Download Basic Suturing and Wound Management

Fremantle Sailing Club
Cruising Section
Practical Medical Procedures
“Wound Management Manual”
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Basic Suturing And Wound Management
Learning Module For Long Distance Sailors
Introduction
The purpose of this module is to introduce long distance sailors to the basics of wound
management and to provide an opportunity to learn simple suturing. Although
suturing technique is important, the sailor managing a wound (from now on referred
to as “the physician”) must also have a thorough understanding of wound
management in general to effectively care for a patient with an injury.
Disclaimer
These notes are intended for the use by the crews of long distant ocean yachts who
do not have ready access to qualified medical care. Cleaning, debriding and dressing
a wound is within the skill set of individuals trained in Advanced First Aid. Individuals
who do not have an appropriate professional qualification should only utilise the
suturing skills discussed in this document if no medical care is available and only if
they have undertaken supervised training in simple suturing techniques. Suturing a
wound by non medically qualified individuals should be considered as a last resort.
Before you suture a wound you should advise the patient of your level of expertise,
and of the possible complications. The patient should be assessed by a medically
qualified individual as soon as possible after the wound has been treated at sea.
Objectives
On completion of this module participants will:
1. Understand the principles of wound management as they apply to a simple
laceration.
2. Be able to demonstrate the preparation of a simple laceration for closure.
3. Be able to demonstrate sterile technique while preparing and suturing a simple
laceration on a model.
4. Be able to demonstrate basic suturing techniques on a model.
5. Have access to notes to assist with the management of other wounds
encountered at sea (ie grazes, bites, burns, splinters and embedded fish
hooks.)
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Wound considerations
Each wound that is encountered and considered for repair must be addressed
independently. Factors such as location, size, mechanism of injury, time elapsed since
injury, likelihood of contamination and patient dependent factors must be addressed
prior to formal treatment. As well, the physician should consider whether or not they
have the skill or experience to adequately manage a particular wound.
Wound location is important. Lacerations on the face, hands and perineum
(bottom), for example, are more complicated for cosmetic and structural reasons.
These areas should be reserved for more experienced physicians. Lacerations of the
scalp, trunk and proximal extremities (above the hands and feet) tend to be less
complex so more appropriate for beginners. As with all forms of medical care, it is
important to be aware of one's own abilities and limitations. If in doubt, clean and
dress the wound and do not suture. Consider using Steristrips.
A functional assessment of nerves, blood vessels, muscles and tendons is
essential early in the evaluation of the wound. It must be done prior to injection of
local anaesthesia, as this will obviously interfere with the assessment.
Knowledge of the mechanism of injury can provide valuable insight into the
potential for injury to adjacent structures, the likelihood of contamination and the
preferred method of repair. Deep puncture wounds can injure blood vessels and
nerves, and contaminate several tissue planes. They are probably best left open after
thorough cleansing, as there is a high risk of subsequent infection if sutured straight
away. Conversely, a superficial laceration from clean glass may be cleaned and either
sutured or taped to approximate the edges.
Lacerations resulting from significant blunt force often require debridement
(trimming damaged tissue with a scalpel or sharp scissors) and revision of wound
edges to make sure there is healthy tissue at the wound edge to optimise healing. In
addition the swelling and inflammatory response resulting from blunt injury can
adversely affect the already tenuous blood supply to the area.
All traumatic wounds must be assumed to have some degree of
contamination by virtue of the presence of dirt, micro-organisms and devitalised
tissue. An infected wound will not heal properly due to adverse effects on tissue
regeneration.
The time elapsed from injury to repair has a direct bearing on the subsequent risk
of wound infection. Any wound that has been exposed for greater than 8 hours is at
significant risk for infection, regardless of the mechanism of injury.
Wounds that are more than 8 hours old, and grossly contaminated wounds
such as animal bites and farming injuries, are at such high risk for subsequent
infection that consideration should be given to leaving them open. Initial management
should focus on thorough cleaning and close monitoring for infection. Suturing a
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grossly contaminated wound, which greatly increases the risk of infection, should
always be balanced against the benefits of faster healing and better cosmetics.
Patient dependent factors known to negatively influence the process of wound
healing include advanced age, poor nutritional status and co-existing illness such as
diabetes. These factors can lead to delayed healing, wound breakdown, abnormal
scarring and infection and must be considered when instructing the patient regarding
follow-up.
Categories of wound closure
Closure by primary intent:
This refers to wound closure immediately following the injury and prior to the
formation of granulation tissue. In general, closure by primary intent will lead to
faster healing and the best cosmetic result. Most patients presenting within 8
hours of injury can have the wound closed by primary intent. Simple and clean
facial wounds, by virtue of the rich vascular supply to the face and the need for a
good cosmetic result, can be closed by primary intent as late as 24 hours after
the injury.
Closure by secondary intent:
This refers to the strategy of allowing wounds to heal on their own without
surgical closure. Of course the wound should be cleaned and dressed as with any
wound. Certain wounds such as small partial thickness avulsions (loss of tissue)
and fingertip amputations are best left to close by secondary intent.
Closure by tertiary intent:
This refers to the approach of having the patient return in 3-4 days, after initial
wound cleansing and dressing, for wound closure. This is also referred to as
delayed primary closure. Closure by tertiary intent is used for patients with
wounds who present late (>24 hours) for care, contaminated crush wounds and
mammalian bites when leaving the wound open would result in an unacceptable
cosmetic result.
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Wound antisepsis and sterile technique
Unquestionably, efforts taken to properly prepare the wound and the surrounding skin
surfaces will reduce the risk of infection and will directly improve the process of wound
repair.
Before you start taking care of the wound, wash your hands well with soap and water
to remove any dirt and debris from your hands and finger nails. Then use an
antiseptic hand wipe to disinfect your skin. Wear non sterile disposable gloves when
cleaning the wound and injecting local anaesthetic. This will protect you from the
patient's blood products and from potential needle stick injuries and protect the
patient from wound contamination from your skin. After you have cleaned and
anaesthetised the wound, remove your gloves, clean your hands again with sterile
wipes and ideally use sterile gloves when you suture the wound. If you don't have
sterile gloves, clean non-sterile disposable gloves are better than nothing.
The skin surface surrounding a wound about to be sutured should be washed with
soap and water to remove dirt and debris. A small amount of dish washing liquid in
fresh water is also an appropriate alternative to soap to clean the surrounding skin.
Most disinfectants are excellent cleansers of the skin but these solutions are
potentially toxic to the local wound defences and may increase the rate of subsequent
wound infection if they are spilled into a wound in large quantities. If used, these
solutions should be irrigated from the wound with a sterile normal saline solution or
clean fresh water as the final step in wound cleansing1.
What to do about hairy skin at the site of the wound.
It is rarely necessary to remove significant quantities of body hair prior to repair a
simple laceration. In fact, razor removal of hair has been shown to damage surface
skin follicles and lead to increased rates of wound infection. Occasionally, for repair of
scalp lacerations, for example, scissor trimming will allow for easier identification of
wound margins and will facilitate later wound care. Due to inconsistent regrowth of
eyebrow hair, it should never be shaved when repairing lacerations in that area.
1 To make a sterile normal saline solution, add 1.5 teaspoons of salt to a litre of drinking
water (boiled for 10 minutes and cooled) or add one part sea water (boiled for 10 minutes
and cooled) to 3 parts cooled boiled drinking water.
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Preparation of the wound itself
Prior to cleansing the wound itself, the area around a wound may have to be
anaesthetised to reduce the discomfort to the patient. If a local anaesthetic is needed,
use 1% lignocaine without adrenaline.
This involves cleansing and debridement.
1.
Wound irrigation will effectively remove bacteria and other debris. Flush the
wound with large quantities of soap and boiled water for 10 minutes, and
then irrigate the wound with saline. These solutions are used because they
do not irritate body tissues. A syringe can be used for the irrigation.
2.
If the wound is dirty apply a dilute solution of Polyvidone-iodine 10%
solution (Betadine) before using the irrigation technique described above.
Do not use Dettol, alcohol based products or peroxide to clean wounds.
3.
Following irrigation, all remaining debris and devitalised tissue must be
removed with fine forceps or with a scalpel. Dead tissue does not bleed
when cut. Irrigate the wound again.
4.
Normal saline should be used as the final solution when cleaning a wound.
5.
If the wound was dirty and needed debridement of dead tissue, do not
suture. Leave the wound open. Pack it lightly with disinfected or clean gauze
that has been moistened in saline and cover the packed wound with a dry
dressing. Change the packing and dressing at least daily. (See healing by
secondary and tertiary intent in the previous section.)
6.
If the wound is a clean wound but the wound edges do not hold together
consider Steristrips, or as a last resort suturing.
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Local Anaesthetics
For any patient about to be sutured, attention must be given to obtaining adequate
analgesia and ensuring overall comfort. After documenting the neurovascular status
of adjacent structures (ie determine if there is any nerve or blood vessel damage by
identifying any numbness or loss of muscle function “downstream” from the wound or
any major bleeding within the wound) a local anaesthetic can be injected into the
tissue in and around the wound. A 1% solution (10 mg/ml) of Xylocaine can be used
for most wounds.
Xylocaine 1% (10mg/ml) is very safe when used in the small quantities usually
required for simple lacerations. The physician should not use in excess of 3mg/kg
body weight of Xylocaine (eg for a 70kg person do not use more than 210 mg or 21
ml of a 1% solution of Xylocaine). Its onset of action when infiltrated locally is within
seconds and its duration of action is generally 30 to 60 minutes.
Adrenaline is added to some of the commercially available Xylocaine solutions. It is a
potent vasoconstrictor (constricts blood vessels) and functions to prolong anaesthesia
by slowing vascular uptake of the Xylocaine, and to reduce the bleeding into the
wound, which can impair visualisation of structures. Solutions containing adrenaline
are best avoided by inexperienced physicians as there are risks associated with their
use.
Xylocaine causes an intense burning sensation when injected locally. The burning is
dependent on the rate of injection and the acidity of the solution. The burning can be
minimised by slow injection (over 30 seconds using a small gauge needle (25g =
orange). An experienced physician can inject local anaesthetic with virtually no
discomfort if time and care are taken.
Painless wound suturing
Illustration 1: A relatively painless method of
administering local anaesthetic at a wound site
requiring suturing
1.
For non contaminated wounds, rather than inserting the needle into the
skin, insert it into the subcutaneous tissue through the open wound
(Illustration 1). You can irrigate the wound with a small volume of LA first to
make the subsequent injections even less painful.
2.
Infiltrate for the length of the wound on both sides.
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Recapping of needles
Although the recapping of needles should be avoided, probably the safest way, if it
really must be done, is to scoop up the needle guard with the used needle and syringe
unit, using the dominant hand only. This reinforces the principle of always staying
‘behind the needle’, and keeps the thumb and forefinger of the non-dominant hand
out of danger. The needle/syringe unit should be disposed in a sharps container or a
plastic drink bottle.
Use sterile technique when repairing a wound
Ensuring sterile technique while repairing a wound is, perhaps, the most difficult
concept for the inexperienced person to grasp. A break in sterile technique, with
contamination of the field, is a common procedural error. It leads to an increased
incidence of wound infection and breakdown.
Sterile technique requires that the physician:
• is able to open and don gloves without contamination to the sterile (outer)
surface of the gloves.
• is able to clean and drape the wound and surrounding area.
• is
able to control the instruments and suture, such that they are not
contaminated by non-sterile surfaces.
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The suture tray
The basic emergency department suture tray has the equipment necessary to manage
a simple laceration. Your kit may not have all of this equipment. It is advisable to
obtain several disposable sterile dressing packs from the chemist shop before you
depart. If your instruments are not in a sterile pack you can sterilise them by
scrubbing them to remove any debris and then placing them in clean, rapidly boiling
water for 10 minutes.
Surgical Drapes
The surgical drapes should be used to completely
surround the wound and a portion of the surrounding
sterile field.
4" x 4" Gauze
The gauze is used to clean the wound area.
Suture Materials - 4.0 and 6.0
For facial wounds, a smaller gauge suture such as
6.0 is used. For wounds under greater stress and of
less cosmetic importance such as a thigh laceration,
a 4.0 suture would be appropriate.
Antiseptic Solution and Saline
The antiseptic solution is for cleansing the skin
around the wound and saline is used to cleanse and
irrigate the wound itself.
Syringe with splash cover
Wound irrigation has been shown to be the most
effective
means
of
removing
debris
and
contaminants. The splash cover helps to avoid
exposure to the patient's blood and body fluids.
Scalpel
The operator may request a scalpel to allow a wound
to be extended or wound edges to be debrided.
Straight Haemostat
The straight haemostat can be used for blunt
dissection. It should not be used to clamp blood
vessels or tissues since it will injure these structures.
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Curved Haemostat
The curved haemostat can be used for blunt
dissection. It should not be used to clamp blood
vessels or tissues since it will injure these structures.
Toothed Forceps
The toothed forceps are used to grasp the skin edges
while suturing. They tend to be less traumatic than
non-toothed forceps but can damage tissues if
applied forcefully.
Non-toothed Forceps
This is considered to be a more traumatic instrument
than its toothed counterpart for grasping tissue.
Needle Driver
The needle driver is reinforced instrument designed
to grasp the suture needle.
Scissors
The scissors are intended only to cut sutures. They
have no rule in the dissection or removal of tissue.
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Suture Materials
There are a number of suture materials available, but it is beyond
the scope of this document to cover them in any detail. In selecting
a particular suture, the physician needs to consider the physical and
biological characteristics of the material in relation to the healing
process.
Suture materials can be broadly categorised as absorbable and non-absorbable.
Absorbable sutures do not require removal as they are digested by tissue enzymes.
Non-absorbable or permanent sutures need to be removed at a later date.
Absorbable sutures can be further divided into rapidly absorbing (days) and slowly
absorbing (months). Fortunately, the choice is often not an issue in the emergency
setting because most wounds encountered require support for a matter of days to
weeks.
Both absorbable and non-absorbable sutures are graded for size or diameter of the
strand. The grading system uses the letter O and the number of stated O's indicates
the size. The more O's, the smaller the size. For example, a 6-O is smaller than a 4-O.
Accordingly, tensile strength of a particular suture type increases as the number of O's
decreases.
The needles supplied with sutures also have important features. The needles are
either large or small and either cutting or non-cutting. Large needles have the
advantage of closing a deeper layer of tissue with each "bite". The concern with small
needles is that there will be inadequate closure of deep subcutaneous tissues, leaving
potential space for haematoma formation (ie collection of blood) . However, small
needles create smaller puncture wounds and may have the advantage of reducing
scarring
Cutting needles have at least two opposing cutting edges to facilitate passage through
tough tissue. These needles are used for skin closure. Non-cutting or tapered needles
are used to close subcutaneous tissue, muscle and fascia. They have sharp points, but
do not have cutting edges.
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Lacerations
Lacerations vary enormously in complexity and repairability. Very complex lacerations
and those involving nerves or other structures should be referred to an expert.
Principles of repair
• Have the patient lying down and ensure good lighting
• Good approximation of wound edges minimises scar formation and healing time.
• Pay special attention to debridement.
• Inspect all wounds carefully for damage to major structures such as nerves and
tendons and for foreign material:
o shattered glass wounds require careful inspection
o high-energy wounds (e.g. motor mowers, firearms) are prone to have metallic
foreign bodies and associated fractures
• Be aware that lacerated wounds may also have foreign objects or fractures
(compound fractures).
• Trim jagged or crushed wound edges with a scalpel, especially on the face.
• All wounds should be closed in layers.
• Avoid leaving dead space.
• Do not use primary closure for an 'old' wound (greater than 8 hours) or it is
contaminated recent wound. Clean, debride and dress regularly for 4 days
before suturing if not infected at that time.
• Take care in poor healing areas, such as backs, necks, calves and knees; and in
areas prone to hypertrophic scarring, such as over the sternum of the chest and
the shoulder.
• Use atraumatic tissue-handling techniques.
• Everted edges heal better than inverted edges.
• Practise minimal handling of wound edges.
• A suture is too tight when it blanches the skin between the thread—it should be
loosened.
• Avoid tension on the wound, especially in fingers, lower leg, foot or palm.
• The finest scar and best result is obtained by using a large number of fine
sutures rather than a fewer thicker sutures more widely spread.
• Avoid haematoma.
• Apply a firm pressure dressing when appropriate, especially with swollen skin
flaps.
• Consider appropriate immobilisation for wounds. Many wound failures are due to
lack of immobilisation from a volar slab on the hand or a back slab on the leg.
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Holding the needle
The needle should be held in its middle; this will help to avoid breakage and
distortion, which tend to occur if the needle is held near its end (Illustration 2).
Illustration 2: Correct and incorrect methods of holding the
needle
Types of sutures
• simple suture (Illustration 3a)
• vertical mattress suture (Illustration 3b)
• Three point (or flap suture)
Illustration 3: Everted wounds:
(a) correct and incorrect methods of making a simple
suture;
(b) making a vertical mattress suture
It is important to evert the wound edges. Eversion is achieved by making the “bite” in
the dermis (deeper layer) wider than the bite in the epidermis (skin surface) and
making the suture deeper than it is wide. Alternatively the mattress suture is the ideal
way to evert a wound.
Number of sutures
One should aim to use a minimum number of sutures to achieve closure without gaps
but sufficient sutures to avoid tension. Place the sutures as close to the wound edge
as possible.
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In wounds with a triangular flap component, it is often difficult to place the apex
of the flap accurately. The three-point suture is the best way to achieve this while
minimising the chance of strangulation necrosis at the tip of the flap.
Method
• Pass the needle through the skin of the non-flap side of the wound.
• Pass it then through the subcuticular layer of the flap tip at exactly the same
level as the reception side.
• Finally, pass the needle back through the reception side so that it emerges well
back from the V flap.
Illustration 4: The three-point suture
Tetanus prevention
Tetanus is a serious disease characterised by muscle spasm and rigidity. The mortality
rate is approximately 20% and is due to spasm of the muscles of respiration. Tetanus
is an illness preventable through primary immunisation and regular booster shots.
Make sure all of your crew are up to date with their Tetanus immunisation before they
embark on a long distance cruise.
Patients with clean, minor wounds are considered adequately immunised if they have
received primary immunisation and have had a booster within the past 10 years. If a
wound is "dirty" (which includes wounds contaminated with saliva, faeces or dirt, and
burn injuries) then a booster within the past 5 years is necessary to ensure
immunisation. Ideally it should be less than 5 years since any crew member's last
immunisation to cover for the possibility of a crew member receiving a tetanus prone
wound in a remote location.
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Infection prevention and treatment
Antibiotic prophylaxis is indicated for wounds at high risk of becoming infected such as
• contaminated wounds,
• penetrating wounds,
• abdominal trauma,
• compound fractures,
• lacerations greater than 5 cm,
• wounds with devitalised tissue,
• high risk anatomical sites such as hand or foot.
• For antibiotic coverage for bites and coral cuts see separate section pertaining to these
injuries
Recommended antibiotic prophylaxis (ie prevention when no infection is present) consists of
penicillin and metronidazole. In the hospital setting it is given intravenously and only given once:
• • Penicillin G ADULT: IV 8-12 million IU once. CHILD: IV 200,000 IU/kg once.
• • Metronidazole ADULT: IV 1,500 mg once (infused over 30 min). CHILD: IV 20 mg/kg
once.However if you only have intramuscular injections or tablets in your first aid kit where
a wound is contaminated it is best to give something rather than nothing. For example if the
patient is not allergic to penicillin give Procaine penicillin 1.5gm IMI once (adjust dose for
children according to information in Pack) or a penicillin based tablet such as Augmentin
Duo twice daily for 5 days, penicillin 500 mg 6 hourly , dicloxacillin 500 mg 6 hourly or
flucloxacillin 500 mg 6 hourly as well as oral metronidazole (flagyl) 400mg twice times daily
for 5-7 days. If the patient is allergic to penicillin use erythromycin 500mg 6 hourly instead
of penicillin.
Please note that this advice is based on what a long distance sailor is likely to have in his or
her first aid kit. Seek medical advice by radio if at all possible to establish the most
appropriate antibiotic for your patient from what you have available in your first aid kit.
Antibiotic treatment
If infection is present seek medical advice. If no medical advice is available commence antibiotics
(and continue to seek medical advice). In hospitals, antibiotics for wound infections are given via
the IV (intravenous) route. IV Penicillin G and IV metronidazole for 5-10 days provide good
coverage or metronidazole 400 mg twice daily for 5–10 days plus either cefotaxime 1 g IV 8 hourly
or ceftriaxone 1 g IV daily for 5–10 days. On your yacht it is unlikely you will have IV antibiotics so
in that case give the antibiotics as described above in the section on prophylaxis but continue to
give them for 7-10 days. If you have IM Procaine give this daily together with the oral
metronidazole.Infection prevention and treatment
If an acute allergic reaction occurs with penicillin give IM adrenaline 0.5 - 1.0 mg to adults.
0.1 mg/ 10 kg body weight to children.
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Wound dressing
Dressings are applied after suturing for several reasons. They shield the wound from
gross contamination, which is more or less important depending on the patient's
occupation. As well, a dressing can absorb blood and serous material oozing from the
wound, which serves to protect clothing and bed linen. Finally, a dressing can
improve patient comfort by immobilising injured tissue and avoiding further injury.
Although dressings can prevent gross contamination, it has been shown that wounds
which remain covered for periods of greater than 48 hours without an inspection or
change are more likely to become infected than wounds left open. After suturing a
simple laceration, the patient should be instructed to change the dressing at 48 hours.
Dressing material should be clean, but does not necessarily have to be sterile. Most
wounds are covered with a simple, light dressing. If a layered dressing is required for
the purpose of greater absorption or application of pressure or splinting, then the first
layer should be a non-adherent material such as Vaseline gauze.
Subsequent layers can include absorptive gauze and a pressure pad, if desired.
The final layer should be a Kling™ wrap or elastic bandage to secure the dressing and
apply pressure as needed.
Bulky pressure dressings can improve patient comfort by splinting the wound and by
supporting the surrounding tissues and may reduce the risk of dehiscence2. They also
serve to reduce wound drainage and deter haematoma formation. Haematoma
formation can increase the potential for infection.
Dressings wet from wound seepage should be changed immediately and dirty
dressings should be changed as often as 12-24 hours.
Many patients will ask when they can get the sutured wound wet. A clean minor
wound can be immersed for brief periods after 48 hours. This allows them to bathe,
shower and even swim.
The patient should be cautioned against prolonged
immersion, as this tends to break down the wound.
2 Wound dehiscence is a surgical complication in which an apparently healed wound breaks
open along the previous surgical suture line.
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Instructing the patient
After wound management and suturing, patients need a specific set of instructions for
ongoing wound care and routine follow-up. As well, they need to be cautioned about
possible complications.
Wound care will vary, but in general patients should be told to keep the area clean
and dry. The wound may be gently cleaned with plain water, saline or soapy water to
remove crusting and debris. Dressings that have become wet or dirty should be
changed.
If there is significant swelling associated with the wound, elevation of the affected
area will improve patient comfort. In areas under stress, such as over joints, splinting
for a few days can improve comfort and aid in healing.
Instructions for suture removal need to be given in each case. The length of time
sutures are left in depends on the amount of tension in the tissues in the area of the
wound, balanced against the fact that sutures will cause additional scarring when left
in too long.
The most common and important complication for patients to be aware of is infection.
Signs and symptoms of infection include increased pain, swelling, redness, fever or
red streaks spreading proximally (ie up the limb). Sutures should be removed if the
wound is infected. The wound should be cleaned and dressed and the patient should
be given antibiotics (as described above).
Time after insertion for removal of sutures
Area
Days later
Scalp
6
Face
3 (or alternate at 2, rest 3–4)
Ear
5
Neck
4
Chest
8
Arm (including hand and fingers)
8–10
Abdomen
8–10 (tension 12–14)
Back
12
Inguinal and scrotal
7
Perineum
2
Legs
10
Knees and calf
12
Foot (including toes)
10–12
Table 1: Time after insertion for removal of sutures
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Removal of skin sutures
Suture marks are related to the time the suture remains in the skin, its tension and
position. The objective is to remove the sutures as early as possible, as soon as their
purpose is achieved. The timing of removal is based on common sense and individual
cases (Table 1 below provides some guidance). Nylon sutures are less reactive than
silk and can be left for longer periods. After suture removal it is advisable to support
the wound with micropore skin tape (e.g. steristrips) for 1–2 weeks, especially in
areas of skin tension.
Decisions need to be individualised according to the nature of the wound and health of
the patient and healing. In general, take sutures out as soon as possible. One way of
achieving this is to remove alternate sutures a day or two earlier and remove the rest
at the usual time. Steristrips can then be used to maintain closure and healing.
Method
1.
Use good light and have the patient lying comfortably.
2.
Use fine, sharp scissors which cut to the point, a stitch cutter or the tip of a
scalpel blade, and a pair of fine, non-toothed dissecting forceps that grip
firmly.
3.
Cut the suture close to the skin below the knot with scissors or a scalpel tip
(Illustration 5a).
Illustration 5:Removal of skin sutures:
(a) cutting the suture;
(b) removal by pulling towards wound
4.
Gently pull the suture out towards the side on which it was divided—that is,
always towards the wound (Illustration 5b).
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Summary Of Skills Required For Wound Management
Step 1: History and physical examination
Each wound that is encountered must be addressed independently. Factors such as location, size,
mechanism of injury, time elapsed since injury, likelihood of contamination and patient dependent
factors must be addressed prior to formal treatment.
Mechanism of injury: provides insight into potential injury to adjacent structures, likelihood of
contamination and preferred method of repair. Laceration resulting from blunt force often require
debridement and revision of wound edges to optimise healing.
Time elapsed from injury to repair: any wound that has been exposed for greater than 8 hours is at
significant risk for infection, regardless of the mechanism of injury. Grossly contaminated wounds
such as animal bites and farm injuries are at such great risk for infection that they are best left
open.
Patient dependent factors: include advanced age, poor nutritional status and coexisting illnesses
such as diabetes which can lead to delayed healing, abnormal scarring and infection and must be
considered when instructing the patient regarding follow-up.
A functional assessment of nerves, blood vessels, muscles and tendons is essential and must be
done prior to injection of local anaesthesia as this will obviously interfere with the assessment.
As with all medical care, it is important to be aware of one's own abilities and limitations and to
request assistance if necessary.
Step 2: Use of non-sterile gloves
Exploration of any open wound should be done with universal precautions in mind. As such, it is
necessary for the student or physician to use non-sterile gloves during the initial physical
examination and when injecting local anaesthesia.
Step 3: Drawing up local aesthetic
Step 4: Injecting local aesthetic
Step 5: Donning Sterile gloves
Step 6: Clean and irrigate wound
Step 7: Draping
Step 8: Simple interrupted suture
Step 9: Vertical mattress suture
Step 10: Disposing of sharps
In the interest of safety, all sharps should be disposed in a yellow sharps container immediately
upon completion. This includes needles, scalpels and scalpel blades.
Step 11: Instructing the patient
Step 12: Suture removal
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Special Situations
1.
Beware of slivers of glass in wounds caused by glass—explore carefully
2.
Avoid suturing the tongue, and animal and human bites (see below).
3.
Gravel rash wounds are a special problem because retained fragments of
dirt and metal can leave a ‘dirty’ tattoo-like effect in the healed wound.
4.
A haematoma is a large collection of extravasated blood that produces an
obvious and tender swelling or deformity. The blood usually clots and
becomes firm, warm and red; later (about 10 days) it begins to liquify and
becomes
fluctuant.
Principles of management
 Explanation and reassurance





RICE (for larger bruises/haematomas) for 48 hours
◦ R: rest
◦ I: ice (for 20 minutes every 2 waking hours)
◦ C: compression (firm elastic bandage)
◦ E: elevation (if a limb)
Analgesics: paracetamol/acetaminophen
Avoid aspiration (some exceptions)
Avoid massage
Heat may be applied after 72 hours as local heat or whirlpool baths
Abrasions
Abrasions vary considerably in degree and potential contamination. They are common
with bicycle or motorcycle accidents and skateboard accidents. Special care is needed
over joints such as the knee or elbow.
Rules of management
• Clean meticulously, remove all ground-in dirt, metal, clothing and other material.
• Scrub out dirt with sterile normal saline under anaesthesia (local infiltration or
general anaesthesia for deep wounds).
• Treat the injury as a burn.
• When clean, apply a protective dressing (some wounds may be left open).
• Use paraffin gauze and non-adhesive absorbent pads such as Melolin.
• Ensure adequate follow-up.
• Immobilise a joint that may be affected by a deep wound.
Repair of tongue wound
Wherever possible, it is best to avoid repair to wounds of the tongue because these
heal rapidly. However, large flap wounds to the tongue on the dorsum (top) or the
lateral border may require suturing.
Afterwards the patient should be instructed to rinse the mouth regularly with salt
water until healing is satisfactory.
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The amputated finger
In this emergency situation, instruct the patient to place the severed finger directly
into a fluid-tight sterile container, such as a plastic bag or sterile specimen jar. Then
place this ‘unit’ in a bag containing iced water with crushed ice.
Note: Never place the amputated finger directly in ice or in fluid such as saline. Fluid
makes the tissue soggy, rendering micro-surgical repair difficult.
Care of the finger stump:
• Apply a simple, sterile, loose, non-sticky dressing and keep the hand elevated.
Bite wounds
Human bites and clenched fist injuries
Human bites and clenched fist injuries can present a serious problem of infection.
Antibiotics at the time of injury reduce the risk of infection.
Principles of treatment
• Clean and debride the wound carefully (e.g. aqueous antiseptic solution or dilute
betadine then flush with saline).
• Give prophylactic penicillin if a severe or deep bite.
• Avoid suturing if possible.
• Tetanus toxoid (although minimum risk).
• Consider rare possibility of HIV and hepatitis B or C infections.
• For high-risk wounds, give procaine penicillin 1.5 g IM one dose and/or
amoxycillin/clavulanate 875/125 mg twice daily for 5 days.
• If established infection in a deep wound seek medical advice. Until this advice is
available give antibiotics as described in the section on infection above.
Dog bites (Non-rabid)
Dog bites typically have poor healing and carry a risk of infection with anaerobic
organisms, including tetanus, staphylococci and streptococci. Puncture and crush
wounds are more prone to infection than laceration. Up to 25% of dog bite wounds
become infected with the first signs appearing in about 24 hours.
Principles of treatment
• Clean and debride the wound with dilute betadine, allowing it to soak for 10–20
minutes.
• Aim for open healing—avoid suturing if possible (except in ‘privileged’ sites with
an excellent blood supply such as the face and scalp).
• Apply non-adherent, absorbent dressings (paraffin gauze and Melolin) to absorb
the discharge from the wound.
• Ensure your patient has had a tetanus immunisation within the past 5 years, if
not seek medical care ASAP.
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• Give prophylactic penicillin for a severe or deep bite: 1.5 million units procaine
penicillin IM immediately, then orally for 5–10 days. An alternative is
amoxycillin/clavulanate (Augmentin)for 5–7 days. Use this antibiotic for 7–10
days for an established infection.
• Inform the patient that slow healing and scarring are likely.
Rabid or possibly rabid dog
(or other animal) (not currently applicable in Australia)
Treat bite as above and seek medical help.
Cat bites
Cat bites have the greatest potential for suppurative infection with Pasteurella
multocida being the most common organism. The same principles apply as for the
management of human or dog bites. Use amoxycillin + clavulanate (Augmentin)for
prophylaxis for 5 days. For infection commence metronidazole + doxycycline or
ciprofloxacin. It is important to clean a deep and penetrating wound. Another problem
is cat-scratch disorder, presumably caused by a Gram-negative bacterium, Bartonella
henselae.
Clinical features of cat-scratch disorder
• An infected ulcer or papule/ pustule at bite site (30% of cases) after 3 days or so
• 1–3 weeks later: fever, headache, malaise regional swollen lymph glands (may
discharge pus)
• Benign self-limiting course
• Sometimes severe symptoms for weeks, especially in immuno-compromised
• Treat with erythromycin or roxithromycin for 10 days
Coral cuts
Wounds from coral cuts are at risk of serious infection with Vibrio organisms (marine
pathogens) or Streptococcus pyogenes.
Such wounds require cleaning with
antiseptics, debridement, dressing and antibiotic cover with doxycycline 100 mg bd or
cephalexin 500 mg bd for 7 days.
Scalp lacerations in children
If lacerations are small but gaping use the child's hair for the suture, provided it is
long enough.
Method
• Make a twisted bunch of the child's own hair on each side of the wound.
• Tie a reef knot and then an extra holding knot to minimise slipping.
• Ask an assistant to drop compound benzoin tincture solution (Friar's balsam) on
the hair knot.
• Leave the hair suture long and get the parent to cut the knot in 5 days.
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Forehead and other lacerations in children
Despite the temptation, avoid using reinforced paper adhesive strips (steristrips) for
children with open wounds. They will merely close the dermis and cause a thin,
stretched scar. Steristrips can be used only for very superficial epidermal wounds in
conjunction with sutures.
Adhesive glue for wound adhesion
A tissue adhesive glue can be used successfully to close superficial smooth and clean
skin wounds, particularly in children. An expensive commercial preparation Histoacryl
(active ingredient enbucrilate) is available, but Superglue also serves the purpose
although sterility and toxicity have to be considered. The glue should be used only for
superficial, dry, clean and fresh wounds. No gaps are permissible with this method.
Avoid glues if possible.
Repair of cut lip
While small lacerations of the buccal mucosa (inner part) of the lip can be left safely,
more extensive cuts of the lip require careful repair of muscles and mucosal surfaces
with absorbable cat gut suture. You will almost certainly not have this in your first aid
kit so do not use your non-absorbable suture inside the lip. If you are suturing the
outside of the lip and the wound crosses the vermilion (lip/skin) border, meticulous
alignment is essential. The slightest step is unacceptable (Illustration 6). It may be
advisable to pre-mark the vermilion border with a marker pen. Insert a monofilament nylon suture to bring both ends of the vermilion border together. This is the
key to the procedure.
Illustration 6: The lacerated lip: ensuring meticulous suture of the
vermilion border
The outer skin of the lip (above and below the vermilion border) is closed with
interrupted nylon sutures.
Post repair
1.
Apply a moisturising lotion along the lines of the wound.
2.
Remove nylon sutures in 3–4 days (in a young person) and 5–6 days (in an
older person).
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Burns
Management depends on extent and depth (burns are classified as superficial or deep
—otherwise first, second or third degree).
First-degree burns are superficial and involve only the epidermis, causing pain,
redness and swelling. A scald, which is a burn caused by moist heat, is an example.
Healing proceeds quickly.
Second-degree or partial skin thickness burns cause the epidermis to blister and
become necrotic with subsequent serous ooze.
In third-degree or full thickness burns, there is deep necrosis and perhaps anaesthesia
from destroyed nerve endings. If extensive (> 9% of body surface area) and deep
there is a possibility of loss of body fluids and shock.
First aid
The immediate treatment of burns, especially for smaller areas, is immersion in cold
running water such as tap water, for a minimum of 10–15 minutes (ideally 20
minutes). Do not disturb charred adherent clothing but remove wet clothing
Chemical burns should be liberally irrigated with water. Apply 1 in 10 diluted vinegar
to alkali burns and sodium bicarbonate solution for acid burns.
Refer the following burns to hospital:
• > 9% surface area, especially in a child
• > 5% in an infant
• all deep burns
• burns of difficult or vital areas (e.g. face, hands, perineum/genitalia, feet)
• burns with potential problems (e.g. electrical, chemical, circumferential)
• suspicion of inhalational injury
For extensive burns always give adequate pain relief such as morphine. During
transport, continue cooling by using a fine mist water spray.
Treatment
1.
Very superficial—intact skin. Can be left with application of a mild antiseptic
only, e.g. aqueous chlorhexidine (Savlon). Review if blistering.
2.
Superficial—blistered skin. Apply a dressing to promote healing (e.g.
hydrocolloid sheets, hydrogel sheets) covered by an absorbent dressing
or
(best
option)
a retention adhesive material (e.g. Fixomull, Mefix, Hyperfix) with daily or
twice daily cleaning of the serous ooze and reapplication of outer stretch
bandage. Fixomull can be left in place for up to 2 weeks.
25
Guidelines for retention dressings
• First 24 hours: keep dry.
If there is any ooze coming through the
dressing, pat dry with a clean tissue.
• From day 2: wash over dressing twice daily. Use gentle soap and water,
rinse then pat dry. Do not soak. Rinse only. Do not remove the
dressing as it may cause pain and damage to the wound. If the wound
becomes red, hot or swollen or if pain increases treat as for infected
wound.
• From day 7 : Removal of the dressing. Soak the dressing with olive oil
then cover with plastic wrap e.g. Glad Wrap for two hours. The dressing
is then soaked off with oil (e.g. olive, baby, citrus or peanut). Debride
‘popped blisters’. Only pop blisters that interfere with skin circulation.
3.
Deep burns: If considerable ooze, apply the following in order:
• Solosite gel
• non-adherent neutral dressing (e.g. Melolin)
• layer of absorbent gauze or cotton wool (larger burns)
Change every 2–4 days with analgesic cover. Surgical treatment, including skin
grafting, may be necessary.
Exposure (open method)
• Keep open without dressings (good for face, perineum or single surface burns)
• Renew coating of antiseptic cream every 24 hours
Dressings (closed method)
• Suitable for circumferential wounds
• Cover area with non-adherent tulle (e.g. paraffin gauze)
• Dress with an absorbent bulky layer of gauze and wool
• Use a plaster splint if necessary
Burns to hands
For superficial blistered burn to the hand or similar ‘complex’ shaped parts of the body
apply strips of the retention stretch adhesive dressings as described above. They
conform well to digits. Apply an outer bandage. At 7 days soak the dressings in oil
for 2 hours prior to removal as described above.
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Splinters under the skin
The splinter under the skin is a common and difficult procedural problem. Instead of
using forceps or making a wider excision, use a disposable hypodermic needle to
‘spear’ the splinter (Illustration 7) and then use it as a lever to ease the splinter out
through the skin.
Illustration 7: Removal of splinters in the skin
A ‘buried’ wooden foreign body can be detected by ultrasound.
Embedded fish hooks
Two methods of removing fish hooks are presented here, both requiring removal in
the reverse direction, against the barb. Method 2 is recommended as first-line
management.
Method 1
1.
Inject 1–2 mL of LA around the fish hook.
2.
Grasp the shank of the hook with strong artery forceps.
3.
Slide a D11 scalpel blade in along the hook, sharp edge away from the
hook, to cut the tissue and free the barb (Illustration 8).
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Illustration 8: Removal of fish hooks by cutting a path in the skin
4.
Withdraw the hook with the forceps.
Method 2
This method, used by some fishers, relies on a loop of cord or fishing line to forcibly
disengage and extract the hook intact. It requires no anaesthesia and no instruments
—only nerves of steel, especially for the first attempt.
1.
Take a piece of string about 10–12 cm long and make a loop. One end slips
around the hook, the other hooking around one finger of the operator.
2.
Depress the shank with the other hand in the direction that tends to
disengage the barb.
3.
At this point give a very swift, sharp tug along the cord.
4.
The hook flies out painlessly in the direction of the tug (Illustration 9).
Illustration 9: Fisherman's method of removing a fish hook
intact
Note: You must be bold, decisive, confident and quick—half-hearted attempts do not
work.
For difficult cases, some local anaesthetic infiltration may be appropriate. Instead of a
short loop of cord, a long piece of fishing line double looped around the hook and
tugged by the hand, or flicked with a thin ruler in the loop, will work.
28
Credits
•
•
•
This module has been adapted by Dr Kaye Miller for the use by Fremantle Sailing Club
sailors on long distance ocean going yachts.
The source documents were from a module developed by Adam Szulewski based on content
written by Dr. Bob McGraw, Jaelyn Caudle, Jordan Chenkin, and Kari Sampsel for the
Queen's University Department of Emergency Medicine Summer Seminar Series and
Technical Skills Program).
An additional source document used was “Practice Tips” by Dr John Murtagh.
Useful Web Links
Document: Practical plastic surgery for non-surgeons Chapter 1:
http://practicalplasticsurgery.org/docs/Practical_01.pdf
Video: How to give an IM injection:
http://www.youtube.com/watch?v=aqWGuFjBDRE&feature=related
Video: How to suture in a hospital setting:
http://www.wonderhowto.com/how-to-suture-wound-hospital-setting-371906_3/
Video: How to suture in Austere conditions:
http://www.wonderhowto.com/how-to-suture-wound-with-first-aid-kit-austereconditions-371915_4/
Video: How to give a subcutaneous injection:
http://www.wonderhowto.com/how-to-administer-subcutaneous-injection-195379/
Video: How to prepare for giving an intramuscular injection:
http://www.youtube.com/watch?v=tizT_9ZH-oc
Document: How To Give An Intramuscular Injection:
http://www.drugs.com/cg/how-to-give-an-intramuscular-injection.html?printable=1
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