Where the wound edges tend to evert
> Advantages: Greater closure strength and better distribution of wound tension
> Disadvantages: Scar formation and the formation of edge necrosis.
> The strongest type of sutures, very far away (8mm from the edge).
> Indications: Large distances between tissues, bone grafts and implants, and closure of extraction socket.
> Advantages: Good for hemostasis, less prominent scarring.
> Disadvantages: Leave a gap between flaps and it is difficult to remove.
When to follow up
> Infection prone wound
> 48-72 hours
> Any of the following signs/symptoms:
> Wound site ascending lymphangitis
> Systemic signs of illness
> Nausea, Vomiting
> Wound dehiscence