What are common signs of wound infection?
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Redness, pain, edema, exudate, fever, and chills.
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What are common signs of wound infection?
Redness, pain, edema, exudate, fever, and chills.
What type of suture is recommended for tissues that heal rapidly?
Absorbable sutures. For stomach, colon, bladder.
What should you ensure when an assistant hands you an item in a sterile field?
Ensure the package is sufficiently open and the item can be grasped without risking the sterile field.
What is a linear wound?
A simple straight laceration.
What are the main types of closure materials?
Absorbable and Non-absorbable. Monofilament vs Multifilament.
What are non-absorbable sutures made of stainless steel commonly used for?
They are commonly used for the sternum, bone, and tendon.
What is a stellate wound?
A wound where lacerations radiate out from the central defect, resulting in a round, oval, crescent, star, or stellate appearance.
What type of X-ray should be ordered for soft tissue evaluation?
A 'soft tissue' X-ray, which is slightly underdeveloped.
What precautions should be taken during foreign body removal from the skin?
Universal precautions and sterile/clean technique.
What is a key characteristic of stainless steel sutures in terms of strength?
Stainless steel sutures are strong.
What is one advantage of stainless steel sutures in terms of infection?
They resist infection.
What is a Straight (Keith) Needle?
A handheld needle that is long to obtain wide bites and is ideal for skin.
What does the sterile field include?
The draped patient and anyone scrubbed in or the field set up at bedside.
How does undermining with scissors help in wound closure?
It releases tension on the final closure and reduces dead space.
How many individuals are typically involved in maintaining a sterile field in an OR setting?
A minimum of two individuals.
What are the two ways to hold the needle holder?
You can put your thumb and fourth finger in the rings or hold it in your palm ('palming') with your index finger stabilizing it.
What types of wounds are considered high risk for infection?
Dog/cat/human bites, exposed joints or tendons, open fractures.
What might be necessary if a puncture wound is heavily contaminated?
Antibiotic treatment or the wound may need to be closed loosely or left open.
What views may be needed for a comprehensive X-ray evaluation of a lesion?
PA (Posteroanterior), Lat (Lateral), Oblique, and Tangential views.
What type of anesthetic agent should be used during foreign body removal?
An appropriate anesthetic agent based on the location and size of the foreign body.
How accurate are patients typically in identifying the location of a foreign body?
Patients are usually very accurate regarding the location of the foreign body.
What can an assistant use to hold the tongue during suturing?
Gauze.
When should an X-ray be considered in foreign body removal?
If indicated by the assessment.
What should be included in patient instruction and education during foreign body removal?
Information on the procedure, aftercare, and signs of complications.
Why should caution be exercised when deciding to close a wound on the palm of the hand?
Because the palm of the hand is very prone to infection.
What are the two forms that nylon and polyester sutures can come in?
Braided or monofilament.
How do polyester sutures compare in strength to silk sutures?
Polyester sutures are stronger than silk sutures.
What are the requirements for using subcuticular sutures effectively?
Minimal tension and minimal dead space.
Why is it useful to start in the middle of wounds longer than 3 cm?
To avoid 'dog earing'.
What are the steps in removing a needle?
Release the needle, PRONATE hand, grasp needle proximal to tip, and then supinate through.
Can one person perform a sterile procedure in an office setting or bedside?
Yes, but having an assistant is optimal.
What should be done with contaminated or infected wounds before deciding to close them?
Exercise caution.
What is often used to finish a subcuticular suture?
Steri-Strips.
How are suture sizes denoted?
By the number of zeros. Increases in number as diameter of suture decreases.
Smaller size = less tensile strength.
3 > 2 > 1 > 0 > 2-0 > 3-0
How should you cut sutures with scissors?
Cut with the tip, not beyond with the screw facing up at a 45 degree angle to suture.
What are some common materials used for wound bandaging?
Neosporin, adaptic, 4x4’s, kling, tape, ace.
What is the key principle to remember when tying knots in wound closure?
Approximate, don’t strangulate.
Why should an X-ray be evaluated for multiple shards?
To ensure all fragments of the foreign body are identified.
What suture technique is recommended for corner wounds in avulsion lacerations?
A half-buried horizontal mattress suture is recommended for corner wounds in avulsion lacerations.
What is the purpose of using scissors for undermining in wound closure?
To divide the dermis from the subcutaneous layer.
What additional measure should be taken after closing a wound on the palm of the hand?
Immobilization.
What should be done if there is doubt about the sterility of an item?
Remove and replace it with a sterile item.
What is an avulsion flap?
A flap of skin that is torn loose and hanging or completely removed that can bleed heavily.
What healing method is recommended for contaminated or infected wounds?
Heal by secondary intention.
How long does Dermabond typically stay on the wound?
It sloughs off in 5-10 days no follow up.
What are some possible complications of wound closure?
Infection, bleeding, trauma to local vital structures, scarring, and inability to remove or completely remove a foreign body with resultant further surgery with needle localization, fluroscopy, ect.
How do stainless steel sutures react with the body?
They are minimally reactive.
What are common examples of puncture wounds?
Dog bite, cat bite (pasturella), and stepping on a nail. Do NOT close these.
What type of laceration is an avulsion laceration?
An avulsion laceration is a type of wound where a portion of tissue is forcibly detached from its normal point of insertion.
What technique is recommended for closing wounds to ensure even closure?
Bisect each distance until closed, known as the rule of halves.
How should the edges of a wound be aligned during repair?
The edges should be aligned and everted.
Why is it important to follow the lines of Langer during wound repair?
Following the lines of Langer helps in minimizing scarring and improving cosmetic outcomes.
Why is it important to monitor wounds?
To prevent and identify infection.
Where should you hold the needle when suturing?
2/3 to 3/4 way down the needle using the dominant hand with the forcep in the other.
How are sterile supplies packaged?
Packaged to allow an unsterile person to open and pass them into a sterile field without contamination.
What type of suture is recommended for tissues that heal slowly?
Non-absorbable sutures. For skin, fascia, tendon.
Why is wound eversion important in wound closure?
Wound eversion is important because it helps to minimize scar formation and ensures better healing by reducing tension on the wound edges.
What is degloving?
A type of avulsion wound in which an extensive section of skin is completely torn off the underlying tissue, severing its blood supply.
What tool should be used to evert wound edges while stapling?
Forceps.
What type of wound is suitable for Dermabond application?
Straight cuts with edges that can be approximated, low tension wounds, dry surface wounds.
What type of specialist is often required to repair a crush wound?
A plastic or trauma surgeon because can be devestating and complex and may require multiple types of repair.
What is the recommended approach for handling tissues during wound closure?
Gentle handling of tissues and grasp the dermis if possible with toothed forceps. Use minimum required pressure.
What can be used to create a sticky surface for Steri Strips to adhere to?
Benzoin can be used to create a sticky surface for the strips to stick to.
What structures need to be seen when evaluating metal, teeth, or bone on an X-ray?
The underlying structure.
What type of suture is recommended for cosmetic purposes?
Small inert monofilament (Nylon, Prolene®), Subcuticular suture (vicryl), steri-strips, dermabond.
What is a crucial step in managing contaminated or infected wounds?
Irrigate the wound and debride.
What are the benefits of a simple interrupted suture?
Easy to perform, good healing/circulation, easy to remove, minimal trauma, allows for some minimal drainage.
Name two common cleansing agents used for wound preparation.
Betadine (cannot use if allergic to shellfish) and Chlorhexidine.
When are antibiotics generally not given after wound care?
Unless there is a high risk of infection.
What is the visibility of glass larger than 2 mm on an X-ray?
It may have a 'slight shadow'.
What is the role of the sterile person in the OR setting?
To work within the sterile field.
What are the benefits of using Dermabond or wound adhesives?
They are quick and painless to apply plus have an antimicrobial effect.
What types of wounds should not be closed due to gross contamination?
Grossly contaminated wounds (sticks, dirt), most bite wounds, gunshot or fragmentation wounds, wounds > 8 hours old.
What can scissors do in procedures?
Undermining is used to separate tissue layers, Dissection, cutting.
How should you apply Dermabond to a wound?
Paint over the wound edge, holding the skin together, and allow 60 seconds of drying time.
What is an advantage of using a continuous running suture?
Rapid placement and approximation and provides a good seal.
What type of injury commonly results in a stellate wound?
An exit wound from a gunshot wound (GSW).
What is the primary use of a Straight (Keith) Needle?
It is ideal for skin suturing, central line kits, and triangular cutting needle.
What is a common technique used to address a 'dog ear' deformity during wound repair?
Repairing 'dog ear'.
What type of closure is recommended for wounds on the palm of the hand?
Partial, loose closure.
What is a common use for nylon sutures?
Skin closure with mild degradation.
What are Prolene® sutures commonly used for?
Skin closure and tendon repair, and they hold knots better.
What types of wounds?
Linear, Avulsion (flap or degloving), stellate, puncture, crush, abrasion.
Why is it important to leave no dead space during wound repair?
Leaving dead space can lead to infection.
What is one of the uses of the horizontal mattress suture besides permanent closure?
Temporary approximation of wound edges.
Which synthetic absorbable sutures maintain their tensile strength for 8 weeks?
PDS® and Maxon®.
What are Steri Strips used for?
They can be used for simple wound closure along with Dermabond and after sutures are removed to help with closure and healing.
What should you ask about before using Benzoin with Steri Strips?
You should ask about an iodine allergy.
What initial steps are important in the assessment of a foreign body in the skin?
Good history and physical examination, including orientation and size of the foreign body.
What is the key principle to follow when approximating tissues during wound closure?
Approximate, don’t strangulate.
Why is it important to know the anatomy during foreign body removal?
To accurately locate and safely remove the foreign body.
What is the difference between absorbable and non-absorbable subcuticular sutures?
Absorbable sutures are not removed, while non-absorbable sutures are removed.
What is sterile technique?
A method by which contamination with microorganisms is minimized. Sterile is defined as germless and free from all living or viable microorganisms.
How should lacerations that run parallel to the lines of Langer be treated?
Lacerations that run parallel to the lines of Langer should be re-approximated. Langer lines correspond to the natural orientation of collagen fibers in the dermis, and are generally parallel to the orientation of the underlying muscle fibers. Incisions made parallel to Langer lines may heal better and produce less scarring than those that cut across.
What are the common shapes of surgical scissors?
Curved or straight, blunt or sharp.
For what types of wounds is the Continuous Running suture pattern commonly used?
Cosmetic skin wounds and abdominal fascia closure.
What is the role of the unsterile person in the OR setting?
To use unsterile hands to pass supplies into the sterile field.
What is the width of each stitch in a simple interrupted suture?
The width of each stitch equals the distance between sutures.
What should be left on monofilament knots and sutures requiring removal?
Leave tails on monofilament knots and on sutures requiring removal.
How should you position a patient when applying wound adhesive near the eye?
Position so dripping occurs away from the eye.
What is a major disadvantage of the Continuous Running suture pattern?
Breakage disrupts the entire suture line, it can transmit infection along the entire length of the suture.
What are the advantages of synthetic absorbable sutures?
Better tensile strength and less tissue reaction.
Is the horizontal mattress suture more commonly used in fascia or skin?
Fascia more commonly than skin.
What is the technique description for placing a horizontal mattress suture?
The suture is placed 'across, over, and back.'
What suture material is recommended for the vermilion border of the lip?
6-0 Nylon.
What suture materials are recommended for the red tissue of the lip?
6-0 plain gut or vicryl.
Where is a subcuticular suture placed?
In a line parallel to the dermis, just under the epidermis.
What should be done if an avulsion flap is still attached?
Lay it flat and realign it to its normal position for repair.
What is a key benefit of using subcuticular sutures?
They provide the best cosmetic result.
How should buried skin knots be cut?
Cut buried skin knots short.
Where should the sterile drape be placed during wound preparation?
Under and over the area of the wound.
For which types of lacerations is silk suture commonly used?
Silk suture is commonly used for eyelid and intraoral lacerations.
What may be required for treating tongue lacerations in children?
Conscious sedation.
What must be done with non-absorbable sutures if they are used on exterior skin?
They require removal.
What is the proper technique for applying a cleansing agent to a wound?
Use a circular motion from inside out.
What is a multifilament (braided) suture?
Several strands twisted or braided together. It provides more tensile strength, but has more of a FB reaction. Higher infectious risk but better knot security. Rarely placed extenally, usually INTERNAL.
In what type of wounds is the horizontal mattress suture commonly used?
Wounds under tension.
On which body parts are staples commonly used?
Scalp, trunk, and extremity lacerations.
Which suture technique is used for wound eversion?
Vertical mattress, horizontal mattress, deep dermal.
What is the significance of maintaining adequate tension during wound repair?
Adequate tension helps in proper wound closure and healing.
What is the primary characteristic of a horizontal mattress suture?
It is an everting suture technique.
What is a simple interrupted suture pattern?
A suture pattern that uses several separate strands. It is secure and wound integrity is not dependent upon a single suture.
What should you do to the knot during suture removal?
Pull up on the knot.
What should be checked when treating a tongue laceration?
The ventral tongue.
Which suture materials are recommended for tongue lacerations?
Vicryl or Monocryl.
What is a corner stitch used for?
A corner stitch is used to close wounds that form a corner or an angle, such as those found on the face or joints.
In which part of a laceration are absorbable sutures used?
In the deep muscle layers of a laceration.
What is the goal of sterile technique?
To provide an environment for the patient that promotes healing, prevents infection, and minimizes the length of recovery time.
What type of suture pattern uses one strand of material and is faster to apply?
Continuous Running
What added benefit does the horizontal mattress suture provide?
Added strength, especially in fascia and thick skin.
Which synthetic absorbable sutures maintain their tensile strength for 5 weeks?
Vicryl® and Dexon®.
How are synthetic absorbable sutures broken down in the body?
They are hydrolyzed in tissue fluids.
What type of suture material is recommended for inside the mouth?
Absorbable sutures.
What is wound eversion?
Wound eversion is when the wound is elevated to minimize scar depression as it heals.
In which types of tissues is the continuous running suture commonly used?
Bowel, vascular, and skin.
In what type of tissue are non-absorbable sutures typically used?
In tissue that heals slowly or never regains its strength.
What is an instrument tie?
An instrument tie is a technique used to secure sutures using surgical instruments rather than by hand. Loop the suture twice around the needle drive, then only once after.
How should normal saline (NS) be applied during wound irrigation?
NS should be repeatedly squirted into the wound site in short bursts to dislodged remaining particulate matter.
In what settings is sterile technique typically used?
Operating room (OR), office procedures, and bedside procedures.
What should you avoid when applying wound adhesives like Dermabond?
Do not let glue seep into the wound.
What type of suture is silk?
Silk is a non-absorbable suture that is braided that can remain undetectable in tissue after 2 years.
How long does Monocryl® maintain its tensile strength?
21 days.
What might you need to do when removing sutures?
Remove every other suture.
Which organs are commonly sutured with absorbable sutures?
Stomach, colon, and bladder.
When should a wound recheck be scheduled after initial care?
2 days.
What are Metzenbaum scissors primarily used for?
Dissection.
What effect does antibiotic ointment have on wound adhesives?
Antibiotic ointment can soften the bond.
What is the first step in preparing Dermabond for application?
Crush the ampule and invert it, soaking a cotton-tipped applicator.
What tools are best for suture removal?
Iris scissors or a #11 blade.
What is crucial to ensure during suture removal?
Make sure you have the entire suture out and don't just cut the knot off.
What vaccination is recommended as part of wound aftercare?
Tetanus.
In what type of wounds is a vertical mattress suture particularly useful?
Gaping wounds and wounds with high tension.
In cases involving foreign bodies or joint prosthetics, how long should the wound be kept dry?
Longer than usual to minimize the risk of water contamination and infection.
What is a subcuticular suture?
A subcuticular suture is a type of suture placed just under the skin, running parallel to the wound edges.
What type of lacerations are staples best suited for?
Linear lacerations.
What can be used after sutures are removed?
Steri-Strips.
How should you hold dissection scissors?
With the thumb and 4th (ring) finger with the screw of scissors facing up and at 45 degree angle and the index finger supports the shaft of the scissors. Insert the blunt tipped scissors into wound, spread to divide tissue planes, and blunt outer edges separate tissues.
What is another name for the continuous running suture?
Baseball stitch.
When do tongue lacerations less often require sutures?
If they are less than half an inch.
How should forceps be held?
Like a pencil in the non-dominant hand.
How many days after surgery should sutures/staples be removed from the hand?
8-10 days
What should always be checked when treating a lip wound?
Always check for full thickness.
What is a disadvantage of using staples?
Scarring is increased, removal is more painful than sutures, and cannot do if you plan to use CT or other imaging.
What is a disadvantage of the continuous running suture in terms of appearance?
It is less cosmetic.
Can absorbable sutures be used for some skin repairs?
Yes, absorbable sutures can be used for some skin repairs.
What type of medication is suggested for pain management after wound care?
Oral pain medications.
How often should the wound be washed after the initial recheck?
Daily with soap and water, followed by good drying and reapplication of dressing.
What should be avoided to prevent wound infection?
Prolonged soaking.
How many days after surgery should sutures/staples be removed from the back?
12-14 days
What is a key characteristic of non-absorbable sutures?
They are not digested or hydrolyzed.
Name some types of forceps used in medical procedures.
Debakey forceps, Adson/toothed forceps.
For what types of prosthetic attachments are non-absorbable sutures used?
Implanted defibrillators, pacemakers, pumps, and nerve stimulators.
Which type of suture is recommended for intraoral lacerations?
Absorbable suture.
Do all foreign bodies need to be removed?
No, not all foreign bodies need to be removed.
What are some contraindications for using Dermabond or wound adhesives?
Areas of high motion, mucosal surfaces, dirty wounds, bites, irregular edges, wounds >10cm, and punctures.
What suture sizes are recommended for the extremities?
4-0, 5-0
What is a continuous running suture?
A suture technique using a single continuous strand.
What are the instruments needed for suturing?
Blades, Scissors, Forceps, Needle holders/drivers.
What is a vertical mattress suture known for?
Everting and providing precise edge approximation with great wound strength.
How long should the wound site be kept clean and dry after initial care?
24-48 hours.
How many additional days should be added for suture/staple removal on joint extensor surfaces?
2-3 days
What imaging techniques might be used to locate a foreign body before removal?
X-ray or ultrasound (US).
What suture sizes are recommended for the back?
2-0, 3-0
Where are absorbable sutures used in an incision?
In the deep layers of an incision.
What is the general guideline for selecting suture size?
Use the finest suture size appropriate for the natural strength of the tissue.
What type of suture is indicated for vascular ligation?
Absorbable suture.
Why might absorbable sutures be chosen for cosmetic reasons?
Because they cosmetically look better.
What is the stitching pattern used in a vertical mattress suture?
Far-Far/Near-Near.
Why is it important to close dead space in a wound?
To prevent the accumulation of fluids and reduce the risk of infection.
How many days after surgery should sutures/staples be removed from the chest/abdomen?
8-10 days
What are the potential complications of sutures related to bacterial contamination?
• Infection
• Scarring – keloid
• Loss of function and structure
• Loss of a cosmetic appearance
• Wound dehiscence
• Tetanus
What are some relative contraindications for using Dermabond?
Wounds in areas with hair or skin folds, axillae, and perineum.
What suture sizes are recommended for the neck?
4-0, 5-0
At what angle should the needle enter the skin?
90 degrees / perpendicular into skin. Supinate through with the ring finger pushing down and the thumb base pushing up. Drivers are in line with the forearm.
When are sutures contraindicated?
• Contaminated wounds
• Wounds older than 8-12 hours
• Facial, neck or scalp lacerations older than 24 hours
• Presence of foreign bodies
• Wounds involving tendons, nerves, arteries
• Needs repaired by specialist
For what type of tissue healing are absorbable sutures particularly suitable?
For tissue that heals rapidly.
What is the steps of post-procedure care?
Irrigate the wound. May need reapproximation of wound edges if excised. Sterile bandage. Good pt instructions. FU in 1-2 days, then usually 5-7 days. Antibiotics (topical) as necessary. Tetanus eval / prophylaxis if needed. Referral if needed. Good hx and exam on FU.
What is a monofilament suture?
A suture made of a single strand. Provide less tensile strength and have less FB reaction. Ties down smoothly. Has a lower risk risk of infection, but less knot security / requires more throws.
What are the characteristics of a needle driver/holder?
Broad and strong jaws with smooth surfaces to help prevent needle slippage. They are regular, heavy, or fine-tipped. Should be held in the dominant hand.
What are common materials used for absorbable sutures?
Common materials include vicryl, monocryl, coated vicryl, PDS, plain gut, chromic gut.
How many days after surgery should sutures/staples be removed from the fingertip?
8-12 days
What is a non-absorbable suture?
A type of suture material that is not broken down by the body and remains in place until it is removed. Usually Nylon, Polyester, Polyprolene, Silk.
What is the first step in wound preparation?
The first step in wound preparation is cleansing the wound to remove debris and reduce the risk of infection.
What suture sizes are recommended for the torso?
3-0, 4-0
How many days after surgery should sutures/staples be removed from the scalp?
6-8 days
How many days after surgery should sutures/staples be removed from the arm/leg?
8-10 days
What suture sizes are recommended for the face?
5-0, 6-0
How many days after surgery should sutures/staples be removed from the face?
4-5 days
How many days after surgery should sutures/staples be removed from the ear?
4-5 days
When should a patient be referred to a surgeon for foreign body removal?
If needed, based on the complexity or risk of the removal procedure OR if FB removal req X-ray / US.
How many days after surgery should sutures/staples be removed from the foot?
12-14 days
What materials are needed for cleansing a wound?
20-30 or 60 mL syringe with 18 G angiocatheter, scalpel or scissors, gloves, and goggles, irrigation.
What are the methods for removing a foreign body from the skin?
Irrigation, sterile metal probe, grasp with Adson pickup/forceps with teeth and remove, punch biopsy tool removal, excisional removal
What materials are indicate the need for foreign body removal?
Reactive material – wood, vegetative materials
• Contaminated material
• Clothing should always be considered contaminated
• Most foreign bodies in the foot
• Impingement on Neurovascular structures
• Impairment of function
• Easy to remove and without risk of complication
What are splinter forceps?
Splinter forceps have fine pointed ends with NO teeth.
What are the step in removing a surface, palpable foreign body from the skin?
Cleanse and anesthetize the area if needed. Do not pinch or squeeze area. Splinter forceps / tweezers can be used, or an 18 G needle or 11 blade.
What type of solution is recommended for irrigating surface wounds during foreign body removal?
Sterile 0.9% normal saline. Do NOT use H2O2 on open area. Use a syringe and needle, bulb irrigation, splash guard if available.
What should you do if a foreign body (FB) is not visible at the entrance wound after palpation?
Prep the area and lightly probe the wound with a sterile instrument until gentle contact is made with the FB. The try to remove with Adson’s forceps. (DO NOT blindly grasp anything unless you are sure it is the FB). If not removed with forceps, use punch bx tool for removal or do a surgical excisional removal.
What are the principles of sterile technique?
• All items used within sterile field must be sterile
• A sterile barrier that has been permeated must be considered contaminated
• The edges of a sterile container are considered
contaminated once the package is opened
• Tables are sterile at table level only
• Sterile persons and items touch only sterile areas
• Unsterile persons and items touch only unsterile
areas
• All items and areas of doubtful sterility are considered contaminated
• Movement within or around a sterile field must not contaminate the field
What are the indications of sutures in wound management?
• Hemostasis
• Supporting and strengthening wounds until
healing increases their tensile strength
• Decrease healing time
• Reduce infection
• Improve cosmetic appearance
• Decrease scar tissue likely to form
What is a horizontal mattress suture?
It is a suture technique that provides good wound edge approximation and is useful in areas under tension.
What is the difference between a one hand tie and a two hand tie?
A one hand tie is performed using only one hand, while a two hand tie is performed using both hands.
What are the different types of sutures?
Ties, one hand tie, two hand tie, instrument tie, simple interrupted, running, subcutaneous/subcuticular, vertical mattress, horizontal mattress.
What is a running suture?
It is a continuous suture technique where the suture is run in a continuous manner without tying off each stitch separately.
What is a vertical mattress suture?
It is a suture technique that provides good wound edge eversion and is useful in areas under tension.
What is an instrument tie in suturing?
It is a method of tying sutures using surgical instruments rather than hands.
What is a subcutaneous/subcuticular suture?
It is a suture technique used to close a wound just below the skin surface.
What is a simple interrupted suture?
It is a suture technique where each stitch is tied off before starting the next one.
How are absorbable sutures digested in the body?
By tissue enzymes, causing tissue reaction.
What is the tensile strength duration of chromic gut sutures?
14 days.
From which animal's submucosa are these sutures derived?
Sheep intestine.
What is the tensile strength duration of plain gut sutures?
7 days.
