For injuries that require further management, it is imperative to assess the wound and determine how best to treat it. Multiple techniques can be used for wound closure. These include sutures, staples, and adhesives.
For many minor wounds, sutures are the gold-standard method for closure. In a case where you have a linear laceration located on the scalp or extremities, it is a reasonable alternative to using staples. The advantage is that they can be placed quickly. This is immensely useful in situations where there is brisk bleeding and in mass casualty settings where there are multiple wounds to which to attend. Staples are cost-effective, easily placed, require minimal training, and have similar healing times and infection rates as sutures.
In primary wound closure, sutures are the standard of care. There are two types of sutures, absorbable and non-absorbable. Non-absorbable sutures are preferred because they provide great tensile strength, and the body’s chemicals will not dissolve them during the natural healing process. Non-absorbable sutures are used primarily to close superficial wounds; whereas, absorbable sutures can be placed in a double layer closure for deeper wounds. In doing so, absorbable sutures help decrease the tension and better approximate the wound edges. This will allow for a lower risk of wound dehiscence and a more aesthetically pleasing outcome.
The choice of suture and technique depends on the type of wound, depth, the degree of tension, and desired cosmetic results. Simple interrupted sutures have the advantage of more cosmetically appealing results as the use of separate stitches allows for a better approximation of the skin and fascia. They provide greater tensile strength and have less risk of injuring cutaneous circulation. Also, in the case of an infection, the entire length of sutures would not need to come out.
For rapid hemorrhage control or long wounds with minimal tension, running sutures are the best choice. They can be applied quickly and spread tension along the wound. The disadvantage for running sutures is the risk of dehiscence if part of the suture material ruptures. This would cause the entire length of suture to unravel.
For a wound that is deeper in nature, a mattress stitch can be placed, providing better strength. The deeper penetration into the skin layers minimizes tension and allowing for better closure at the wound edges. They can be thrown in as temporary stitches are removed after the tension is more evenly distributed across the wound. If there is still tension after wound closure, the mattress stitch can be left in place to decrease the risk of dehiscence.
In percutaneous wounds or simple pediatric cases, skin glues are particularly useful as they are quick and relatively painless. Adhesive tapes and skin glues are a useful adjunct to deeper sutures too. They are cause minimal wound inflammation, have a lower infection rate than sutures, and are removed easily.
Primary intention healing is when the wound edges are brought and kept together by sutures or staples. The healing occurs with wound epithelization and connective tissue deposition. This allows for lower infection rates. In the case of wound healing by secondary intention, the wounds heal by leaving them open and allowing for granulation tissue to form contraction of the wound edges and eventual epithelialization. Typically, this is seen with chronic wounds. These take longer to heal due to the volume of tissue needed to fill the defect. Healing by secondary intention puts the patient at risk for more infections as there is no epidermal barrier.
In the process of wound healing, nutrition, lifestyle, medications, and infections all play a significant role. Active children and adults who exercise regularly tend to have better circulation and heal quicker due to better oxygenation and nourishment provided to the wound. Also, smoking limits the oxygen-carrying capacity of the blood and has been linked to forming clots, all which can inhibit the wound healing process. Medications such as steroids, blood thinners, or antineoplastic agents tend to prolong healing as well.
Regardless of which wound closure technique the responder chooses, it is important to remember that to achieve a thoroughly-healed incision with minimum scarring you should keep in mind the following:
Wound closure is not a painless event, and some anesthesia should be provided. For small wounds, lidocaine with epinephrine will suffice. The addition of epinephrine not only causes vasoconstriction and limits blood loss, but it also increases the duration of the anesthetic. However, it is vital not to inject epinephrine around the ears, the tip of the nose, penis, and distal phalanges. Otherwise, tissue necrosis can occur.
It is important to know when not to close the wound. Some wounds best heal by secondary intention. When the wound is dirty, or there is significant tissue loss, wound closure should be delayed. The immediate closure of animal and human bites is not recommended, and these wounds should be left open as this can lead to florid infection.
Anyone who closes wounds should understand of sutures. No suture is ideal for every wound, and in most cases, several types of sutures are required to close the wound adequately. Today there are natural, synthetic, absorbable, non-absorbable, multifilament, and monofilament sutures available. Synthetic sutures are preferred around the face as they cause a limited reaction, and inflammation is minimized. Absorbable sutures are used in areas where there is no need for extensive support and the wound heals faster, like the face. Non-absorbable sutures are used when one wants continued mechanical support. Monofilaments are less susceptible to infection but can be traumatized by the surgical instruments. The multifilaments can sustain infections, but they are prone to tangles.
Healthcare workers including nurse practitioner should not only know when to close wounds but also when to leave them open. Premature closure of infected or contaminated wounds usually leads to prolonged hospitalization and higher healthcare costs. There are many techniques of wound closure and it is important to be familiar with them as all of them have certain indications and contraindications. Once a wound is closed, the patient must be monitored to ensure that healing is occurring without complications.
Generally, post-closure assessment includes:
Document finding and report unexpected findings to the healthcare team.
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