Intro to Suturing and Wound Closure

Skin Anatomy

• The epidermis is the outermost layer of the skin and has five layers: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum (deep to superficial).
• The dermis contains collagen, elastic fibers, nerve fibers, blood vessels, sweat and sebaceous glands, and hair follicles.
• The subcutaneous tissue contains blood vessels, nerves, lymph, and loose connective tissue.

Phases of Healing

• Hemostasis: the body stops bleeding by constricting blood vessels and forming a clot.
• Inflammatory Phase: involves inflammation, white blood cells clearing out debris, and the beginning of tissue repair.
• Proliferative Phase: new blood vessels develop, and granulation tissue fills the wound.
• Maturation Phase: collagen fibers remodel, and the scar strengthens, and gains tensile strength.

Types of Wound Healing

• Primary Intention: Wounds are closed at the time of surgery.
• Secondary Intention: Wounds are left open to heal by granulation, which occurs in a contaminated wound.
• Tertiary Intention: Wounds are left open for a few days before being closed with sutures.

Patient Evaluation

• History should include the mechanism of injury, wound location, and any factors that could affect the wound's healing process.
• Examine the patient's neurovascular status, muscle function, any foreign bodies, and evaluate the patient's pain.
• Wound imaging (radiographs, CT, MRI, US) can be used to identify and locate foreign bodies.

Laceration Repair Techniques

• Sutures: Time-honored method, requiring time and precision, provides excellent tensile strength, and can be difficult to remove.
• Staples: Fast, low tissue reactivity, less meticulous, good for high-tension wounds, and removal can interfere with wound healing and some imaging.
• Tissue Adhesives: Fast, comfortable, little risk of infection, less expensive, and not appropriate for high-tension wounds.
• Hair Apposition: Fast, comfortable, easy to apply, less expensive, and only good for simple lacerations.

Supplies for Laceration Repair:

• Ruler in centimeters
• Irrigation device and sterile saline
• Anesthetic
• 1 to 10ml syringe
• 27g ¼ in. needle; 18g needle
• Surgical sterile preparation
• Sterile drapes; fenestrated drape
• 4x4 gauze sponges
• Sterile pack containing: Needle Holder/Driver, Iris and suture scissors, Hemostat, Adson Forceps
• No. 15 blade scalpel
• Suture materials
• Gloves/Sterile gloves
• Face shield

Anesthesia

• Topical, local, and regional anesthesia can be used for wound repair.
• Factors that affect anesthesia effectiveness:
  • Blood supply
  • Size of the area to be anesthetized
  • Location of the wound
  • Patient factors (e.g., infection, anxiety, chronic disease)

Skin Anatomy

• The epidermis has five layers: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum
• The dermis contains collagen, elastic fibers, nerve fibers, blood vessels, sweat and sebaceous glands, and hair follicles
• Subcutaneous tissue consists of blood vessels, nerves, lymph, and loose connective tissue

Phases of Healing

• Hemostasis: stops bleeding
• Inflammatory/Substrate Phase: Inflammation and cell migration; lasts 1-3 days
• Proliferative Phase: granulation formation and epithelialization; lasts 3-21 days
• Maturation Phase: remodeling and scar formation; occurs over months

Types of Wound Healing

• Primary intention: wound edges are closed with sutures, tapes, or adhesives at the time of injury
• Secondary intention: wound is left open to heal by granulation
• Delayed Primary Closure: wound is left open for a few days before being closed primarily

Patient Evaluation for Lacerations

• History should include: mechanism of injury (sharp, blunt, bite/puncture, foreign body), dirty vs. clean, time since injury, contributing factors (intentional/unintentional, assault, etc.), symptoms (pain, swelling, paresthesia, muscle weakness), functional details (occupation, handedness), allergies, medications, tetanus immunization history, factors impairing healing or increasing infection risk, and previous scar formation
• Physical examination should include: calm, cooperative, well-positioned patient, optimal lighting, minimal bleeding, functional examination (neurovascular, muscular, tendons, joints), exploration for foreign bodies

Diagnostic Evaluation for Lacerations

• Wound imaging to identify potential foreign bodies, especially metal, bone, teeth, and certain plastics
• Types of imaging include: plain radiographs, CT, MRI, and ultrasound

Laceration Repair Techniques

• Sutures: Time-honored technique, provides the most tensile strength, but requires anesthesia and needle stick
• Staples: Rapid, low tissue reactivity, but may be less meticulous and can interfere with some types of imaging
• Tissue adhesives: Rapid, comfortable, low cost, but have lower tensile strength, cannot submerge in water, and may only be suitable for hairless areas
• Hair tapes: Least reactive, cost-effective, require no needle stick, but come with the lowest tensile strength and are primarily suitable for the scalp

Supplies for Laceration Repair

• Ruler in centimeters
• Irrigation device and sterile saline
• Anesthetic agent
• Syringe
• Needles (27g ¼ in. and 18g)
• Sterile preparation
• Sterile drapes
• 4x4 gauze sponges
• Sterile pack containing: needle holder/driver, iris and suture scissors, hemostat, adson forceps
• No. 15 blade scalpel
• Suture material
• Gloves/sterile gloves
• Face shield

Anesthesia for Laceration Repair

• Most lacerations require anesthesia for examination, irrigation, and repair
• Topical, local, and regional anesthesia are used
• Anesthetic effectiveness is impacted by factors such as blood supply, area size, nerve ending density, infection, anxiety, diabetes, peripheral vascular disease and obesity

Skin Anatomy

• The epidermis is composed of five layers with the stratum basale being the deepest and stratum corneum being the most superficial layer.
• The dermis is composed of collagen, elastic fibers, nerves, blood vessels, sweat and sebaceous glands, and hair follicles.
• The subcutaneous tissue layer contains blood vessels, nerves, lymph, and loose connective tissue.

Phases of Wound Healing

• Hemostasis involves the control of bleeding.
• The inflammatory phase begins immediately after injury.
• The proliferative phase is characterized by collagen deposition.
• The maturation phase is characterized by scar formation and remodeling.

Types of Wound Healing

• Primary intention involves wound closure using sutures, tapes, or adhesives at the time of injury.
• Secondary intention involves allowing the wound to heal on its own.
• Delayed primary closure involves waiting to close a wound for 3-5 days to reduce the risk of infection.

Patient Evaluation

• Initial History:

  • The mechanism of injury should be clarified, including whether it was sharp, blunt, a bite/puncture, or foreign body.
  • The wound should be classified as clean or dirty
  • The time since injury is essential for decision making. This includes a 12-hour time limit for sutures and 24 hours for facial lacerations.
  • Underlying factors influencing the injury such as intentionality, occupation, and assault should be known.
  • Any preexisting symptoms should be noted.
  • The patient's occupation and handedness should be documented to understand the impact on function.
  • Allergies to anesthetics, antibiotics, latex, etc. should be documented.
  • Medication details should be noted.
  • Tetanus immunization history is crucial.
  • Potential factors that may impair healing or increase infection risk should be considered. These include patient factors like immunosuppression, tissue ischemia, and poor wound healing as well as wound factors like crush injuries, tissue loss, contamination, foreign bodies, and peripheral location.
  • Previous scar formation history is relevant for understanding the possibility of hypertrophic scars or keloids.

• Physical Exam:

  • The patient should be calm, cooperative, and appropriately positioned.
  • Optimal lighting and magnification are required for assessment.
  • Limited or controlled residual bleeding is expected; a tourniquet or epinephrine-containing anesthetic can be employed for this purpose.
  • A functional examination involving neurovascular, muscular, tendons, and joints is conducted before administering the anesthetic.

Diagnostic Evaluation

• Wound imaging may be necessary if foreign bodies are suspected.
  • Plain radiographs can identify metal, bone, teeth, pencil graphite, certain plastics, glass, gravel, sand, fish bones, some painted wood, most aluminum.
  • CT and MRI are useful for objects with densities similar to soft tissue.
  • US can be useful, especially for wooden foreign bodies.

Laceration Repair Techniques & Materials

• Repair Techniques:
  • Sutures are time-honored, meticulous, and provide tensile strength.
  • Staples offer a rapid, low-tissue reactivity, and low-cost option.
  • Tissue adhesives offer rapid comfort, no removal, low cost, and a low risk of needle stick.
  • Hair tapes are least reactive, simple, cost-effective, and offer rapid comfort with no need for needles.
• Supplies:
  • A ruler in centimeters is essential.
  • Irrigation devices and sterile saline are crucial for wound care.
  • Appropriate anesthetic is required.
  • Syringes (1 to 10 ml) and needles (27g ¼ in. and 18g) are needed for administration.
  • Surgical sterile preparation is important.
  • Sterile drapes and a fenestrated drape are needed to protect the sterile field.
  • 4x4 gauze sponges are needed for absorption.
  • A sterile pack containing needle holder/driver, iris and suture scissors, hemostat, and Adson forceps are required.
  • A No. 15 blade scalpel is needed for cutting sutures.
  • Appropriate suture material is chosen depending on the wound.
  • Gloves/Sterile gloves are essential for maintaining sterility.
  • A face shield is helpful to protect the clinician.

Anesthesia

• Most wounds require anesthesia for examination, irrigation, and repair.
• Different types of anesthetic include topical, local, and regional.
• Important factors influencing the effect of anesthetic include blood supply, size of the area being anesthetized, location of the wound, and patient factors such as infection, anxiety, and chronic disease.

Skin Anatomy

• The epidermis has five layers: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum.
• The dermis contains collagen, elastic fibers, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles.
• The subcutaneous tissue contains blood vessels, nerves, lymph, and loose connective tissue.

Phases of Healing

• Hemostasis: The initial phase where bleeding is stopped.
• Substrate/Inflammatory Phase: The inflammatory response occurs with redness, swelling, pain, and heat.
• Proliferative Phase: New tissue is formed, including granulation tissue.
• Maturation Phase: Remodeling of the new tissue occurs.

Types of Wound Healing

• Primary Intention: Wound closure with sutures, tapes, or adhesives.
• Secondary Intention: Wound healing by granulation without closure.
• Delayed Primary Closure: Healing by tertiary intention where the wound is intentionally left open, but then closed after a few days.

Patient Evaluation - History

• Mechanism of injury: Determine the type of force (sharp, blunt, bite/puncture, foreign body) and if it was clean or dirty.
• Time since injury: Ideally, sutures should be placed within 12 hours, but facial lacerations ideally within 24 hours.
• Patient factors: Assess for allergies, medications, tetanus immunization status, immunosuppression, tissue ischemia, previous scar formation, and other factors that could impact healing or increase risk for infection.
• Symptoms: Assess for pain, swelling, tingling, numbness, or muscle weakness.

Patient Evaluation - Physical Examination

• General: Ensure the patient is calm, cooperative, and positioned safely.
• Lighting & Magnification: Have adequate lighting for clear visualization.
• Bleeding: The patient should have minimal or no residual bleeding after applying pressure or placing a tourniquet.
• Functional Examination: Before anesthetizing, evaluate the injured area for neurovascular, muscular, tendon, and joint function.
• Foreign Bodies: Carefully and thoroughly explore the wound for foreign objects (e.g., glass, metal, wood).

Diagnostic Evaluation

• Radiography: Order plain radiographs to detect foreign bodies like metal, bone, teeth, pencil graphite, some plastics, glass, gravel, sand, fish bones, painted wood, and most aluminum.
• Computed Tomography (CT) and Magnetic Resonance Imaging (MRI): Use these for identifying and locating foreign bodies that have similar densities to soft tissue.
• Ultrasound (US): Useful for detecting foreign bodies, particularly wood.

Laceration Repair Techniques and Materials

• Sutures: The gold standard for wound closure.
• Staples: A rapid, less meticulous option for closing tissue, but do not require sutures.
• Tissue Adhesives: A rapid, comfort-based option for closure, with low infection risks.
• Hair Apposition: Used in certain cases on scalp lacerations, where hair alignment is used to close the wound.

Supplies

• Assessment Tools: Ruler, a sterile irrigation device, and saline.
• Anesthesia: Topical, local, or regional anesthetic based on need.
• Administration: Syringe, 27g ¼ inch needle, and 18g needle.
• Sterile Preparation: Sterile gloves, gowns, and drapes.
• Gauze Sponges: 4x4 gauze sponges for cleaning and hemostasis.
• Wound Closure Instruments: Needle holder/driver, iris & suture scissors, hemostats, adson forceps, and a No. 15 blade scalpel.
• Sutures: Select the appropriate suture based on the type of wound and desired healing.
• Safety Equipment: Eye protection (face shield), and gloves.

Anesthesia

• Most wounds require anesthesia for examination, irrigation, and repair.
• Types: Topical, local, and regional.
• Factors Influencing Effectiveness: Blood supply, size of the area, location of the wound, infection, anxiety, chronic disease, and patient factors.

Anesthetic Agents

• Amides (with and without epinephrine): Bupivacaine (120-240 min duration without epinephrine, 2-10 mg/kg maximum dose) and Lidocaine (30-120 min duration without epinephrine, 24 hours old), are common anesthetic agents.

Skin Anatomy

• The epidermis is the outermost layer of skin and has five layers: stratum basale, stratum spinosum, stratum granulosum, stratum lucidum, and stratum corneum.
• The dermis is underneath the epidermis and contains collagen, elastic fibers, nerve fibers, blood vessels, sweat glands, sebaceous glands, and hair follicles.
• The subcutaneous tissue is the deepest layer and contains blood vessels, nerves, lymph, and loose connective tissue.

Phases of Healing

• Hemostasis is the first phase of wound healing, stopping the bleeding.
• The substrate/inflammatory phase is the second phase, where inflammatory cells are recruited to the wound.
• The proliferative phase is the third phase, and a scar develops in the wound.
• The maturation phase is the last phase, and the scar is remodeled and strengthened.

Types of Wound Healing

• Primary intention is wound closure with sutures, tapes, or adhesives at the time of injury.
• Secondary intention wound healing means no attempt to close the wound, and it heals on its own.
• Delayed primary closure is where the wound would benefit from closure but is delayed to avoid infection.

Patient Evaluation

• Laceration repair aims to achieve hemostasis, prevent infection, preserve function, restore appearance, and minimize discomfort.
• Initial history should include mechanism of injury, cleanliness, time since injury, causative factors, symptoms, function, allergies, medications, tetanus history, and factors that could impair healing.
• Physical examination should be performed on a calm, cooperative, and appropriately positioned patient with optimal lighting and magnification, ensuring minimal bleeding.

Diagnostic Evaluation

• Imaging may be necessary if a foreign body is suspected.
• Plain radiographs can identify metals, bone, teeth, and some plastics.
• CT, MRI, and US are helpful in identifying objects with soft tissue densities.

Repair Techniques

• Sutures are a time-honored method, meticulous, offer tensile strength, and have a low risk of dehiscence but require removal, anesthesia, and needle sticks.
• Staples are rapid, low tissue reactivity, and cost-effective but require expertise in application and removal.
• Tissue adhesives are quick, comfortable, low cost, and minimize needle sticks but have lower tensile strength, cannot be submerged in water, and contain toxic adjuncts.
• Hair tapes are the least reactive, simple, rapid, comfortable, and minimize needle sticks but only for scalp lacerations, limited tensile strength, cannot be submerged in water, and cannot be used on hairless areas.

Supplies for Laceration Repair

• Necessary supplies include: ruler, irrigation device and saline, anesthetic, syringes, needles, surgical preparation, drapes, gauze sponges, sterile pack (needle holder, iris and suture scissors, hemostat, adson forceps), scalpel, sutures, gloves, and face shield.

Anesthesia for Laceration Repair

• Topical, local, and regional anesthetics are used.
• Anesthetic effects are influenced by blood supply, area size, nerve ending size and density, patient factors such as infection, anxiety, and chronic disease (diabetes, peripheral vascular disease, obesity).

Test your knowledge on skin anatomy and the phases of wound healing. This quiz covers the structure of the skin, the healing process, and different types of wound healing. Enhance your understanding of this essential topic in healthcare and biology.