Dr. Anand Shandilya*
Consultant Pediatrician, Mumbai
- Incised wounds
- CLWs (Contused and Lacerated Wounds)
- Contaminated wounds
- Infected wounds
- Penetrating/Puncture/Stab wounds (Deep to seemingly innocuous skin puncture wounds, vital structures may de damaged. Avoid skin closure till this is ruled out. Also avoid pulling out the weapon/instrument responsible for the puncture, especially over the chest, abdomen or in the vicinity of major vessels. This may eliminate the plugging effect that the instrument may have over a vascular injury).
- Healing takes place best if skin edges are accurately apposed to each other, without tension.
- Skin edges should be slightly everted for best results. Inversion of skin edges will not result in a fine scar.
- All wounds should be as clean as possible before suturing. Cleaning adequately is often best achieved under the effect of local anaesthesia.
- Any dead space in the depths of the wound should be eliminated using deep sutures.
- Sutures should be fine, equally placed and close together.
- Sutures should be removed as soon as possible. Those on the face can be removed by the 5 th day; those on the scalp may be removed after 7-8 days, while those on the trunk or extremities can be removed after 10 days.
- After removal of sutures, further wound support can be given using strips of adhesive tape applied in strips, perpendicular to the wound axis.
- Sterile gauze pieces
- Povidone iodine solution
- Normal saline
- Tincture Benzoin
- Adhesive tape (Micropore/Transpore)
- Sterile plastic sheet/sterile drapes
- 2% lignocaine solution
- Sterile water for injection
- Suture material
- Needle holder
- Fine (Adson's) Toothed Forceps
- Tissue cutting scissors
- Suture cutting scissors
- Fine haemostat
- Disposable syringes/fine needles (no. 25/26)
- Cleaning the wound: Irrigate the wound using saline and povidone iodine solution, using either a wet gauze piece, or a syringe. Let the irrigating fluid flush away small particulate foreign bodies from the raw surfaces.
- Isolate the wound from surrounding areas using sterile towels or plastic sheets.
- Infiltrate local anaesthesia in the wound edges and in the skin surronding the wound. The recommended dose of lignocaine for infiltration is 2 mg/kg body weight. 1% lignocaine (2% lignocaine solution double-diluted using water for injection) contains 10 mg of lignocaine per ml. of solution. Wait for a few minutes and confirm that the anaesthesia is effective.
- Complete cleaning the wound. Explore to gauge the depth of the wound, check for damaged deeper structures. Check for devitalized or crushed tissues; these may be trimmed using scissors. Remove any contaminating particles, foreign bodies, etc. Decide whether deep sutures are necessary to close fascia or muscles in the depth of thee wound.
- If an obvious bleeding vessel is identified, it may be held in a hemostat and ligated. Most small bleeding vessels can be included in the stitch.
- Proceed to suture the deeper layers using absorbable suture material. 30 or 40 catgut or vicryl are suitable.
- Skin is sutured using non-absorbable suture material. Nylon or silk are suitable.
- Check for satisfactory skin apposition, clean with povidone iodine, and cover wound with a dry sterile gauze held in place by adhesive strips.
- Check wound after 4-5 days and remove sutures when appropriate.
Sutureless Wound Closure using Adhesive skin-closure Strips
Superficial wounds involving skin, especially on face, digits
- Deep wounds
- Infected wounds
- Actively bleeding wounds
- Dressing materials as above
- Pre-packed sterile skin closure strips (Ethistrips / Steri-strips)
- Fine forceps
- Lean wound as described earlier
- Dry area around wound completely
- Hair growth around skin edges may need trimming
- Apply tincture benzoin solution around the skin edges. Take care to ensure that this solution does not enter the wound. Wait until dry.
- Prepare adhesive skin strips by cutting to adequate size.
- Hold skin edges in apposition using forceps and apply tape at a perpendicular axis to the wound.
- Use multiple adhesive strips to ensure tension-free skin approximation.
- Cover with sterile gauze and strap in place.
- Inspect wound after 2-3 days to ensure continued adherence of skin strips
- Remove after 10 days.
- If skin strips do not adhere well, check for factors which may be responsible: inadequate skin cleansing, presence of greasy residue on skin, bleeding from the wound, hair growth, tension at the skin edges.
- When used for wounds on digits, avoid encircling the digit around its full circumference to prevent a tourniquet effect on a digit which may develop oedema due to inflammation, induced by trauma.
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|Shandilya A D.. Available From : http://www.pediatriconcall.com/fordoctor/ Conference_abstracts/report.aspx?reportid=499|