Wound Management and Suturing Skills for the Nurse Practitioner ”

1. 0 Wound Management and Suturing Skills for the Nurse Practitioner ” Steve Branham PhD, RN, ACNP-BC, FNP-BC, FAANP Rita Dello Stritto PhD, RN, ACNP, ENP Hugo Pavel Gutierrez, LSA

2. Abscesses

3. Laceration repair Trunk, Extremity, scalp and neck

4. Laceration repair Face, Ear, Eye, Nose, Genitalia

5. 0 Four Major types of wounds • Blunt= stab with a dull object • Sharp= stab with a sharp object • Foreign Bodies • Bites • Can further be defined as avulsion (partial, complete), abrasion or deep

6. 0 Wound healing • Primary right away • Secondary intent (inside out) • Delayed Primary. Closed after some granulation of wound margins

7. 0 Rules for wound closure • Don’t do a primary closure on dirty wounds • Don’t close wound on extremities or trunk over 12 hours • Don’t close wounds on face over 24 hours old • Bites- should always avoid closure and if mammal, place on antibiotics (Augmentin is first line)

8. 0 Wound cleaning • 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!!!!!!!!

9. 0 Location of injury • Were is it and will it be moving • General health status of patient

10. 0 Foreign bodies • Is it suspect • If so x-ray not everything shows up, ie wood/plastic? • Always x-ray if glass is involved or if source is not known • Remove FB that can be easily found. • Those that are deep or difficult to find should be closed/referred with the patient aware (ie some glass)

11. 0 Tetanus Status • Always ask tetanus status • Update anyone over the age of 7 who has not been updated in 5 years

12. 0 Local Anesthetic • In general most patients prefer use in random control studies • Inject through wound edges not directly into skin • Can buffer 10cc of local with 1 cc of NaHCO3 • Can warm in your pocket (the bottle)

13. 0 Typical Topical Anesthetics • All local are amides and are alkaline • Effect depends on amount of acid in the tissue. PKA is decreased in acid environment • No cross reaction or sensitivity in the group (most are allergic to the preservative methylparaben) • Lidocaine allergy does not mean marcaine allergy

14. 0 Lidocaine bupivicaine • Lidocaine normally 1% is OK • Toxic is above 5 mg per kilo • 1% = 10 mg per ml so 5ml or 50mg would be the toxic dose for a 10 kilo child • Bupivicaine 0.25-0.5 % normally 0.25 is enough

15. Lidocaine Onset fast, 2-5 min Max does 5mg/Kg Max with epi 7mg/Kg Allergy rare, dizziness, tinnitus, metal taste, seizure coma, ↓ BP,↓ HR death Bupivicaine Onset slower 5-10 min Max does 2mg/Kg Max with epi 3mg/kg IV injection can cause refractory asytole. 0 Lidocaine/bupivicaine

16. 0 Word on use of Epinephrine • Be careful • Increase risk for infection • Takes about 10 min. to help with bleeding • Prolongs the effects of locals • Should never be use at distal circulation sites: fingers, toes, tip of nose, ears, or penis

17. 0 Digital blocks • It is very difficult to block distal aspects of toes and fingers as they have such a good nerve root supply. • Use a digital block.

18. Digital blocks Method Why

19. Digital blocks

20. 0 Tissue response to injury phase 1 Day 1-5 inflammatory response

21. 0 Phase 2 migration/proliferation • Day 5-14

22. 0 Phase 3 Maturation/Remodeling • 14 days to 1 year/protect from sun

23. Suturing absorbable a) synthetic b) animal non-absorbable a) synthetic b) biological Staples good for hidden wounds as it tends to produce more of a scar Glue good for superficial closure non flexible area (no bends or wrinkles) not in or near hair do not use petroleum based products close to it Steri Strips superficial closure only must be kept fairly dry increased utility in elderly with friable skin. 0 Methods of Closure

24. 0 Absorbable • Gut last 3-4 days • Chromic gut 7-10 days • Vicryl/Ethicon up to 14 days (least reaction)

25. 0 Non- Absorbable • Nylon (Ethilon/Prolene) synthetic less reaction harder to tie • Silk. Biologic so increased risk of infection and braided.

26. 0 Needle types • Straight not used much for closing injuries • Curved straight needle with curved end also not used much in injuries • Circle ¼ to 5/8 normally use 3/8 to ½ • Two types of circle needles • FS For skin does not last as long as P or PS plastics quality needle

27. 6-0 very small used on face 5-0 small used on hands and fingers 4-0 small but larger than 5-0 used on arms and legs 3-0 medium used on backs, thighs and legs 2-0 medium/ large general not used for simple closure (central lines) 1-0 large The larger that greater the risk of scaring. 0 General types knots * The smaller the suture the more knots you have to throw

28. 0 Knots • It takes practice to throw knots • You must throw at least 5 knots for nylon type of suture. Some say more for smaller grades

29. Face 3-5 days Scalp 5-7 days Truck and extremities 7-10 days Over a joint 14 days May want to splint if it is in a bendable joint such as finger When sutures are removed you may want to use tincture of benzoin and place steri-strips for a few days of extra tensile strength. 0 When do you take those puppies out

30. Needle holder “Driver” Goal is to not touch skin. Only probe with curved objects Forceps best to use toothed kind to evert skin. Flat only crushes tissue Iris scissors delicate scissors used for wound debridment. 0 What do I do

31. 0 General rules • Everted wound edges and enter at 90 degrees • Aligned tissue layer • Do not tie suture to tight, just approximate the edges • Make it symmetric • Do not over or under approximate • Big bites (depending on site)

32. Line up anatomic lines first- in the palm put the crease together first. On the lip do the vermillion border first Wrist make sure it was not an attempted suicide Can control bleeding with tourniquet no longer than 20 min. Dressing make it look good All that is needed is clean and dry May use antibiotic ointment. On area such as face a scalp for 24 hours After 24 hours dressings and ointment not needed due to escar formation Protect from sun 0 Pointers

33. 0 Skin entry This is it

34. 0 Major types of suturing • Continuous • Can be external or buried increased risk of infection and scaring • Interrupted • Most useful • Can external or buried

35. 0 Interrupted sutures Major types to follow

36. 0 Simple interrupted • Most common and useful • Should always be used over running • Each Bite should be ½ the depth of the dermis.

37. This is good for distributing wound tension over a greater area Good of palms, soles lower extremities Here it is 0 Horizontal mattress

38. Contrary to belief does not reduce wound tension It everts wound edges Useful in loose or flabby skin (back or arm Size and placement is the same 1st entry is ½ depth of dermis 2nd should be “3 cells thick” 0 Vertical mattress

39. Here it is Another example 0 Vertical mattress

40. Figure of 8 • 1 stitch equals 2 • Better tensile strength • Can be used Areas over joints To Tie off bleeders When the area movers Tying in Tubes

41. Figure of 8 Method

42. Adds tensile strength esp. in cosmetic areas Allows for earlier removal of cutaneous suture Start first stitch deep in the opposite side as if using simple suture. Bury knot Use absorbable suture Here it is 0 Deep buried interrupted

43. Interlocking 0 Continuous Continuous

44. Poor tensile strength More risk of infection running Great to decrease scar in those prone to hypertrophic scar or Keloids Must use absorbable Check it out 0 Continuous/subcuticular

45. 0 Antibiotics • Prophylactic antibiotics should be used in mammal bites (Augmentin/Unasyn) • No proven benefit of prophylactic in non-bites* • If wound already infected should be started on something to cover skin flora • **** diabetics should have gram negative coverage for leg and foot wounds

46. Increasing pain Systemic signs of illness (nausea, vomiting) Wound dehiscence 0 When to follow up • Infection prone wound • 48-72 • Any of the following signs • Fever • Redness • Wound site ascending lymphagitis