- Wash hands
- Gloves
- History – allergies, medications, tetanus
- Ensure proper equipment – needle driver, Addison’s, sutures/staples/glue/steristrips, freezing
- Suture selection
- Non absorbably monofilament (Prolene 4-0, 3-0), with a cutting needle (less trauma to skin) – remove in 5-7 days
- Non-absorbable (silk, Prolene)
- Absorbable (plain and chromic gut, vicryl and monocryl)
- Monofilament (Monocryl, Prolene)
- Multifilament (Silk, Vicryl)
- Freezing
- xylocaine 5mg/kg without epinephrine, 7mg/kg with epinephrine
- marcaine 2mg/kg without epinephrine
- 1% = 10mg/cc, 1g/100cc
- SE: decrease CVS, anaphylaxis, bradycardia, hypotension; with epi may have seizures, convulsions, somnolence, vision disturbances
- If allergic: benadryl 50 mg IM, epinephrine 0.5ml of 1:1000 SC
- Irrigate wound with 30cc syringe, 18gauge needle and saline
- Debride devitalized tissue
- Suture
- Tetanus schedule
- 0.5 cc absorbed toxoid if clean, incomplete shots, shorts >5 years
- Tetanus prone: >6hr, tissue loss, >1cm in size and depth, missle/crush/burn/frostbite, devitalized, denervated, contamination
- Td 0.5 cc IM
- Tetanus IMG 250-500 units IM
- Must be in separate sites
- If unknown status or <3 doses give Td and TIG if prone, and just Td if not prone. If 3 doses or more give Td if > 5 years and prone, or >10 years and not prone
- Wound healing stages
- Coagulation
- Inflammation (days 0-4) – PMNs, macrophage
- Proliferation (3 days to 3 weeks) – fibroblasts, collagen laid
- Maturation (3 weeks to 2 years) – crosslinks
- Clean (atraumatic, no break in aseptic technique, no GI/GU/resp/biliary) vs clean-contaminated (atraumatic, minor break in aseptic technique, minor spillage of GI/GU/resp/biliary) vs contaminated (traumatic, major break in aseptic technique, gross spillage GI/GU/resp/biliary) vs infected
- Universal precautions:
- Gown
- Gloves
- Mask
- Eye protection
- Don’t handle sharps
- Dispose of sharps
- Don’t recap sharps
- In OR pass sharps carefully
- Get your own immunizations (Hep B)
- Get patient’s history/status
- Report needle sticks and splashes to occupational health