Advancing Athletic Training Skills: Wound Closure

Advancing Athletic Training Skills: Wound Closure Douglas Stevens BS, MMS, PA-C Physician Assistant- Didactic Coordinator Indiana State University Beth Neil MS, LAT, ATC PhD Candidate Indiana State University

DISCLOSURE STATEMENT • No known conflicts of interest • The views expressed in these slides and today’s discussion are ours • Our views may not be the same as the views of our colleagues or Indiana State University • Audience must use discretion when using the information contained in this presentation

OBJECTIVES • Upon the end of the presentation, participants will be able to: • Differentiate between various types of wounds and identify the wound types that are more likely to benefit from closure in the field. • Perform a step-by-step wound examination. • Prepare a wound for closure. • Choose an appropriate wound closure material depending on the type of the wound. • Demonstrate ability to perform wound closure by using suture (via simple interrupted technique), tissue adhesive, or staples

SUTURE SKILLS • Surgical incision closure is a skill set in itself. • Incisions made in the operating room setting are usually clean, and ready to close upon completion of said procedure. • There are other considerations when suturing injuries in an emergency department, urgent care, or office setting.

WHY DO WE SUTURE WOUNDS?

HOW TO PREPARE WOUNDS FOR CLOSURE

SUTURING STEPS • For acute injuries requiring suture repair a few recommendations will hold true most of the time: • 1. Utilize Simple, Interrupted knots with instrument tie • 2. Utilize non-absorbable suture • 3. Approximate, don’t strangulate!

SUTURING STEPS • Wounds must be evaluated to decide if a suture closure is indicated. Some wound types such as avulsions, punctures, deep abrasions, or partial amputations may not benefit from suturing. • Wounds must be evaluated to ensure there are no residual foreign bodies. This includes evaluating visually, with palpation, and with XR if indicated. • Wound inspection must include functional evaluation of underlying structures such as flexor/extension tendons in the hand, vascular supply to extremities, and neurological findings (sensation, etc..).

SPECIAL CONSIDERATIONS • Foreign Bodies must be anticipated and addressed

TO ANESTHETIZE THE WOUND • Preparing the wound for closure: • Anesthetize the wound with 1%-2% lidocaine. May locally infiltrate or use a block technique if appropriate (extremities, fingers, toes, etc...). Lidocaine with epinephrine may be utilized in some cases to help control bleeding but this must be avoided when addressing injuries on distal extremities (fingers/toes). Use a 25, 27, or 30 gauge needle to inject the lidocaine.

DO NO HARM NEVER USE LIDOCAINE WITH EPINEPHRINE ON DIGITS OF THE EXTREMITIES cc: Leo Reynolds - https://www.flickr.com/photos/49968232@N00

SUTURING STEPS • Next, copiously irrigate the wound with 0.9 normal saline (NS), use large syringes, and debride any devitalized tissue. • Chose the best suture material based on the type and location of the injury. A 3-0 or 4-0 nylon suture works well for most simple lacerations. Use a 5-0 or 6-0 for facial injuries. (Notice the size of the suture gets smaller the higher the number).

SPECIAL CONSIDERATIONS • Irrigation: 1 Liter 0.9NS and consider more!

SUTURING STEPS • Finally, chose the best closure technique: Remember, wound edges should be brought together and approximated or slightly everted. Avoid inverted wound edges. • Simple interrupted sutures will close a majority of wounds. Begin by bisecting the incision, then bisect the remaining injury and so on. This will help prevent from forming a “dog ear” at one end of the incision. These are non-absorbable sutures.

SUTURING STEPS • Vertical mattress sutures are a good choice if there is any tension on the wound. The deep bite takes the tension off of the wound while the narrow bite approximates and everts the wound edges. These are non-absorbable sutures. • Sub-cutaneous interrupted or running sutures are typically used in the operating room. These are absorbable sutures (EX: monocryl).

SUTURING STEPS • Most sutures on/about the face can be removed after 5 days. Other sutures are typically taken out in 7-14 days. Ensure sutures that overly surfaces of joints (knees and elbows) are left in 10 or even 14 days. • Patient are typically instructed to keep incisions clean, dry, covered, and protected 3 days. After day 3, may use soap and water to cleanse (no soaking) and be open to air. • ***Avoid topical hydrogen peroxide or alcohol based cleaning because these agents also kill the new granulating tissue.

SUTURING STEPS • Make sure your patient’s tetanus vaccination status is updated and that they are instructed to inspect for signs/symptoms of infection (erythema, streaking, exudate, etc.). Ensure they know who to call for questions/concerns. • Antibiotics (typically Keflex) are often prescribed for 7-10 days. (Discuss with your supervising MD/DO. Sometimes it’s a matter of policy).

SIMPLE INTERRUPTED SUTURE TECHNIQUE

SUTURING IN AT cc: pennstatenews - https://www.flickr.com/photos/53130103@N05

LET'S SUTURE cc: peretzp - https://www.flickr.com/photos/68877611@N00

REFERNCES • Worster B, MD, Zawora MQ, MD, Hsieh C, MD. Common Questions About Wound Care. American Family Physician. 2015;91:86-92. • Hochberg J, Meyer K, Marion M. Suture Choice and Other Methods of Skin Closure. SURGICAL CLINICS OF NORTH AMERICA. 2009;89:627-627. • Hoyt KS, Flarity K, Shea SS. Wound care and laceration repair for nurse practitioners in emergency care: part II. Advanced emergency nursing journal. 2011;33:84-99.

CHECK OUT THESE ARTICLES! • Helps from Flipped Classroom in Learning Suturing Skill: The Medical Student’s Perspective (Wu, Sheng-Chu, Chien-Chih, Yi-No) • Self-directed Practice Schedule Enhances Learning of Suturing Skills (Safir) • Plus, check out our references for some great materials to help!

QUESTIONS? Mr. Doug Stevens Ms. Beth Neil @bethneil13 Douglas.stevens@indstate.edu eneil@sycamores.indstate.edu

Advancing Athletic Training Skills: Wound Closure