sensation or pain when a sharp object is gently appliedto the skin.Administering local anesthesia is similar exceptyou are anesthetizing nerves immediately adjacent towhere you will be working instead of nerve trunks.There are two generally accepted methods ofinfiltrating the anesthesia. One is through the skinsurrounding the margin of the wound and the other isthrough the wound into the surrounding tissue. Ineither case, sufficient quantities must be infiltrated toeffect anesthesia approximately ½ inch around thewound, taking care not to inject into a vein or artery.CAUTION: The maximum recommendedamount of Xylocaine to be used is 50 cc for a1% solution or the equivalent.General Principles of Wound SuturingWounds are closed either primarily or secondarily.A primary closure takes place within a short time ofwhen the wound occurs, and it requires minimalcleaning and preparation. A secondary closure, on theother hand, occurs when there is a delay of the closurefor up to several days after the wound's occurrence. Asecondary closure requires a more complex procedure.Wounds 6 to 14 hours old may be closed primarily ifthey are not grossly contaminated and are meticulouslycleaned. Wounds 14 to 24 hours old should not beclosed primarily. When reddening and edema of thewound margins, discharge of pus, persistent fever, ortoxemia are present, do not close the wound.Do not use a primary closure for a large, gaping,soft-tissue wound. This type of wound will requirewarm dressings and irrigations, along with aseptic carefor 3 to 7 days to clear up the wound. Then a secondarywound closure may be performed.The steps to perform a delayed wound closure areoutlined below.1. Debride the wound area and convert circularwounds to elliptical ones before suturing.Circular wounds cannot be closed withsatisfactory cosmetic results.2. Try to convert a jagged laceration to one withsmooth edges before suturing it. Make sure thatnot too much skin is trimmed off; that wouldmake the wound difficult to approximate.3. Use the correct technique for placing sutures.The needle holder is applied at approximatelyone-quarter of the distance from the blunt end ofthe needle. Suturing with a curved needle isdone toward the person doing the suturing.Insert the needle into the skin at a 90angle, andsweep it through in an arclike motion, followingthe general arc of the needle.4. Carefully avoid bruising the skin edges beingsutured. Use Adson forceps and very lightlygrasp the skin edges. It is improper to usedressing forceps while suturing. Since there areno teeth on the grasping edges of the dressingforceps, the force required to hold the skinfirmly may be enough to cause necrosis.5. Do not put sutures in too tightly. Gentle approxi-mation of the skin is all that is necessary. Rememberthat postoperative edema will occur in and about thewound, making sutures tighter. Figure 4-33illustrates proper wound-closure techniques.6. If there is a significant chance that the suturedwound may become infected (e.g., bites,delayed closure, gross contamination), place aniodoform (anti-infective) in the wound. Orplace a small rubber drain in the wound, andremove the drain in 48 hours.7. When suturing, the best cosmetic effect isobtained by using numerous interrupted simplesutures placed 1/8 inch apart. Where cosmeticresult is not a consideration, sutures may beslightly farther apart. Generally, the distance ofthe needle bite from the wound edges should beequal to the distance between sutures.8. When subcutaneous sutures are needed, it isproper to use 4-0 chromic catgut.9. When deciding the type of material to use onskin, use the finest diameter that will satis-factorily hold the tissues. Table 4-4 providesguidance as to the best suture to use in selectedcircumstances.10. When cutting sutures, subcutaneous catgutshould have a 1/16-inch tail. Silk skin suturesshould be cut as short as is practical for removal onthe face and lip. Elsewhere, skin sutures may havelonger tails for convenience. A tail over ¼ inch isunnecessary, however, and tends to collectexudate.11. The following general rules can be used indeciding when to remove sutures:a. Face: As a general rule, 4 or 5 days. Bettercosmetic results are obtained by removingevery other suture and any suture with4-44
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