Wound Management and Suturing Skills for the Nurse

Practitioner ”Steve Branham PhD, RN, ACNP-BC, FNP-

BC, FAANPRita Dello Stritto PhD, RN, ACNP, ENP

Hugo Pavel Gutierrez, LSA

Abscesses

ICD-9ICD-9 MedicareMedicare ConventionalConventional Hospital chargeHospital charge

1006010060

simplesimple$86.67$86.67 $282.00-$282.00-

$389.00$389.00$179.00$179.00

1006110061

ComplexComplex$162.84$162.84 $315$315

Laceration repair Trunk, Extremity, scalp and neck

ICD -9ICD -9 MedicareMedicare ConventionalConventional HospitalHospital

12001 to 12001 to 2.5cm2.5cm

$149.31$149.31 $116.23$116.23 $181$181

12002 12002 2.6-7.5 2.6-7.5 cmcm

$158.77$158.77 $159.75$159.75 $233.00$233.00

12004 12004 7.6-12.5 7.6-12.5 cmcm

$186.12$186.12 $194.65$194.65 $274.00$274.00

12005 12005 12.6-20.0 12.6-20.0 cmcm

$232.15$232.15 $263.08$263.08 $342.00$342.00

Laceration repair Face, Ear, Eye, Nose, Genitalia

ICD-9ICD-9 MedicareMedicare ConventionalConventional HospitalHospital

12011 to 12011 to 2.5 cm2.5 cm

$157.87$157.87 $210.66$210.66 $217$217

12013 12013 2.6-5.0 2.6-5.0 cmcm

$173.09$173.09 $261.90$261.90 $248$248

12014 12014 5.1-7.5 5.1-7.5 cmcm

$204.68$204.68 u/au/a $296$296

12015 12015 7.6-12.5 7.6-12.5 cmcm

$257.74$257.74 u/au/a $435$435

12016 12016 12.6-20 12.6-20 cmcm

$305.93$305.93 u/au/a $461$461

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

Wound healing

• Primary right away

• Secondary intent (inside out)

• Delayed Primary. Closed after some granulation of wound margins

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)

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!!!!!!!!

Location of injury

• Were is it and will it be moving

• General health status of patient

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)

Tetanus Status

• Always ask tetanus status

• Update anyone over the age of 7 who has not been updated in 5 years

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)

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

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

Lidocaine/bupivicaine

• 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.

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

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.

Digital blocks

Method Why

Digital blocks

Tissue response to injury phase 1

Day 1-5 inflammatory response

Phase 2 migration/proliferation

• Day 5-14

Phase 3 Maturation/Remodeling

• 14 days to 1 year/protect from sun

Methods of Closure

• Suturingabsorbable

a) syntheticb) animalnon-absorbablea) syntheticb) biological

• Staples good for hidden wounds as it tends to produce more of a scar

• Glue good for superficial closurenon flexible area (no bends or wrinkles)not in or near hairdo not use petroleum based products close to it

• Steri Stripssuperficial closure onlymust be kept fairly dryincreased utility in elderly with friable skin.

Absorbable

• Gut last 3-4 days

• Chromic gut 7-10 days

• Vicryl/Ethicon up to 14 days (least reaction)

Non- Absorbable

• Nylon (Ethilon/Prolene) synthetic less reaction harder to tie

• Silk. Biologic so increased risk of infection and braided.

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

General types knots * The smaller the suture the more knots you have to throw

• 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.

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

When do you take those puppies out

• 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.

What do I do

• 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.

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)

Pointers

• 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

Skin entry

This is it

Major types of suturing

• Continuous– Can be external or buried increased risk of

infection and scaring

• Interrupted– Most useful– Can external or buried

Interrupted sutures

Major types to follow

Simple interrupted

• Most common and useful

• Should always be used over running

• Each Bite should be ½ the depth of the dermis.

Horizontal mattress

• This is good for distributing wound tension over a greater area

• Good of palms, soles

lower extremities

Here it is

Vertical mattress

• 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”

Vertical mattress

• Here it is • Another example

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

Figure of 8 Method

Deep buried interrupted

• 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

Continuous

• Interlocking Continuous

Continuous/subcuticular

• 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

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

When to follow up

• Infection prone wound

• 48-72

• Any of the following signs

• Fever

• Redness

• Wound site ascending lymphagitis

• Increasing pain• Systemic signs of

illness (nausea, vomiting)

• Wound dehiscence