Supervised byDR HISHAM

Prepared byANWARIAH ARIS

NOOR MOHAMMAD SAFWAN

OUTLINESObjectivesPre-proceduresProceduresPost-proceduresTake home messages

OBJECTIVESTo identify indications & contraindications

To be able to performTo be aware of complications and how to avoid or minimalize

PRE- PROCEDUREInformed consent: • Indications• Anatomy • Procedure ( Risks & Benefits)

PRE PROCEDUREAseptic technique: Prepare equipment-

MaskApronGownHand washSterile glovePovidone

PRE PROCEDURELocal anaesthesia:Lidocaine/lignocaine1% (10mg in 1ml)/2%(20mg in 1ml)With/without epinephrine 100000u

PRE PROCEDUREMax dose 4mg/kgMax dose with epinephrine:7mg/kg1% lignocaine:

Alone: 28ml in 70kg ptWith epinephrine: 49ml in 70kg pt

1.TOILET AND SUTURINGIndications:Presence of laceration woundLaceration wound closed by:

Primary closure in clean wound or

Secondary closure in dirty wound

Anatomy

Equipments:T&S setScalpelWater for irrigationSyringeLignocaine injectionSutureNeedle holderForceps

Sutures:Type: Non-absorbable for skin, absorbable for

deep tissue Size

Face & Scalp - 3/0 Limb & Trunk - 3/0 Lips & Ear -4/0

Needle: Cutting edge body for skinRounded body for tissue

Procedure:Clean surrounding skin with povidoneGive adequate local anaesthesiaWound assessment

DepthForeign bodySign of infectionActive bleedingNecrotic tissueAny structural injury

Irrigation with copious amount of salineRemove foreign bodyDebride ragged, nonviable skin edges

and necrotic tissue

Secure hemostasis:• Compressed with gauze• Suture with figure of 8

Continuous interlocking

• Ensure good bite of tissue taken• Make sure wound are free of contaminant

before closing

Timing of closure:Primary closure: Immediate closure for

clean wounds <12 hours old (24 hours on face)e.g. assault wound, clean cut

Secondary closure: Dirty wound e.g. animal bite, wound contaminated with soil

Complications:HematomaWound breakdownInfectionScar

Post T&SDressing with CMC For patient to keep wound clean and drySuture removal:

Face: 3-5 daysScalp: 7-10 daysArms: 10-14 daysLegs: 10-14 daysTrunk : 10-14 days

2.INCISION AND DRAINAGEIndications:

Cutaneous abscess: painful swelling at cutaneous, indurated, tender, warm, redness, fluctuant

If in doubt, confirm with needle aspiration

ANATOMY

Equipment:ScalpelPovidoneLignocaine injectionArtery forcepsGauze/gamgeeSyringe Swab for c+s

PROCEDUREClean and drape

Give adequate local anaesthesia

Make a cruciate incision at most fluctuant

area

PROCEDUREExpress pus (swab for C+S)

Break loci using artery forceps

Secure hemostasis with gauze compression

PROCEDURECopiously irrigate with sterile waterWash with povidone + hydrogen peroxidePacked the wound loosely with ribbon

gauze(soaked with povidone)Dressing with gauze/gamgee

Complications:PainIncomplete drainageScar Bleeding

POST INCISION AND DRAINAGEWound inspection: pus or slough Daily dressing–normal saline or povidonePain managementContinue packing of wound until no

significant dischargeAntibiotics in presence of

Localized cellulitisFever or chillsIn immunocompromised patient

3.WOUND DESLOUGHING & DRESSING

Indications:

Acute Wounds

Chronic Wounds

Anatomy:

ACUTE WOUND

Proliferative Phase

Proliferation, Granulation

and Contraction

Haemostasis & Inflammatory

Phase

Remodelling Phase

Healed Wound

Time

Hemostasis

Platelet Aggregation

Neutrophil Immigration

Monocyte Immigration

Granulation

Re-epithelialization

Wound Closure

Scar Formation

Remodeling

Minutes Hours Days Weeks Months Years

CHRONIC WOUND

Wound Healing Continuum (Gray et al. 2005) havebeen developed. This tool incorporates intermediate colour combinations between the four key colours

Procedure

Equipments:CurettageDressing setBladeGauzeCotton woolCleansing agents

Normal Saline Hydrogen Peroxide Povidone iodine

Post Wound Dressing & Desloughing:Wound Inspection Daily desloughing or dressingAntibiotic Analgesia

Complications:Excessive bleedingInfectionDelay wound closure

4. CHEST TUBE INSERTION

Indications:•Pneumothorax / hemothorax•Massive pleural effusion•Empyema •Post operative procedures Eg : Thoracotomy, Cardiac surgery •Pleurodesis : Chronic, recurrent pneumothorax or effusion

ProcedureEquipment:

Chest tube Child : 16-20FAverage size adult :24-32FLarge size adult : 36-40F

Underwater seal systemAccessory : Chest tube set, blade, LA, gauze, suture

Insertion site:Safety triangle

Procedure

Lateral border of pectoralis

majorMid

Axillary Line

4th or 5th intercostal space

Complications:• Bleeding• Lung injury• Infection• Abdominal organ injury if chest tube

inserted too low

Post Chest Tube Insertion:Vital signs monitoring (BP, HR, T) and Spo2 monitoringStart analgesia & start antibiotic if indicatedEncourage incentive spirometryCXRWatchout for complications of chest tube insertion

TAKE HOME MESSAGES1. Adequate analgesia maximum of 4mg/kg

without adrenaline or 7mg/kg with adrenaline should be administer before invasive procedure.

2. Clearly written details of each procedure and post procedure instructions is a must.

3. Disposal of all sharp equipment are done by the person performing the procedure.

4. Informed consent should be taken and explained by the person performing the procedure.

CONT..5. Puncture all loci to ensure complete drainage

of pus and packed adequately to ensure good healing of the wound.

6. In toilet and suturing, make sure the wound is clean and free of contaminant before closing.

7. Desloughing are done until we reach to the normal tissue and evidence of bleeding seen.

8. Open method of chest tube insertion at the safety triangle is the preferred method.

Referrences

Herbert Chan, Juan E. Sola, Keith D. Lillemoe, “Manual of Common Bedside Surgical Procedure”, 2nd ed,2000.

Henry Gray, Susan Standring, Harold Ellis, BKB Berkovitz, “Gray’s Anatomy and Basis Clinical Practice”, 39th ed, 2005.