Which is the most common Traumatic Injury that you usually encounter in the ED??....TBI??.... Chest concussion with Hypertensive Pneumothorax ??!Cardiac Tamponade??...Limbs Amputation??....No it’s the usual, simple, boring…superficial cutaneous wound….
Every ED resident or Registrar across the world sooner or later had to handle this kind of wound and suture it….
For this reason I decided to post a Quick extremely simple guide on superficial wound management and sutures…
First and most important rule: never close gun-shot wounds and extremely dirty wounds because they are at high risk of infection and Abscess; so let them to heal by second intention!!!
What you need:
- Normal Saline (NaCl 0,9%) or Tap Water (YES tap Water - look at this study:Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial.) and a BIG Siringe
- At least 3 sterile drapes
- Surgical sterile gloves
- Disinfectant (Betadine)
- 10 cc Siringe
- 22G or 24G needle
- Kidney shaped basin
- Cup to put in the disinfectant
- Local Anaestetic (Lidocaine 2%)
- Needle holder
- Haemostatic Clamp
- Grasping forceps
How to do It:
STEP 1: STOP BLEEDING
press on the wound for at least 2-3 minutes.
STEP 2: CLEANING
Irrigate the wound with copious Normal Saline or Tap Water in order to:
Clean the wound,
Move small foreign objects to the edges of the wound, so will be easier to remove them,
Explore the wound to establish the deepness
And finally to identify bigger foreign objects and remove them quickly.
STEP 3: TRICHOTOMY of the zone surrounding the wound.
STEP 4: DISINFECTION
Disinfect the wound and sorrounding tissues with abundant Betadine.
STEP 5: BE STERILE
if you are in the ED is MANDATORY;
of course if you are in a tent in the mid of the desert do the best as you can;
Wash your hands accurately and wear sterile gloves;
Border the sterile zone with sterile drapes….from now everything from suture instruments to gauzes
must be passed to you in a sterile way.
Look at the you tube links below:
STEP 6: LOCAL ANAESTHESIA
The best option is Lidocaine 2% (is cheap and available everywhere):
Onset time 2 min.
It lasts for 1.5-2 hours
Do not use more than 280 mg; maximum dose in 70 Kg man: 14 ml.
Sistemic Adverse effects come from OVERDOSAGE and INTRAVASCULAR INJECTION:
-CNS: tongue numbness, eyebrows shivering, seizures.
-Cardiovascular App: Arhytmias.
Local Adverse effects are allergic reactions: Urticaria, Hives, rush, Oedema, Anafilactic shock.
aspire 10 cc of Lidocaine 2%;
Change the needle provided with the 10 cc siringe with a 22G or 24G needle;
Irrigate the wound with the local Anaesthetic.
REMEMBER: ALWAYS ASPIRE BEFORE INJECTING THE ANAESTHETIC SO YOU ARE SURE THAT YOU AREN’T PERFORMING AN INTRAVASCULAR INJECTION.
Look at the you tube link below:
STEP 7: SUTURE
Which needle and thread:
Thread: For superficial cutaneous wound always use non absorbable sutures;
usually the most common available are:
Needle: For superficial cutaneous wound: cutting curved needle.
-Other body parts: 4/0
Single interrupted suture is the best choice;
Look at the you tube link below:
Just for face wounds aiming to minimize the residual scar Intradermic continuous suture is better.
FINALLY YOU DID IT:
Just dress the sutured wound and remove stitches approximately after 7 days…
NOW you are ready for the next patient:
the shift especially at night is still very far from the end!!!!!!!!!!!!!!!
…AND…as alway have a good day or “NIGHT” on the EDGE……