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Basic techniques
That somehow everyone doesn’t know
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Wound care priorities
Discover and treat injuries to critical deep structure
Cover critical structures with skin Maintain function without contracture Prevent infection Cosmesis is a distant fifth priority
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Basic techniques
Managing contaminated wounds Wound eversion Inverted dermal sutures as primary closure Instrument tying
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Managing contaminated wounds
Never close an infected wound If wound merely contaminated, clean it up
and then make a decision for primary, secondary or tertiary (delayed primary closure)
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Timing of delayed closure in contaminated wound
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Managing contaminated wounds
Debride all dead or marginal tissue (if unsure cut a little, does it bleed?)
Remove all foreign debris When irrigation needed use either a
hydrostatic irrigator or a 10 cc syringe with an 18 ga angicath or Zerowet
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Klenzalac irrigation tray
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Managing contaminated wounds
If wound is over 6 hours old and exudative, prep it, then gram stain it for white cells and/or bacteria
Frequently, where there are no important structures and skin is loose enough to avoid tension, better simply to excise a dirty wound, then close it
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Wound excisionScore skin in ellipse
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Excise wound with scissors or scalpel
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Undermine excised wound to allow eversion on closure
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Evert to allow flat scar after healing
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Use dermal stitches as primary closure allows natural eversion from technique tissue 1/2 life of about a month allows for
far longer support for healing than skin sutures
after dermal layer placed, often can close skin with rapid techniques (tapes, running suture, glue)
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Wound is weakest when skin sutures are removed
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Use dermal stitches as primary closure
Wound must be clean Technically a little more difficult than skin
sutures
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Instrument tie
Surgeon’s knot Follow with at least three square throws Granny knots will lead to untieing
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Driver in middle, two overhand throws
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Grab loose tail
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Cross hands to lay flat
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Finish by
Placing needle driver between tails single overhand throw, grasp loose tail cross hands to lay flat at least 3 more throws