Class Notes

This material is designed to supplement the specific handouts for each session.

Wound Evaluation

Evaluate for potential damage to arteries, nerves and tendons before anesthesia and again during wound exploration. Document your findings! Remember, it's like a picnic.
Search for ANTs!

Arteries typically pump blood out.

Nerves are small white thread like fibers.

Tendons are silvery white in color and similar to what is seen in chicken, beef, and pig's feet. They generally move when the attached body part moves. If not... Repair of nerve and tendon damage is generally possible if done within 2 weeks of injury. Timing of the repair of tendon and nerve damage is subject to the preferences of your surgical consultant.

Wound Preparation

Trim Hair

Pack Wound

Skin Preparation

Wound Irrigation

Simple Interrupted Suture

Advantages

• Simplest suture technique to do
• Individual suture if needed without disrupting entire repair

Disadvantages

• May be time consuming to place many at one time

Uses

• General wound closure
• Building block of suturing. Many of the more complex suture patterns are built on this suture.

Skin Staples

Advantages

• Fast placement
• Excellent wound edge eversion
• Non-reactive material
• Easy to remove

Disadvantages

• Requires special instruments for removal
• May take 2 people to put in
• Can't use in areas that will have CT or MRI studies done

Uses

• Scalp wounds
• Longer linear wounds
• Children

Anesthesia

Pain Nerve Fibers:

No insulating myelin sheath; Smallest in diameter; First affected by a local anesthetic.

Nerve Fibers:

Carry impulses from pressure and touch have an insulating myelin sheath, a larger diameter and are not usually affected by a local anesthetic. Higher concentrations of local anesthetic such as 2% lidocaine may affect the nerve fibers for pressure and touch as well.

Remember, people still have feeling after anesthesia, but not pain.

What to Use:

Lidocaine 1% with added sodium bicarb (75 mg/ml) mixed 1:10 with lidocaine. Mixture is stable for 24 hours.

How to Do it:

Use 27-30g needle, inject just under the dermis using enough to raise a wheal.

Agent	Brand Name	Duration	Max Adult Dose (mg) plain	Max Audlt Dose (mg) w/epi	Type
tetracaine	Pontocaine	long acting	100	100	ester
procaine	Novocaine	30-45 minutes	500	600	ester
cocaine (topical only)	N/A	medium acting	200 1	N/A	ester
lidocaine	Xylocaine	30-120 minutes	300 2	500 3	amides
bupivacaine	Marcaine	4-8 hours	175	250	amides

1. Reactions have been reported at lower levels.
2. 4 mg/kg. This is 30 ml of a 1% lidocaine solution.
3. 7 mg/kg. This is 50 ml of a 1% lidocaine solution.

To reduce burning sodium bicarbonate can be mixed with lidocaine or bupivacaine at a ratio of 1:10 (1 part bicarbonate with 10 parts lidocaine [0.9 ml bicarb + 9.0 ml lidocaine])

Suture & Needle Selection

For skin closure generally a reverse cutting needle is used. A reverse cutting needle has the cutting edge on outer curve and is used for tough, difficult to penetrate tissues such as skin. This is the most common needle used in wound closure. There is a standard reverse cutting needle and a plastics reverse cutting needle. The plastics version is much sharper but more expensive. Select a 3/8 or 1/2 circle needle for wound closure. P-3 and CE-4 are examples. Non-absorbable suture is less reactive and used for closing skin wounds.

• 4.0 thick tissue and over joints
• 5.0 generally used
• 6.0 finer closures

Suture Placement

• Evert wound edges.
• Use instruments not fingers.
• Number of "0s" is number of throws.
• Consider wound tension. Undermining will reduce tension on wound edges
• As far back from edge as skin thickness.

Suture Removal Guidelines

• Remove sutures early enough to avoid suture marks but late enough to prevent the wound from reopening.
• With early suture removal reinforce the wound edges with Steri-Strips.
• Always check to be sure the wound is ready for suture removal. If not recheck in 2 days. Consider removing every other suture.

Site	Adult	Children
Face	4-5 days	3-4 days
Scalp	6-7 days	5-6 days
Trunk	7-10 days	6-8 days
Arm (not joint)	7-10 days	5-9 days
Leg (not joint)	8-10 days	6-8 days
Joint extensor surface	8-14 days	7-12 days
Joint flexor surface	8-10 days	6-8 days
Dorsum of hand	7-9 days	5-7 days
Palm	7-12 days	7-10 days
Sole of foot	7-12 days	7-10 days

Suture Removal Technique

• Clip suture.
• Pull across wound not away from it.

Referral Guidelines

• When in doubt refer it out!
• Deep wound on face.
• Inside the mouth.
• Around eyes.
• Into joint.
• Ligament or tendon involvement.
• Finger tip with tissue loss.
• You're not comfortable.

Typical Instrument Set

Get the best instruments you can afford.

• 5 inch Webster needle holder
• 4.5 inch Adson forceps (with or without teeth)
• 4 inch curved iris or tetonomy scissors (for tissue only)
• General purpose scissors (for suture only)
• Curved mosquito hemostats
• #15 scalpel with handle (handle could be reusable type)

Safety Considerations

Futura Medical Corporation makes a very nice, disposable scalpel called the "Lark Safety Scalpel." It can be activated with one hand and the blade can be exposed and retracted repeatedly. Information on this can be obtained from Michael Bush at PSS. His number is 800.688.8620 X-24. Email mbush@pssd.com.

Suturing Chart Note Example

CC: Jumped up and cut head on underside of kitchen counter.

HPI: Last DTP at age 18 mos. Injured while playing in kitchen. No LOC, no head ache, no bleeding problems.

0: Alert, 3-year-old white male. There is a 6 mm full-thickness wound on the scalp. Wound edges sharp. TAC applied for 15 minutes, area around wound cleaned with Betadine. Wound infiltrated using 1.0 ml of 1% lidocaine with epi buffered with sodium bicarbonate. Wound closed with 1 simple interrupted suture of 5.0 Ethilon.

A: 6 mm scalp laceration

P:

1. Wash hair gently to remove blood then keep area clean and dry.
2. Report persistent pain, bleeding, increasing erythema, or any cloudy discharge. ER precautions for head injury reviewed with mom and handout given.
3. RTO for suture removal in 5-6 days.

Biopsy Chart Note Example

CC: Spouse noticed mole on back changing and getting larger.

HPI: Mole on back for indeterminate time. Client remembers first noticing it approximately six months ago and since that time it has been getting larger in size. No bleeding, no recurrent trauma, and no pain. Worked as a lifeguard for two years during high school and four years during college. Has had recurring exposure since that time. No family history of skin cancers. No previous problems with wound healing. No known reactions to local anesthetics, no known drug allergies.

0: Alert, 42 year old white male. There is a 6 mm uniformly brown lesion with a slightly irregular border on the superior aspect. It is on the right upper back just lateral to the spine. Procedure reviewed with client. Options discussed including the option of no treatment. Informed consent was obtained. Anesthetized using 1.5 ml of 1% lidocaine with epi buffered with sodium bicarbonate. The area was prepped with Betadine and draped. Using a # 15 scalpel blade an elliptical incision was made allowing a 1 mm margin from the edges of the lesion. A marking suture was placed at 12:00. (Note to reader, the marking suture is placed when the first edge is free but before the second edge is incised.) Following removal the wound edges were undermined and 4 simple interrupted sutures of 4.0 Ethilon were placed. Skin prep was applied around the wound edges and a Tegaderm dressing was placed on top of the wound.

A: Suspicious lesion right upper back

P:

1. Leave dressing in place for 48 hours then remove and apply triple antibiotic ointment, changing dressing daily until RTO.
2. Report persistent pain, bleeding, increasing erythema, or any cloudy discharge.
3. RTO for suture removal in 10 days.
4. Biopsy specimen for pathology review.
5. Avoid stretching pulling or excessive movement of the biopsy site.

References

Brown, John Stuart. Minor Surgery, A Text and Atlas, 2nd Edition. Chapman & Hall Medical. 1992.

Cracknell, Ian D. and Mead, Michael G. Atlas of Minor Surgery. Churchill Livingstone. 1997.

Trott, Alexander. Wounds and Lacerations. Mosby Year Book. 1997.

Last updated:  October 23, 2002