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Trauma Service Conference Suturing Technique

Trauma Service Conference Suturing Technique. 陳昭文 醫師 高雄醫學大學附設醫院外傷科. 基本傷口縫合技巧. KNOW HOW/WHEN/WHY? 傷口癒合 傷口準備 傷口縫合. Step 1 : 瞭解傷口癒合過程. Wound Healing - A. Inflammatory Phase Immediate to 2-5 days Hemostasis Vasoconstriction Platelet aggregation Thromboplastin makes clot

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Trauma Service Conference Suturing Technique

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  1. Trauma Service ConferenceSuturing Technique 陳昭文 醫師 高雄醫學大學附設醫院外傷科

  2. 基本傷口縫合技巧 KNOW HOW/WHEN/WHY? 傷口癒合 傷口準備 傷口縫合

  3. Step 1 : 瞭解傷口癒合過程 Trauma Service / KMUH

  4. Wound Healing - A • Inflammatory Phase • Immediate to 2-5 days • Hemostasis • Vasoconstriction • Platelet aggregation • Thromboplastin makes clot • Inflammation • Vasodilation • Phagocytosis Trauma Service / KMUH

  5. Wound Healing - A • Inflammatory Phase • 紅,腫,熱,痛 • 脆弱  完全靠外在力量封閉傷口 • 為避免過度發炎 • 清創徹底 • 移除異物 • 無創傷性縫合技巧 Trauma Service / KMUH

  6. Wound Healing - B • Proliferative Phase • 2 days to 3 weeks • Granulation • Fibroblasts lay bed of collagen • Fills defect and produces new capillaries • Contraction • Wound edges pull together to reduce defect • Epithelialization • Crosses moist surface • Cell travel about 3 cm from point of origin in all directions Trauma Service / KMUH

  7. Wound Healing - B • Proliferative Phase • 傷口張力部份恢復 • 病患本身及傷口狀態之影響 • 營養不良 • 組織缺氧 • 貧血 • 慢性病 Trauma Service / KMUH

  8. Wound Healing - C • Remodeling Phase • 3 weeks to 2 years • New collagen forms which increases tensile strength to wounds • Scar tissue is only 80 percent as strong as original tissue Trauma Service / KMUH

  9. Step 2 : 瞭解如何準備傷口縫合 Trauma Service / KMUH

  10. Skin preparation • Lavage • Quantity is better than quality • Watch out critical areas • Eyes, perineum, peripheral skin… • Adequate drape • Adequate anesthesia Trauma Service / KMUH

  11. Preparation – Debridement • Wound irrigation • Alcoholic Hibitane • Alcohol-Betadine  70% Alcohol • 避免使用於眼周,口內,會陰,或傷口內 • N/S or L/R solution • 移除異物與壞死組織 Trauma Service / KMUH

  12. Trauma Service / KMUH

  13. 局部麻醉劑使用- Xylocaine • Avoid acid pain • Add 1ml NaHCO3 in 20 ml Xylocaine • + Epinephrine ? • 延長藥效, 減緩出血 • 避免用於皮瓣或四肢末端 • 施打麻藥方式 • 由近而遠  病患較易忍受疼痛 • 保持移動  避免血管內注射 Trauma Service / KMUH

  14. Digital Nerve Block Trauma Service / KMUH

  15. Xylocaine (Lidocaine) • Onset 1-5 mins • Duration 30-120mins • Max Dose 4.5mg/kg • 1ml(2%)x1000mg=20mg • 60kgX4.5mg/kg=270mg  13.5ml CNS 過度興奮 頭暈 耳鳴 抽筋 眼振 Cardiopulmonary 低血壓 心肌抑制 呼吸抑制 Trauma Service / KMUH

  16. Risky Area for Epinephrine Use Trauma Service / KMUH

  17. Premedication? • Valium • Is probably the drug of choice • Increase tolerance to local anesthetics • Increase producting sedation and some amnesia • Avoiding use on patients with liver disease • Demeral, Morphine, Fentanyl… Trauma Service / KMUH

  18. Know our Pals - Suture Materials • 可吸收線(Absorbable) • Natural - Catgut • Synthetic – Dexon, Vicryl, PDS • 不可吸收線(Non-absorbable) • Natural - silk • Synthetic – Nylon, Surgilon, Prolene Trauma Service / KMUH

  19. SUTURE SIZE AND DIAMETER Trauma Service / KMUH

  20. Trauma Service / KMUH

  21. Realize our pals – Needle Tip Trauma Service / KMUH

  22. Realize our pals – Needle Curvature Trauma Service / KMUH

  23. Realize our pals – Read the Envelope Trauma Service / KMUH

  24. Selection of Sutures Material 6/0 5/0, 6/0 4/0 3/0, 4/0 4/0, 5/0 4/0 3/0, 4/0 4/0, 5/0 • Eyelid • Face • Oral cavity • Scalp • Lip • Trunk • Limbs • Hands/feet Trauma Service / KMUH

  25. Timing of Sutures Removal 3-5 (days) 3-5 7-8…or dissolve 7-12 3-5 6-12 6-14 7-12 • Eyelid • Face • Oral cavity • Scalp • Lip • Trunk • Limbs • Hands/feet Trauma Service / KMUH

  26. Another Choice… Trauma Service / KMUH

  27. Step 3 : 如何縫合傷口? Trauma Service / KMUH

  28. How to use your instrument? • 持針器夾住離針尖二分之一至三分之一處 • 垂直進針  保持最佳穿透力量 Trauma Service / KMUH

  29. How to use your instrument? 起手式 Trauma Service / KMUH

  30. Method of Skin Suture • Simple interrupted • Good for irregular wounds • Vertical mattress • Good for thick and thin skin • Horizontal mattress • Looks bad early • Half buried • Good for flaps • Continuous intradermal • Cosmetic demand • Simple running • Quick, for linear wounds Trauma Service / KMUH

  31. Simple Suture – Simple Principle • Only one skin layer • the suture should be wider at the bottom • the knot should be tied adequately and cause no blanching Trauma Service / KMUH

  32. Ideal Ratio 1:1 Trauma Service / KMUH

  33. Ideal Dermis Apposition Trauma Service / KMUH

  34. Simple interrupted suture Trauma Service / KMUH

  35. Vertical Mattress Suture Vertical Mattress Suture 適用於邊緣內翻傷口 Trauma Service / KMUH

  36. Vertical Mattress Suture Trauma Service / KMUH

  37. Running “Continuous” Suture Trauma Service / KMUH

  38. Common Error 1 – 跨距不均 Trauma Service / KMUH

  39. Common Error 2 – 皮下死腔 Trauma Service / KMUH

  40. Common Error 3 - 上寬下窄 Trauma Service / KMUH

  41. Distance between Sutures 1-2 (mm) 2-4 3-4 10-15 4-6 6-10 5-8 3-5 2-4 • Eyelid • Face • Nose • Scalp • Forehead • Trunk • Limbs • Volar hand • Dorsal hand Trauma Service / KMUH

  42. Suturing Technique • Removal of dog ears • Some will subside. When removal is necessary there are several methods. Trauma Service / KMUH

  43. Suturing Technique • Triangular edge • Method of insertion of three point suture to prevent strangulation of the tip of a flap Trauma Service / KMUH

  44. Corner Suture Trauma Service / KMUH

  45. Suturing Technique • Atraumatic technique • Avoid crushing with forceps • Avoid sutures and needles unnecessarily large • Avoid bites of tissue unnecessarily large • Avoid strangulation with knots too tight • Avoid drying of tissues Trauma Service / KMUH

  46. Smooth or teethed forceps? • Smooth • Hold knots, tying suture or vessels • Tooth (teethed) • Hold tissue • 無齒鑷子易滑脫,反需更用力,更易造成組織壓傷 Trauma Service / KMUH

  47. Suturing Technique • Suturing sequence • 兩側端點先縫合, 中間調整間距再縫, 可避免”dog ear” • 較難縫合處可先處理對齊 • 重要之地標要優先對齊縫合 Trauma Service / KMUH

  48. Post-procedural Care • 敷料保護 • 滲液吸收 • 局部固定 • 適度壓力 • 避免疤痕 Trauma Service / KMUH

  49. Practice makes perfect! Trauma Service / KMUH

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