Preparation & Wound Management Principles



This post is part of the Basic Guide to Suturing series. It provides an overview of the steps you need to take when assessing and then preparing for closure of a wound. 

As a general guide you would normally;
  1.   1.  Assess
  2.   2.  Gather required equipment
  3.   3.  Prep & Drape
  4.   4.  Anaesthetise
  5.   5.  Clean/Irrigate
  6.   6.  Suture (see Overview of Suturing Techniques for more details)
  7.   7.  Bandaging/Dressing and ongoing wound-care

Steps 3, 4 and 5 can be rearranged, depending on your operating environment, equipment, wound and personnel. In the Emergency Department in particular, the order is flexible, and steps may have to be repeated. For example, you might clean the wound first to remove of the majority of the debris so that you can use your local anaesthesia in a semi-sterile environment. Once the local is working, you could give the wound a more thorough clean again.   

Assessment of Wound

Your assessment of the wound is ultimately going to determine how choose to manage it. Some important characteristics to discuss and examine are;


◘  Mechanism of injury?
◘  How old is the injury?
◘  Where is the injury, how big and how deep?
◘  Examine for foreign bodies and/or contamination
◘  Assess neurovascular status and any search for any deep tissue issue injuries (e.g. tendons)
◘  Need for tetanus prophylaxis
◘  Identify risk factors that may affect wound healing


Based off history and examination consider requirement for any imaging. 

Tip: Achieving some degree of haemostasis is an important step in adequately assessing the wound. In emergency departments this can often be achieved by; applying direct pressure with a gauze pad for 10-15 minutes, or 1% lignocaine with adrenaline (other methods exist).


Indications (for suturing)

In general sutures can be used for wounds that have occurred within 18hrs of the initial injury. This in order to achieve;

◘  Haemostasis
◘  Bring tissues edges together, close defects
◘  Prevent further infection
◘  Securing drains or lines


Contraindications (for suturing)

Concern about wound infection is the primary reason not to close a wound primarily. Several relative contraindications exist for suturing and other methods of wound closure should be considered.

◘  Animal bites
◘  Foreign bodies/debris in wound
◘  Requires excessive tension
◘  Current infection
◘  Patients presenting with wounds >24hrs after initial injury


Equipment

Once you have decided to close the wound you need to get the appropriate equipment.
  1.   1.    Sterile gloves
  2.   2.    Sterile Syringe 5-10ml
  3.   3.    Suture pack
  4.   4.    Sutures
  5.   5.    21-30G Needles (25G is commonly used.)
  6.   6.    Local Anaesthetic (e.g. Lignocaine)
  7.   7.    Antiseptic solution
  8.   8.    Sharps bin
  9.   9.    Formal Drapes (as required)
  10. 10.    Dressings
  11. 11.    Consider other Personal Protective Equipment


Preparation

If you have not done so already inform the patient about what you are about to do, and make sure they are happy to proceed. Written consent is often not required when repairing simple lacerations and verbal consent will often suffice. If unsure, talk to your senior clinician.
  1.   1.   Get all your equipment (as listed above) and a trolley (where able)
  2.   2.   Open your equipment using sterile technique and create a sterile field.
  3.   3.   Ensure that both you and the patient are positioned in a comfortable manner.
  4.   4.   Good lighting.
  5.   5.   Wash your hands
  6.   6.   Place on a pair of a sterile gloves (regular gloves may also be appropriate).
  7.   7.   Clean the wound/s.
  8.   8.   If painful consider anaesthetising at this point before any further cleaning.
  9.   9.   Irrigate with chosen solution
  10. 10.   Normal Saline, Dilute Iodine or even tap water (see below)
  11. 11.   Use your drapes (creating a hole if necessary) to cover the wound 
  12. 12.   If you have not done so already, Get ready to anaesthetise!



Tip: It is may seem obvious, but it is less painful to anaesthetise through the wound, rather than break through fresh skin with a needle to achieve numbness.

References

Stitch Up by Martin Clifton

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