Professional Documents
Culture Documents
in Primary Care
Shawn A. Sutterlin, PA-C
Watauga Orthopaedics
Objectives
Review wound types and classification
Understand the principles of wound
healing
Wound
Classification
Four Classes
Clean
Clean-contaminated
Contaminated
Dirty/infected
Clean Wounds
Most common is elective surgical
incision
Primary closure
1-5% rate of infection
Clean
Contaminated
Wounds contaminated by local
Cholecystectomy, appendectomy
and hysterectomy
Contaminated
Open traumatic wounds in nonsterile
environment
Open fractures
Surgical procedures in which there is
a gross deviation from sterile
technique (emergent open cardiac
massage)
Dirty or Infected
Gross/heavy contamination or
active infection
Wound Healing
Four Stages
Hemostasis
Inflammatory
Proliferative
Remodeling
Phase I:
Hemostasis
Vasoconstriction stimulated by
endothelial injury
Platelet aggregation
Coagulation cascade is activated
and fibrin clot formed
Hemostasis
Phase II:
Inflammatory
Inflammation
Phase III:
Proliferative
Angiogenesis
Granulation
fibroblasts deposit extracellular
Phase III:
Proliferative
Epithelialization
keratinocytes
Contraction
Fibroblast release of actin
Phase IV:
Remodeling
Collagen remodeled along tension
lines
Patient factors
Age
Weight
Nutrition
Dehydration
Blood supply
Immunocompromised
Chronic Disease
Radiation therapy
Wound Closure
Primary closure
Secondary closure
Tertiary closure
Primary Closure
Most common
Preferred method when appropriate
Wounds are re-approximated
acutely
Dermis-dermis apposition
Best cosmetic outcome
Secondary Closure
Known as healing by secondary intention
Wound edges are left un-approximated
Granulation tissue formed
Migration of keratinocytes provide re-
Tertiary Closure
Contaminated wound is I&Dd and
left open for several days
Suture Materials
Traits needed by suture
Tensile Strength
Knot security
Ease of handling
Low tissue reactivity
Characteristics
Size
Tensile Strength
Monofiliment (nylon, prolene,
monocryl)
Characteristics
Dyed
Undyed
Sizes 11-0 to 6
Suture Sizing
Absorbable
Broken down in tissues by
hydrolysis, enzymes and
inflammation
Non Absorbable
Not broken down by hydrolysis or
inflammatory reaction
Suture
Size by Location
Needles
Cutting - skin and other tough
tissue
Before Closing
Hemostasis
Evaluate
Irrigate
Debride devitalized/contaminated
tissues
Before Closing
Evaluate the wound
Time of injury
Size and shape of wound
Soft tissue loss
Gross contamination/foreign
body
Before Closing
Wound depth
Nerve, tendon, vascular
involvement
Wound Preparation
Single most important step in preventing
complications
Control bleeding
Remove all debris and devitalized tissue
Irrigate copiously with NS
Do not use iodine or hydrogen peroxide in
the wound
When to Consult
Specialist
Anesthesia
General/spinal Anesthesia
Used for large wounds and more
invasive procedures
Regional Anesthesia
Lidocaine/bupivicaine infiltrated
Anesthesia
Local
Anesthetic agent infused directly
into the tissues being treated
Lidocaine
Most common
1% should be adequate for most procedures
Sodium channel blocker
Rapid onset
Relatively short duration of action
Available with epinephrine
helps control bleeding
prolong duration of action
Bupivicaine
Longer duration of action
Useful in prolonged procedures as
Local Anesthetics
Caution!!
Do not use local anesthetic with
epinephrine on structures with
limited circulation
Equipment
General
Considerations
Needle
Position
Needle should be secured
1/2 - 2/3 down the length
needle from the tip
Rule of Halves
Allows better approximation of
tissues
Rule of Halves
Basic Suture
Methods
Simple interrupted
Simple running
locked running
Horizontal mattress
Vertical mattress
Running Subcuticular
Subcutaneous (buried knot)
Simple Interrupted
Most common closure performed
Used in superficial wounds with
minimal tension.
Nylon or prolene
Be careful of knot security
Simple Interrupted
Simple Continuous
Rapid
Best in short lacerations with no tension
Helps with hemostasis
If one knot fails, the entire closure is
compromised
Locked Continuous
Used in wounds closed with
moderate tension
Horizontal
Mattress
For fragile tissue
Distributes tension over wider area
Helps evert skin edges
Horizontal
Mattress
Vertical Mattress
Used for maximal edge eversion
Minimizes deadspace in deeper
tissues
Vertical Mattress
Running
Subcuticular
Provides optimum cosmetic results
Not for contaminated or infected
wounds
Running
Subcuticular
Subcutaneous
Buries the knot
Useful for minimizing deadspace in
deeper wounds
Subcutaneous
After Closure
Apply antibiotic ointment
Non adherant sterile dressing
Splint if appropriate
Tetanus
Antibiotics
Schedule follow up 2-3 days
Suture Removal
Face: 3-5 days
Scalp: 7 days
Chest and extremities: 8-10 days
Joints, palms, soles: 10-14 days