Lynn Lawrence, MD Cardon Children s Medical Center

Transcription

1 Lynn Lawrence, MD Cardon Children s Medical Center

2 Objectives Review the evaluation of wounds, basic wound care and suturing Provide the opportunity to practice suturing techniques Review different types of splints, their indications and application

3 Suturing - Indications Laceration Decrease risk of infection Decrease scarring Decrease discomfort of wound

4 Suturing - Contraindications Grossly contaminated wound Should heal by secondary intention Bites If gaping, should be loosely closed. Otherwise, heal by secondary intention. Time elapsed since injury Often don t close wounds >12-24 hours old due to increased risk of infection

5 Options besides sutures Dermabond Indicated for small clean wounds, low tension areas Do not use glue over joints, gaping wounds, irregular edges Less control applying, higher risk of dehiscence Steri strips Indicated for superficial wounds, low tension Staples Indicated for scalp wounds Healing by secondary intention Dirty wounds, more than 12 hours old

6 Suturing - Equipment Laceration Tray Often has tools, drapes, gauze Skin cleansing agent Sterile gauze Local anesthetic 5-10 ml syringe gauge needle to draw up anesthetic gauge needle injection of anesthetic

7 Suturing - Equipment Sterile saline Syringe for wound irrigation Needle driver Forceps with teeth Suture scissors Suture material

8 Suture Material Absorbable Gut Vicryl Monocryl Non-Absorbable Prolene Ethilon

9 Suture Material Location to be sutured Suture size & type Removal time Eyebrow 6-0 nylon or prolene for skin 5 days Lip 5-0 vicryl (mucosa, SQ or muscle) 6-0 nylon or prolene 5 days Face 6-0 nylon or prolene (skin) 5-0 vicryl (SQ) 5 days Trunk 4-0 Vicryl (SQ or fat) 4-0 or 5-0 nylon or prolene (skin) 7-12 days Extremity 3-0 or 4-0 vicryl (SQ, fat, muscle) 4-0 or 5-0 nylon or prolene (skin) days Hands and Feet 4-0 or 5-0 nylon or prolene (apply splint if over a joint) 7-12 days Nail bed 5-0 vicryl n/a, dissolvable

10 Suturing technique simple interrupted sutures Obtain your suture material and tray Open tray in sterile fashion Pour Betadine and saline in designated areas in suture tray Open suture material and place on tray sterilely

11 Suturing technique simple interrupted sutures Clean any large debris off of wound Anesthetize LET (Lidocaine, Epinephrine, Tetracaine) Topical anesthetic. Leave on about 30 minutes Lidocaine (1% or 2%, with or without epi) We tend to avoid lidocaine with epi on areas without a lot of collateral circulation (fingers, toes, penis, nose, and earlobes) New literature states Epi is OK in small amounts with no collateral circulation, but why chance it?

12 Suturing technique simple interrupted sutures Local anesthesia with Lidocaine wound infiltration Insert needle into wound edge, withdraw to make sure you are not within a vessel Inject lidocaine, form a small wheal Continue along margin of wound

13 Suturing technique simple interrupted sutures Now that there is some anesthesia to the wound, put on your sterile gloves to clean it with betadine Drape the wound with sterile drapes (on tray) Explore wound with instruments if necessary to remove any debris, check for tendon involvement Flush to remove debris from wound

14 Suturing technique simple interrupted sutures Load needle onto needle driver to prepare to fix laceration Needle is held vertically and horizontally perpendicular to the needle driver Hold the needle driver with the thumb and 4 th fingers so you have better dexterity with it

15 Suturing technique simple interrupted sutures Take bites equidistant from edge Needle should be at 90 degrees to skin Small amount of tissue eversion important for wound closure

16 Suturing technique simple interrupted sutures Knot tying Instrument parallel to wound First throw 2 wraps, subsequent 1 wrap Grab short end of thread with needle driver Pull through, hands go to opposite edges of wound Repeat. Short end of thread should alternative which side of the wound it is on after each throw Do not tie knot too tight!

17 Suturing - Aftercare Topical antibiotic ointment Limited benefit Does keep wound moist, definitely use on uncovered wounds Cover with sterile, non-adherent dressing when possible Tetanus

18 Suturing - Aftercare Prophylactic antibiotics Not routinely indicated except in contaminated wounds, crush injuries, etc Have patient keep wound dry for the next hours Gentle washing after that Have them watch for signs of infection

19 Suturing - Complications Infection Wound dehiscence Retained foreign body Unnoticed deep structure injury Scarring

20 Time to PRACTICE!!

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22 Splinting - Indications Indications Immobilize injured extremity Decrease Pain Allow healing

23 Splinting - Indications 3 Main injuries that splinting indicated for Fracture of upper or lower extremity Dislocations Stabilize after reduction Sprains/strains Decrease pain

24 Splinting Options Velcro splint Air splint Plaster/Orthoglass splint

25 Splinting Equipment Needed Stockinette Cotton Padding Orthoglass or Plaster Sheets Elastic Bandages Scissors Water

26 Splinting - preparation Exam the injured extremity completely Check distal pulses, sensory, and motor function Evaluate skin/soft tissue for any open wounds, bruising, hematomas Insure that the patient has adequate pain control prior to applying splint Remove any jewelry that may be present on the limb you are going to splint

27 Splinting preparation, con t Place the patient in a comfortable position Measure the uninjured extremity to determine the length of ortho glass or plaster that you will need. If using plaster, also cut your stockinet at this time. It should be 2-3 cm longer at each end than the plaster you are using For plaster, upper extremities require 8-10 layers. Also allow about ½ - 1 cm for shrinkage when it is wet

28 Volar Splinting with Plaster Splint used for wrist and forearm injuries Start by applying stockinet. Remember it should be 2-3 cm longer than plaster on both ends (to create a smooth edge) Cut a hole for the thumb

29 Volar Splinting with Plaster Apply Webril (cotton padding) over the stockinet Overlap by ½ the width with each wrap Apply extra padding to bony prominences of wrist and base of thumb Webril should also extend beyond edges of plaster

30 Volar Splinting with Plaster Submerge the plaster in clean, room temperature water Squeeze out the excess water Pull out the excess water again with the fingers

31 Volar Splinting with Plaster Apply the wet plaster to the volar surface of the forearm Plaster should extend from just below distal end of metacarpal (think of it as distal horizontal crease area) to ~2-3 fingerbreadths distal to elbow Fold the stockinet over the edges of the plaster

32 Volar Splinting with Plaster Apply ace wrap over the plaster You may find it easier to apply another layer of webril over plaster before the ace wrap Cut an adequate hole for the thumb in the ace wrap Mold the splint into the desired shape while the plaster is still wet

33 Splinting Ortho Glass Ortho glass differences Don t need stockinette Still wrap with cotton padding. Pay extra attention to bony prominences Cut ortho glass. Remember to fold end back in and CLIP to prevent the roll from drying out

34 Splinting Ortho Glass Wet down the ortho glass with cool water Wring it out Place on injured extremity, over cotton roll that has been applied Wrap ace wrap, no need for another layer of cotton Mold to form correct splint for the injury Leave dog ears alone! Pushing them in may cause ulcerations from the pressure points!

35 Other Simple Splints Upper Extremity Volar Sugar tong Thumb spica Lower extremity Short leg posterior Stirrup

36 Splinting After Care Re-evaluate Check neurovascular integrity Check patient comfort Durable Medical Equipment as indicated Crutches, sling, etc Analgesia Make sure patient is sent home with script for adequate pain control Follow-up Patient will need to follow up with orthopedics usually in 5-7 days

37 Splinting After Care Patient education Rest, Ice, Elevation Keep splint clean and dry Do not remove splint When to return to ED Increased swelling, pain, discoloration, or difficulty moving distal digits (fingers/toes)

38 Questions??