Intro to Suturing and Wound Closure PDF

INTRO TO SUTURING AND WOUND CLOSURE Clinical Skills II Amanda Fleenor, MMS, PA-C STANDARDS AND COMPETENCIES ▪ The following ARC-PA Standards are addressed during this lecture: ▪ (5th edition, revised 2023): B1.03; B2.04; B2.07a-f; B2.08 a-b, B2.09. ▪ The Following PAEA Competencies for PA Gradu...

INTRO TO SUTURING AND WOUND CLOSURE Clinical Skills II Amanda Fleenor, MMS, PA-C STANDARDS AND COMPETENCIES ▪ The following ARC-PA Standards are addressed during this lecture: ▪ (5th edition, revised 2023): B1.03; B2.04; B2.07a-f; B2.08 a-b, B2.09. ▪ The Following PAEA Competencies for PA Graduates are addressed during this lecture: 1.1, 1.2, 1.3, 1.4, 2.8, 3.1, 3.4, 3.5, 3.6, 3.7, 4.1, 4.3, 4.4, 4.6, 4.7, 4.8, 4.9, 4.10, 5.3, 5.4, 5.5, 5.6 INSTRUCTIONAL OBJECTIVES 1. Describe principles of wound healing 2. Identify the pertinent elements of a patient history and physical examination for a patient presenting with a skin laceration 3. Identify necessary supplies for laceration repair 4. Compare local and topical anesthetics used to facilitate wound closure 5. Compare and contrast wound closure techniques such as suturing, stapling, use of tissue adhesives, and hair apposition 6. Compare suture materials 7. Identify instruments necessary for suturing and demonstrate their use 8. Demonstrate a simple interrupted suture, running suture, horizontal mattress suture, vertical mattress suture, and instrument tie 9. Discuss post-procedural wound care 10. Demonstrate documentation of a procedure note following laceration repair LECTURE OUTLINE Anatomy Review and Phases of Wound Healing Patient Evaluation Laceration Repair Techniques and Material Dressings / Post Procedural Care Procedure Documentation ANATOMY REVIEW & PHASES/TYPES OF WOUND HEALING  SKIN ANATOMY ▪ Epidermis: ▪ Five layers (deep to superficial) stratum basale ▪ stratum spinosum ▪ Stratum granulosum ▪ stratum lucidum ▪ stratum corneum ▪ ▪ Dermis ▪ contains collagen ▪ elastic fibers ▪ nerve fibers ▪ blood vessels ▪ sweat ▪ sebaceous glands ▪ hair follicles ▪ Subcutaneous Tissue ▪ Blood vessels ▪ Nerves ▪ Lymph ▪ Loose connective tissue PHASES OF HEALING ▪ Hemostasis ▪ Substrate/Inflammatory Phase ▪ Proliferative Phase ▪ Maturation Phase OVERVIEW OF THE PHASES  TYPES OF WOUND HEALING Primary Intention - use of sutures, tapes, or adhesives to close the wound at the time of initial surgery or evaluation Secondary Intention - when no attempt is made to close the wound and the wound granulates on its own After a simple shave biopsy Grossly contaminated or infected wounds Wounds that present far too late to consider closure  TYPES OF WOUND HEALING Delayed Primary Closure - healing by tertiary intention Used for wounds that are greater than 12 hours old (24 hours for facial lacerations) but would safely benefit from closure in a few days when repairing them immediately could increase the chance of infection After anesthetizing, evaluating, and irrigating the wound, insert a small piece of petrolatum gauze between the wound edges and place the patient on an antibiotic On day 3-5, the patient should return for definitive repair The wound is then anesthetized, reirrigated, and closed primarily with nonabsorbable sutures (i.e., no deep sutures because they increase the chance of infection) PATIENT EVALUATION LACERATIONS ▪ Commonly seen in primary care offices, urgent care centers, and emergency departments ▪ Can be repaired with sutures, staples, tissue adhesive, wound closure tapes ▪ Goals of laceration repair: ▪ Achieve hemostasis (with large lacerations we can’t control with just pressure) ▪ Prevent infection ▪ Preserve function (especially for deeper lacs that may damage muscle, etc. ) ▪ Restore appearance ▪ Minimize patient discomfort THE INITIAL HISTORY SHOULD INCLUDE: Mechanism of injury Sharp, Blunt, Bite/Puncture, Foreign Body Dirty vs. Clean Time since injury Suture up to 12hr; 24hr on face Factors resulting in injury Intentional/unintentional, occupational, assault, etc. Symptoms Pain, Swelling, Paresthesia, Muscle Weakness Function Occupation, handedness THE INITIAL HISTORY SHOULD INCLUDE: Allergies Anesthetics, Antibiotics, Latex, etc. Medications Tetanus immunization history Factors that might impair healing or increase risk for infection Patient Factors: Immunosuppression, Tissue Ischemia, Poor Wound Healing Wound Factors: Crush Injuries, Tissue Loss, Contamination, Foreign Bodies, Peripheral Location Previous scar formation Hypertrophic scars or Keloids  PHYSICAL EXAMINATION Calm, cooperative, and appropriately positioned patient Optimal lighting and magnification Little or no residual bleeding Tourniquet, epinephrine-containing anesthetic Functional Examination – Before anesthetic administered Neurovascular Muscular Tendons Joints Exploration for foreign bodies DIAGNOSTIC EVALUATION ▪ Wound imaging may be necessary if foreign body suspected ▪ Plain radiographs ▪ Metal, bone, teeth, pencil graphite, certain plastics, glass, gravel, sand, fish bones, some painted wood, most aluminum ▪ CT and MRI - useful for identifying and locating objects that have densities similar to soft tissue ▪ US - may also be useful, particularly for wooden foreign bodies LACERATION REPAIR TECHNIQUES AND MATERIALS REPAIR TECHNIQUES Tissue Adhesive Hair Sutures Staples Adhesives Tapes apposition Rapid, Time honored, Rapid, low comfort, no Least reactive, Simple, cost, meticulous, tissue removal, low low infection, no reactivity, tensile reactivity and cost, no rapid, comfort, no needle strength, low cost, low risk needle stick, cost, no stick dehiscence of needle stick microbial needle stick barrier Removal, Fall off, low anesthesia, Less Lower tensile tensile Only used on needle stick, meticulous, strength, avoid strength, high scalp, can only tissue interferes with high tension, dehiscence, approximate reactivity, cost, some imaging, cannot toxic adjuncts, simple slow removal submerge hairless areas, lacerations application cannot get wet SUPPLIES ▪ Ruler in centimeters ▪ Irrigation device and sterile saline ▪ Appropriate 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 ▪ Appropriate Suture ▪ Gloves/Sterile gloves ▪ Face shield ANESTHESIA ▪ Most wounds require some form of anesthesia to allow examination (if need to look for foreign bodies), irrigation, and repair ▪ Topical, local, regional ▪ The overall effect of an anesthetic can be altered by factors such as: ▪ Blood supply ▪ Size of the area to be anesthetized ▪ Location of the wound in terms of nerve ending size and density ▪ Patient factors such as infection, anxiety, and chronic disease (e.g., diabetes, peripheral vascular disease, obesity) also affect the success of the anesthetic  ANESTHETIC AGENTS Maximum Dose Duration without milligrams/kg without Agent Onset (min) epinephrine (min) epinephrine (with epinephrine) Amides Bupivacaine 120–240 2–10 3 (5) Lidocaine 30–120 24 hours old (