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