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Primary Wound Closure

Monday, 05 May 2014 00:00 Written by  Gary Griffin

Primary closure involves using sutures, staples, or strips to close a wound and is an important aspect of wound management. But, before we get to that point, you must first understand the different types of wounds.

The Centers for Disease Control and Prevention (CDC) identifies four classifications of wounds. 

  • Class I/Clean – Generally associated with a medical procedure. Show no signs of inflammation, and do not involve respiratory, gastrointestinal, or genitourinary tracks. Examples include surgeries skin biopsies, eye, and vascular surgeries. This category accounts for 75% of all surgical wounds in present day America. 
  • Class II/Clean-Contaminated - Generally associated with a medical procedure, but has a higher risk of infection. These types of wounds can include surgeries to remove pins or wires, chest procedures, and ear surgeries. 
  • Class III/Contaminated – Contaminated wounds includes those that come in contact with an outside object. This could be a penetrating wound, bullet, stab wound, or wound caused by a pointed object.
  • Class IV/Dirty-Infected – Include wounds with a foreign object lodged in the wound, such as a bullet or debris. This class also includes traumatic wounds from a dirty source where the treatment was delayed, infected surgical wounds, or any wound that has been exposed to pus or fecal matter. 

If you are considering administering sutures, let’s say part of your emergency or survival medical plan, most of us will deal with Class III/Contaminated and Class IV/Dirty-Infected. These injuries can be caused by accidents with tools, kitchen utensils, or a gunshot wound. In most situations, bacteria and foreign debris will be introduced into the wound. Therefore, Class III and IV wounds should be irrigated to ensure foreign debris and bacteria are removed and/or limited prior to closure. Visible debris will need to be removed using tweezers before flushing. Additionally, antibiotics are normally required to fight infection post closure. 

Not all wounds should be closed. So, you need to be aware of which wounds require immediate primary closure, which ones are left open to drain (secondary closure), and which wounds you can close days after the initial trauma. Examples of when not to suture include injuries that grossly contaminate the wound, deep puncture wounds (because the ability to irrigate is low), lacerations associated with crush injuries, and animal or human bites. These types of wounds have an exceptionally high risk of infection, and are best left open to drain. In addition to wound closure supplies, it is equally important to have items to pack wounds that should not be closed immediately. 

Deciding to close your own wound is a decision that you will need to make on your own. It is recommended to first seek professional care. If you are in an emergency situation and professional help is out of the question, then you will need to weigh the pros and cons of closing your own wound; self or buddy aid may be your own option. So, if you have decided to close your own wound, it should be conducted in the following manner: Conduct a physical exam, gather supplies, anesthetize, flush, preparation, closure, bandage, and post care. 

Conduct a Physical Exam

The physical examination will determine the best method to close the wound or if you should leave it open, if you should administer antibiotics pre/post closure, and identify any circulation or nerve issues that the wound has caused. Ideally, the physical exam is conducted by trained medical professionals. In a survival situation you may decide to close your wound. Therefore, you need to keep track of any possible issues so you can notify medical professionals once their services are available. Track all observations in the patient’s chart (use our Patient Chart).

Directions

  1. Look for signs of excessive blood loss. 
  2. Assess motor and sensory function distal to the wound (side away from the heart), as well as circulation (pulses, capillary refill), and range of motion. 
  3. Make careful note of the size and depth of the lesion, contaminants, and involved tissues. 
  4. Note exposure of bone or transection of large artery or nerve. 
  5. Visualize the wound base to be sure of depth and any foreign bodies. Better visualization will be achieved as you are flushing the wound.

Gather Supplies, Conduct an Inventory

Before you can close a wound, you need the correct supplies. Please see our Wound Closure Kits and our Suture Introduction Guide. Additionally, this guide contains our recommended items for wound closure (located at the beginning of each step). Last, this guide assumes you already have surgical instruments

Step 1: Anesthetize 

If you have local anesthetics, it should be used during Step 1. Local anesthetic is not usually obtained without a prescription, so it may not be available. If you only need to administer a couple sutures or staples, you may elect to skip anesthetizing; the pain cause by anesthetizing may be greater than closing the wound without local anesthetics. 

Directions

  1. Clean the area you will be anesthetizing with sterile water or ChloraPrep. 
  2. Tell the patient that this will sting/burn.
  3. Use 1% lidocaine with epinephrine for most procedures. Use lidocaine without epinephrine when anesthetizing digits and appendages that are in danger of ischemia (restriction in blood supply). 
  4. Draw up the anesthetic with a 10cc syringe and a large needle (18 gauge), then use a small needle to inject (25 gauge). Make sure the air is out of the syringe before you insert the needle. 
  5. Insert the needle through the wound into the subcutaneous tissue, attempt to aspirate before infusing (to make sure the needle is not in a vein), then make a weal under the skin around the wound margins.
  6. Don’t be shy, use plenty of anesthetic. 

Step 2: Flush

Flush Module

(1) ZeroWet Splash Shield

(1) Syringe, 20cc

(1) Povidone Iodine, 10cc bottle

(1) Nitrile Gloves, Pair

(1) Saline Solution, Sterile (250ml or more)

The flushing process, known as wound irrigation, reduces the chances of infection by removing foreign materials and reducing bacteria inside of the wound. Flushing is a simple process if you have the correct equipment, and should be conducted on any Class III and IV wound that will be closed by sutures or closure strips. There are many studies that discuss the importance of the irrigation solution, whether to use Povidone Iodine or only sterile water. Conduct your own research to determine the best method. Lastly, you can make your own saline using salt and water (see our Saline Guide)

Directions

  1. Put on eye protection, if available.
  2. Wash hands thoroughly using soap and warm water. If available, clean hands using a surgical scrub brush. 
  3. Put on gloves, sterile gloves are not needed for this step.
  4. If available, place an absorbable under-pad under the area to be flushed, to catch runoff. The pad will absorb the irrigation solution and/or blood, and can be a medical chux-type pad or a clean towel. Additionally, a basin can be used, or irrigation can be done over a sink or other catchment method. 
  5. Inspect the wound to ensure all large foreign bodies have been removed from the wound by thoroughly inspecting down to the base of the wound. Tweezers can be used to remove any foreign materials. 
  6. Prepare irrigation solution. Mix Povidone Iodine with saline until it takes a lightly stained “dark-beer” like color. The solution can be poured into a sterile/clean container so that the ZeroWet Splash Shield can draw the liquid into the syringe (If your sterile gauze comes in a tray, the tray can be used as a container, as long as the gauze is placed on a sterile location). Alternatively, sterile saline solution can be used by itself; without the addition of Povidone Iodine. 
    • a. Recommended Irrigation solution volume per length of wound: 50-100ml per cm of wound. So, a 1” wound would require 127-254ml of irrigation solution. 
    • b. Note: It is best to purchase irrigation solution in 250ml and 1000ml bottles. 250ml bottles can be thrown into a small medical kit, while 1000ml bottles provide the best value.
  7. Flush the wound with irrigation solution. The ZeroWet splash shield can be used for minor lacerations. Alternatively, you can use bottles of saline to flush large wound areas by using a controlled pour into the wound. 
    • a. ZeroWet Splash Shield procedure.  The ZeroWet Splash Shield can be attached to a luer lock tip syringe. Open both packets, and place the splash shield on the tip of the syringe. Draw irrigation solution from the bottle or from a container. 
    • b. Use a copious amount of irrigation solution (more than you think you need), but factor where the wound is located. A facial laceration may require less irrigation than a laceration on an arm.  
  8. After flushing is complete, remove the basin and/or wet under-pads.
  9. Dry the skin with sterile gauze, being very careful not to contaminate the wound.
  10. Discard under-pad and gloves.

Step 3: Preparation

Prep Module

(3) Povidone Iodine Swabstick

(2) Alcohol Pads

(1) Drape, Fenestrated

(1) Drape, Plain

(1) Surgical Gloves, pair

(1) Surgical Mask

(10) Gauze Sponge, Tray of 10

During the preparation phase, the wound area will be cleaned and drapes will be used to protect the sterile zone. 

Directions 

  1. Wash hands thoroughly using soap and warm water. If available, clean hands using a surgical scrub brush. 
  2. Open the plain drape, and place on an area where your tools will be located. This drape will be used as a sterile work zone. Try not to touch the top part of the drape, so that the zone remains sterile.
  3. Open the fenestrated drape packaging, but leave inside the packaging. Try not to touch the drape, but make it accessible so you can grab it when sterile gloves are on (without compromising the sterile gloves).
  4. Using the Povidone Iodine Swabsticks, grab one swabstick. Using a sweeping circular motion, start from the wound and spiral outwards. This spiral should be a large as the hole in the fenestrated drape (3”). Discard swabstick. Repeat process with remaining swabsticks. If allergic to iodine, or you do not want to use iodine, use the alcohol pads or ChloraPrep instead. 
  5. Let the Povidone Iodine dry, and remove any excess Iodine with the sterile gauze (remaining gauze to be placed on the plain drape). 
  6. Layout sterile tools on the plain drape.
  7. Open suture packaging, but do not touch the suture. Place the sterile components on the plain drape.
  8. Put on sterile gloves.
  9. Place fenestrated drape over the wound to be sutured. 

Step 4: Closure

Closure Module

(1) Suture, Nylon 3/0

(1) Suture, Nylon 4/0

(1) Suture, PGA 4/0

(6) Suture Strips Plus, 1/2”x4”

(3) Steri-Strips, 1/4”x3”

(1) Scalpel, No. 11

(1) Surgical Instruments

Wound closure can be accomplished by using sutures, strips, a stapler, or a combination of these methods. If the wound is located on the scalp, braiding/tying hair may also close the wound.  

Suture Sizes by Location

  • Scalp, Torso (chest, back, abdomen), Extremities
    • Superficial non-absorbable suture: 4-0 or 5-0
    • Deep absorbable suture: 3-0 or 4-0
  • Face, Eyebrow, Nose, Lip
    • Superficial non-absorbable suture: 6-0
    • Deep absorbable suture: 5-0
  • Ear, Eyelid
    • Superficial non-absorbable suture: 6-0
  • Hand
    • Superficial non-absorbable suture: 5-0
    • Deep absorbable suture: 5-0
  • Foot or sole
    • Superficial non-absorbable suture: 3-0 or 4-0
    • Deep absorbable suture: 4-0

Directions - Sutures

  1. Use a scalpel to remove any destroyed tissue or remove tissue to provide a clean suture location.
  2. Using forceps and a needle driver, close the wound appropriately. 
  3. Make sure all sharps are disposed of in a sharps container before leaving the work area.
  4. Remove fenestrated drape and any under-pads, and place directly into a hazmat bag or trash bin. 

http://tinyurl.com/n97cnrn

Directions – Closure Strips

  1. Ensure area is clean and dry at least 2 inches around the wound. Benzoin Tincture can be used to provide a sticky surface for the closure strip to adhere to. 
  2. Remove closure strip using tweezers/forceps, by pulling at a 90 degree angle. 
  3. Starting in the middle of the wound, apply one-half of the strip up to the wound margin, and press firmly in place.
  4. Using fingers pinch skin edges as closely as possible to approximate (line-up) wound.
  5. Press the free half of the closure strip firmly on the other side of the wound. 
  6. Repeat process, working from the middle to each end, applying strips every 1/8 inch. 
  7. Additional strips may be applied parallel to the wound, approximately 1/2 inch from the wound edge, creating railroad tracks. This process reduces stress on the wound and primary strips, and provides a little more adhesion for the strips to the skin. 

http://tinyurl.com/lk2pdhq

Directions – Skin Stapler

  1. Using your non-dominant hand, bring together/pinch the wound to approximate wound edges.
  2. Using your dominant hand, line-up the center line marker of the stapler perpendicular to the center of the wound. This will ensure that the staple is placed on the center of the wound. 
  3. Squeeze the stapler mechanism so the staple will be inserted into the wound. 
  4. Continue applying staples until the wound is closed. Staples should be placed every 1/8 inch to 1/5 inch. If the wound is larger than 3 inches, place the first staple in the middle of the wound. Then, working from the middle close in each direction. 
  5. Remove fenestrated drape and any under-pads, and place directly into a hazmat bag or trash bin. Discard the stapler as well.

http://tinyurl.com/l8mwmlu

Note: If you use elect to apply staples, then you will need a staple remover. A staple remover pinches the staple so the crimped ends come out of the wound correctly.

Step 5: Bandage

Bandage Module

Directions

  1. Cover the closed laceration with antibiotic ointment. 
  2. Place sterile gauze or bandage over the closed wound.
  3. Instruct patient on how to care for the wound, and let them know when sutures/staples can be removed. 
  •  Face: 3-5 Days
  • Neck: 5-8 Days
  • Scalp: 7-9 Days
  • Upper Extremity: 8-14 Days
  • Trunk: 10-14 Days
  • Hands: 14 Days
  • Lower Extremity: 14-18 Days

Post Care: Monitoring Wounds for Infection

After closure is complete, monitor the wound for any sign of infection. 

  • Redness around the wound
  • The skin around the wound is hot to the touch
  • Drainage that is cloudy, discolored, or foul smelling
  • Swelling
  • Fever
  • Increased pain to the area
  • Wound size has increased

For wounds that have been exposed to dirty conditions or deep puncture wounds, it is recommended to administer a 7-10 day cycle of antibiotics. Antibiotics for skin infections include: 

  • Cephalexin
  • Erythromycin
  • Amoxicillin / Calvulanate (Note: If plain Amoxicillin is all that you have, it is better than nothing. Some staph bacteria is resistant to plain Amoxicillin)
  • Ciprofloxacin
  • Mupircoin Ointment

Sources

UC Irvine Emergency Medicine Interest Group, Suture Workshop

Wound Closure Manual, Ethicon

Surgical Wounds, Wound Care Centers

The Survival Doctor’s Guide to Wounds

Surgical Staples for Scalp Laceration Repair

Skin Closure Application – 3M

 

Last modified on Friday, 02 May 2014 00:45
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