1. Wound Care and Repair
By Dr. Kawair

2. Wound Care Lecture Outline Proper sequence for routine wound repair
Options for choices of local anesthetics & types of sutures
Basic suturing techniques
Options for post-suturing wound care
"Secondary" aspects of wound care

3. Objectives of Wound Care
Lessen pain
Prevent infection
Enhance healing
Achieve best cosmesis

4. Classification Scheme for Wounds
Abrasion : tangential, superficial injury to epidermis only
Simple laceration : linear, short length break in epidermis
Deep laceration : penetrates to dermis +/- deeper structures
Complex laceration : irregular edges (nonlinear), +/- deep
Skin avulsion : complete removal of epidermal +/- dermal tissue
Crush injury : vertical compression injury to epidermis & dermis
Burns : thermal or chemical coagulation of epidermis / dermis
Frostbite : freezing injury to epidermis / dermis
Infected : established microbial invasion of tissue
Wounds associated with other injuries : open fractures, etc.

5. Surgical Wound Types Classification
Type I : "Clean" ; usual infection risk 1 to 5 %
Type II : "Clean-contaminated" ; infection risk 5 to 10 %
Type III : "Contaminated" ; infection risk 10 to 15 %*
Type IV : "Dirty" ; infection risk 30 to 50 %*
*Most wounds seen in the E.D. are Type III or IV
(since they occur through unprepped skin)

6. Surgical Wound Types Classification (continued)
Type I ("Clean")
Nontraumatic
No inflammation present
No break in technique
Example : elective groin hernia repair
Type II ("Clean-contaminated")
Nonsterile body region entered (GI or GU tract, biliary tract, resp. tract, oropharynx, etc. )
Or minor break in technique

7. Type III : Contaminated Wounds
Major break in technique
Gross spillage from GI tract
Infected GI, GU, or biliary tract entered
Fresh traumatic wound ( through unprepped skin)
Note that the overall infection rate in the Type III wounds seen in the E.D. should be only about 3 %

8. Type IV : Dirty Wounds Wounds associated with perforated viscus
Traumatic wounds with :
Imbedded foreign body
Fecal contamination
Delayed presentation
> 12 to 24 hours for face or scalp
> 6 hours elsewhere on body
Crossing clean tissue to drain pus

9. Proper Sequence of Steps for Routine Wound Care & Repair
1. Adequately expose the wound area.
need wide area exposed for adequate prep margins.
2. Remove superficial contaminants (gravel, etc.).
leave deeply imbedded objects in place for removal in O.R.
3. Cleanse around the wound.
most cleansing agents damage exposed deep tissues.
4. Consider local hair removal.
usually do not need to remove hair (can just slick it down with betadine or K-Y jelly).
shaving increases wound infection rates.
local shaving causes temporary cosmetic problem.
NEVER shave an eyebrow (it might not grow back).

10. Proper Sequence of Steps for Wound Care & Repair (cont.)
5. Irrigate the wound : the most important step for reducing bacterial counts in the wound.
18 or 19 gauge needle and 20 to 30 cc. syringe give best irrigation pressure (about 20 psi).
6. Reprep wound edges.
need to prep area larger than the drape fenestration.
7. Drape the wound.
8. Locally anesthetize the wound.
9. Close (suture) the wound.
10. Dress and bandage the wound.
11. Instruct the patient in followup wound care.

11. Advantages of Locally Anesthetizing Wounds After the Irrigation & Prep
Can keep sterile syringe on tray for additional later local anesthesia if needed
Uses only one pair of gloves & one anesthetic syringe (saves money)
Less risk of introducing infection into tissue adjacent to wound ( by only injecting into wound surface after irrigation and cleansing of wound)

12. Wound Edge Prep Important to prep a wide area in case the drapes slip
For finger wounds, should at least prep the adjacent surfaces of the 2 adjacent fingers
For very dirty hands, consider placing a sterile surgical glove on the patient's hand, & then tear off a portion of the glove to expose the wound area
Should use an agent with a broad antimicrobial spectrum (e.g. Betadine or Hibiclens)
Most agents need to dry on skin to achieve the best antimicrobial effect
Try to avoid getting the prep agent on the exposed deeper tissue (try to keep it just on the skin surface)

13. Choices for Wound Irrigation Fluids
Usual choice : normal saline
Cheap, isotonic ; however, not bacteriacidal
Normal saline with 3 ppm iodine (2 to 3 gtts iodine per liter)
Perhaps best choice
Bacteriacidal but not tissue toxic
Normal saline with antibiotics ( 1 gram of 1st generation cephalosporin per liter)
Bacteriacidal but expensive
Mild risk of sensitization
Poloxamer 188 ("Shur-clens")
Surfactant agent ; not bacteriacidal
Expensive compared to normal saline

14. Poor Choices for Wound Irrigation Fluids
Sterile water
Hypotonic ; will damage exposed tissue
Full strength (10 %) povidone iodine (Betadine)
Damages tissue & WBC's
Full strength clorhexidine gluconate (Hibiclens)
Toxic also to cornea & middle ear
Hydrogen peroxide 10 to 30 %
Hexachlorophene 3 % (Phisohex)
Only effective against gram positive bacteria

15. Local Anesthetic Agents
Lidocaine (Xylocaine)
0.5 to 2.0 % concentrations
Available with & without 1: 100,000 epinephrine (epi)
Dose limits :
5 mg/kg without epi
7 mg/kg with epi
Topically doesn't work well
Buffering (1 cc of 1 meq/cc or 7.5 % Na HCO3 added to 9 to 10 cc of lidocaine solution) and warming decrease pain of infiltration
Buffered lidocaine is stable at least one week

16. Local Anesthetic Agents
Bupivacaine (Marcaine)
0.25 to 0.75 % concentrations
Available with & without 1 : 200,000 epi
Same local anesthetic class (amide) as lidocaine
Can yield up to 6 to 8 hours of local anesthesia
Can be mixed as 1 : % Marcaine & 2 % lidocaine for digital or intercostal or wrist blocks
Dose limit is variable
Usually quoted as 2.0 to 2.5 mg/kg

17. Allergy to Local Anesthetic Agents
Allergy to amide local anesthetics is rare
Most reactions are actually due to intravascular injection and vasodilatation
Can use cardiac lidocaine (has no preservative) if allergy to the preservative is suspected
If allergy to amide local anesthetic is suspected, then options are :
Use an ester class local anesthetic
Procaine (Novocaine) or tetracaine
Use 1 % diphenhydramine (Benadryl) injection
Use slow injection of normal saline with benzyl alcohol preservative

18. Local Anesthetic Injection Technique
Best to use 27 gauge or smaller needle
Inject slowly
Inject through wound surface (is more painful to inject through intact skin next to wound)
If 1 & 1/2 inch (3 cm) needle is used, can gradually advance a bleb along the entire length of one side of a short wound with just one stick per side
Do not usually need to pull back on syringe before injecting ; just look for raising of subcutaneous bleb (the area of the bleb should be well anesthetized)
For digits, inject on proximal side first
Should limit to 3 cc volume per digit

19. Use of TAC
TAC = tetracaine (0.5 %), adrenalin (1:2000), & cocaine (11.8 %)
Excellent topical anesthetic for open wounds
Contraindicated for:
Wounds on or near mucosal surfaces (due to rapid absorption of cocaine)
Areas of body served by end arteries (digits, penis, ear lobes, tip of nose)
Pregnancy
History of high BP or CAD
Allergy to components
Most useful for scalp or face lacerations in children

20. Use of TAC (cont.) Dose limit : 2 cc for adults
Takes 10 to 15 minutes to work
Blanching of wound margins confirms effect
Blanched areas are anesthetic
For small wounds soak cotton-tipped applicators in TAC & place directly in wound
For larger wounds place soaked cotton ball or 2x2 inch gauze pad in wound
Apply gentle continuous pressure also over wound to facilitate TAC entry into tissue

21. (Lidocaine-Epinephrine-Tetracaine)
Use of LET
(Lidocaine-Epinephrine-Tetracaine)
Composed of 4 % lidocaine, 1:2000 epi, 0.5 % tetracaine
Has largely superseded the use of TAC because of its greater safety and lesser cost
Unlike TAC, it is safe to use on or near mucous membranes
Other contraindications same as for TAC
Application technique same as for TAC

22. Regional Anesthetic Technique "Minidose" Bier Block
Indications
Multiple or extensive lacerations of hand, wrist, or foot
Fracture or dislocations of hand, wrist, or foot, especially if multiple
Safer than previously reported (higher dose) Bier block technique since total amount of lidocaine used in the "minidose" block is nontoxic

23. Minidose Bier Block Procedural Sequence Place double BP cuffs on limb
Place IV catheter distally in limb
Raise limb +/- Esmarch bandage wrap ( to exsanguinate the limb)
Inflate proximal BP cuff (> systolic BP)
Infuse 1.5 mg/kg lidocaine in IV
Wait 15 minutes
Inflate distal cuff & deflate proximal cuff
Perform the wound repair or fracture reduction procedure
Deflate distal cuff

24. Choice of Suture Needle Type
Cutting needle
triangular in cross section
can punch through tough skin
however can tear delicate tissues
main use : epidermis repair (outer layer)
Taper needle
round or circular in cross section
does not puncture epidermis well
good for fascia & deep tissues

25. Cutting and taper needles

26. Choice of Suture Type Nonabsorbable Indications: Absorbable
skin repair
fascia under tension
vascular (blood vessel) repairs
Absorbable
subcutaneous layers
intraoral mucosa (including tongue)
fascia not under tension

27. Suture Type Comparison
Monofilament (single strand)
Advantages :
Less reactive
Less likely to become infected
Braided (multiple strands wound around each other)
Greater tensile strength
Easier to tie knots
Knots hold better

28. Comparison of Nonabsorbable Sutures
Nylon (Dermalon) : inexpensive, fine for most skin repairs.
Polypropylene (Prolene) : smoother & stronger than nylon ; blue color makes it easier to see on dark-haired scalp ; requires 8 knot throws to secure ; is the best pull-out suture.
Braided nylon (Surgilon) : combines strength of nylon with tying ease of silk ; very expensive.
Silk : more reactive, more infection risk ; used by some dentists for intraoral suture ; it has no advantages over other better sutures.
Wire (stainless steel) : least reactive & strongest type of suture ; difficult to tie & uncomfortable for patient ; requires wire cutters for removal.
Cotton : obsolete (high tissue reactivity & infection potential).

29. Comparison of Absorbable Sutures
Plain gut : absorbs in 5 to 10 days (by inflammation).
Chromic gut : absorbs in 10 to 14 days (by inflammation).
Polyglycolic acid or polyglactin (Vicryl, Dexon) : absorb in 30 to 90 days (by hydrolysis) ; are braided ; are stronger, less reactive, and last longer than gut sutures.
Polydioxanone (PDS) : absorbs in 100 to 210 days ; monofilament ; minimally reactive ; smooth to tie.
Gut type of sutures shown in studies to cause more wound pain.
Also can cause wound redness & swelling simulating wound infection.

30. Suture Size Guidelines
Wound Location
Recommended Suture Size
Scalp
3-0 , 4-0
Face
6-0, 5-0
Chin
6-0, 5-0 (2 layer)
Trunk
4-0
Arm
4-0
Hand
5-0
Leg
4-0
Foot
4-0, 3-0
General rule : 6-0 on face, 5-0 on hand, & 4-0 elsewhere on body

31. Suture Removal Guidelines
Wound Location
Suture Removal (Days)
Scalp 7
Face
3 to 5
Chin 7
Trunk
7 to 10
Arm
7 to 10
Hand
10 to 14
Leg
10 to 14
Sole of foot
14 to 21

32. Factors to Consider Leaving Sutures in Longer Than Listed on Previous Slide
Insulin - dependent diabetes
Chronic steroid use
Immunosuppressed
Poor nutrition
Age > 70 years

33. Cosmetic Wound Closure Alternative Techniques
Steri-strips
Good if wound edges not under much tension
Tinture of benzoin helps hold strips
Okay if patient won't get wound wet for 3 days
Start at center of wound & bisect outwards
Running subcuticular polypropylene suture
Probably best cosmetic suture
Difficult to learn
Can tie knots at both ends to anchor
Helpful to buttress with steri-strips

34. Method of application of Steri-Strips (apply benzoin to skin first so tape strips adhere better)

35. Steri strip application technique

37. Lines of Least Skin Tension : "Lines of Langer"
Should perform debridements & elliptical biopsy incisions parallel to the lines of least skin tension to minimize scarring
Lines of Langer generally run parallel to natural skin folds or perpendicular to the underlying muscle fibers ; for example :
Horizontal on forehead
Circumferencial on forearm or leg

38. Elective incisions best made parallel to the Lines of Langer

39. Use of Staples to Close Wounds
Advantage : speed
Disadvantages :
Uncomfortable for patient
Requires staple remover to remove
Poorer cosmetic result
Main use in E.D. :
Rapidly close an actively bleeding scalp laceration in the patient who must be rushed off for emergent other diagnostic tests or surgery

40. Holliman's 3 Rules of Plastic Surgery
If these are followed, the repair will be of "plastic surgery quality"
1. Plan what you're going to do (line up the corresponding skin points on opposite sides of the laceration)
2. Take your time
3. Use a very large number of little tiny stitches

41. Basic Suturing Technique
Grasp needle with needle holder (instrument clamp) at 90 degree angle
Grasp needle about 1/3 of the way up from the suture end of the needle
Hold needle holder with thumb in one finger hole, 4th finger in the other finger hole, and second finger extended for stability
Never grasp the sharp tip of the needle with the needle holder (will dull or break it)

42. Basic Suturing Technique (cont.)
Start to puncture the skin vertically with the needle
If the needle is a small size & the wound is wide, transit the wound in 2 passes (pick the needle up with the needle holder and remount it after pushing it thru just one side first)
Exit needle on other side same distance from wound edge
Usually make the needle pass deeper than wide to achieve wound edge eversion

43. Basic Suturing Technique How to Instrument Tie a Suture Knot
Grasp needle side of suture with left hand
Pull suture partway through, leaving a 1 inch (2.5 cm) "tail"
Point needle holder at tail of suture
Use left hand to throw 2 loops of the suture strand around the end of the needle holder
Grasp the "tail" suture end with the needle holder
Pull the tail thru the 2 loops (this actually creates the knot)

44. Basic Suturing Technique How to Instrument Tie (cont.)
Cinch the double-throw knot down
Make sure the knot sets down flat (may have to cross hands 90 degrees to do this)
Use left hand to throw a single loop around the needle holder
Then grasp tail of suture with needle holder & pull tail thru the loop
Alternate subsequent throw loops above & below the needle holder (so that square, not granny, knots result, which are less likely to unravel)

45. Basic Suturing Technique (cont.)
Space sutures same distance apart & same distance on either side of wound (should be like a "square box") ; examples :
1 mm apart & 1 mm from wound edges for delicate facial lacerations
1 cm apart & 1 cm from wound edge for "cruder" repairs not under tension
Tie at least 5 to 6 knots (throws) for nylon
Tie at least 7 to 8 knots (throws) for prolene
Tie 3 knots for absorbable sutures

46. Basic Suturing Technique (cont.)
Always be conscious of good sterile technique
Don't let your jacket sleeve brush the sterile drapes
Don't let the end of the suture flop off the sterile area
Bring sponges & scissors over to the drapes where you are working so they are available (so you don't have to keep reaching back to your suture tray for these)
Dispose of all needles and sharps in proper receptacles

47. Best wound edge eversion is obtained when you place the sutures deeper than wide, as in the bottom diagram (note the middle diagram shows poor placement with resultant inversion of the wound edges)

48. To avoid gaps in the hair after healing, any debridement of tissue where the hair is coming out at an angle should be at the same angle as the hair (not just straight vertical), such as in the eyebrow

49. Remember the goal of cosmetic wound closure is to try to have the scar be flat with the surrounding skin (if the scar is raised or lowered it causes a noticeable shadow in oblique light)

52. Main Suturing Techniques
Simple interrupted
OK for most wounds
Quick to place
Easiest to learn
May cause wound edge eversion
Continuous over & over
Fastest to place
However, if breaks at one point, the whole suture line will far apart
Generally not recommended unless there is a huge time-consuming total laceration length to repair

53. Most common suture techniques
Subcuticular

55. Main Suturing Techniques (cont.)
Interrupted vertical mattress
Best suture to evert wound edges
Takes longer to place
Can start at center of wound, & once eversion is achieved, finish with simple interrupted
Interrupted horizontal mattress
Good where skin is thin (back of hand, etc.)
Equivalent to having 2 sutures per knot (so is a quick technique)
Interrupted half-buried horizontal mattress
Good to elevate a flap or to repair the tip of a T or Z shaped laceration

62. Use of half-buried horizontal mattress stitch to close V and T shaped lacerations

63. Use of half-buried horizontal mattress suture to close a Z shaped laceration

64. Conversion of a V shaped laceration to a Y shaped laceration (V-Y advancement) ; note use of horizontal mattress suture to close the center of the Y

65. Needle motion sequence for placing a buried (deep) suture with its knot inverted

67. At completion of suturing, pull all the knots over to one side

68. Undermining of Wound Edges
Important to reduce tension on wound edges
Especially important for lacerations on the anterior calf (either horizontal or vertical)
Best technique is to spread with curved mosquito clamp just below the subcuticular layer ; essentially loosens subcuticular layer from the underlying fatty dermal layer (you can use a knife for undermining but this can stir up more bleeding)

69. Using a clamp to spread at the junction of the subcuticular layer and the underlying fat rather than a knife can achieve undermining with less potential for bleeding

70. One technique for correction of a “dog ear” ; usually a better alternative is to remove the sutures already placed, realign the wound edges, and start suturing again from the center of the wound

71. Continuous Interlocking Suture ("Baseball Stitch")
Each loop is partially locked onto next loop
Can cause tissue necrosis
Only useful occasionally in a patient with a coagulopathy who has continued bleeding from the initially placed interrupted suture sites

73. Imbedded Fishhook Removal : 3 Acceptable Techniques
Local anesthesia, then :
Just rip the hook out (suitable only if small barb hook)
Or, insert 18 gauge needle to cover the barb, and then back the needle & hook out together
Or, punch the barb on through the skin, and then cut the barb off with wire cutters, and then back the shank out

75. Correct Definitions
Dressing : the covering immediately next to the wound surface
Bandage : the material holding the dressing in place

76. One method of bandaging a finger

77. Use of Tube-Gauze to bandage a finger

78. Use of Topical Antimicrobial Agents for Wounds
Use of topical agents may :
Decrease scarring
Decrease infection
Lessen coagulum encasing the sutures
Prevent dressing from sticking to wound and redamaging the wound when it is removed

79. Choices of Topical Agents for Wounds
Polymixin - Bacitracin (Polysporin) : best choice
Neosporin (Polysporin + Neomycin) : OK but 10 % risk of sensitivity to neomycin
Bacitracin : only kills gram positive bacteria
Silver sulfadiazine (Silvadene) : bacteriostatic, expensive, good for burns
Sulfamylon : bacteriostatic, stings on application, causes metabolic acidosis (carbonic anhydrase inhibitor)
Povidone-iodine (Betadine) : toxic to exposed tissue, so DON'T use on wounds (OK for IV sites)
Mupirocin (Bactroban) : good but more expensive than Polysporin

80. Choices for Wound Dressings
Dry gauze : suitable for most wounds or if steri-strips used
Nonadherent dressings : preferred for abrasions, nailbed injuries, skin flaps, or thin skinned elderly
Vaseline gauze
Xeroform gauze
Adaptic gauze : most expensive
Telfa : not really nonadherent
Can use clear dressings like Op-site for some wounds
Duoderm commercial dressing also useful for covering some types of chronic open wounds

81. In general, active motion is better
Immobilization of the Injured Extremity Versus Encouraging Active Motion After Wound Repair
In general, active motion is better
Prevents need for physical therapy to regain ROM after immobilization
No increase in wound separation problems if sutures left in for at least 14 days (as on the hand)
Finger splints usually unnecessary for properly repaired finger lacerations

82. Hand immobilization and bandaging

83. Further Wound Care
Don't forget to consider tetanus immunization for all wounds
Consider antibiotics for :
Bite wounds
Contaminated wounds
Hand or foot wounds
If delayed presentation
Wound already infected
Risk factors for infection ( diabetes, chronic steroids, immunosuppressed, malnutrition, PVD, age > 70)

84. Lacerations to Refer to Plastic Surgery
Suspected facial nerve involvement
Flap required for repair
Major cartilage injury
Parotid duct laceration (blood at Stensen's Duct)
? if skin graft needed
? if patient asks for plastic surgeon

85. Lacerations to Refer to Ophthalmologist
Lid margin laceration
Medial canthus laceration
Thru & thru lid laceration
Avulsion of lid or periorbital tissue
Ptosis
Suspected globe injury
Proptosis
Hyphema
Lens or retinal detachment

86. Tetanus Immunization Guidelines
Every 5 year update for tetanus toxoid is good general rule on all cases
Also use TIG (tetanus immune globulin) if :
Patient never immunized
Immunosuppressed
Allergic or severe local reaction to toxoid
? if highly tetanus - prone wound & is > 10 years since last toxoid immunization

87. Beveled laceration best repaired in 2 layers

88. Wound appearance after placement of subcutaneous absorbable sutures

89. Wound appearance after outer layer skin repair with 6-0 nylon

90. Wound Care Lecture Summary Carefully plan any wound repair
Don't forget to inform the patient what you're doing
Follow Holliman's 3 rules of plastic surgery
Don't forget to consider tetanus immunization & antibiotics
Ensure proper followup care