Best Practice of Suturing Wounds Within Pre-Hospital Setting

opera hat Practice of sutura Wounds Within Pre-Hospital SettingTitle Review of shell practice of fibrous joint spites within the pre-infirmary and pinch department mise en scene.EssaySuturing as a preaching for cutaneous exaspe evaluate has been known to mankind for millennia. The Indian Surgeon Susruta (AD c380-c450) described techniques for discase closure using flax, hemp, and hair. Jaws of the common sable ant were also known to be gived at close to this time. Galen recommended silk and catgut in about 150 AD. A Roman, Avicenna, is credited with describing the beginning(a) monofilament suture in the form of pig bristles for infected insults. (Moy R L et al. 2002)Suture material may control evolved from the first recorded homosexual hair and fibrous vegetable material to highly sophisticated unimaginative materials with integral needles, unless the basic optimum technique of closing assassinated space, supporting and potencyening annoys until healing increase s their tensile strength, approximating skin edges for an aesthetically winsome and functional result, and minimizing the fortunes of bleeding and transmitting. atomic deed 18 largely unchanged. (Scott M 1993)In reflection of this content, this essay will consider seam in the context of the seam of scandalises in an Accident and Emergency Dept. or the pre-hospital setting as impertinent to other considerations of suture that atomic number 18 possible.The different ways of suturing. on that point ar a great many different ways to suture a wound. The method employed will depend on factors such as the site and nature of the wound as much as it depends upon the teach and experience of the operatorIn the general context, wounds may be closed by either primary or secondary suturing. Primary suturing takes place shortly after the injury and requires minimal cleaning and preparation. supplementary closure takes place when a delay of much than 24 hrs has occurred and requir es a surgical freshening of the wound to remove and transmission and granulation create from raw material. The presence of reddening or oedema of the wound margins, discharge of pus, persistent fever, or systemic perniciousness ar indications that primary closure should non be attempted as any infection in the wound must be controlled forward closure takes place.If the decision to suture is taken, this should ideally (with very few emergency exceptions) take place in controlled sterile surroundings with proper suturing equipment.In impairment of different ways of suturing, one empennage follow that the textbooks suggest many different varieties of mechanisms with varying degrees of sophistication for closing skin in different circumstances. In long terms however, sutures bottomland be interrupted (single) or continuous (running suture), transcutaneous or subcuticular.Associated Infection pretends to suturing in the pre hospital setting and the emergency departmentThere i s a sizable literature relating to ribaldry wounds and the rationale underpinning the decision whether or not to suture in the pre-hospital setting. The authoritative papers in this commonwealth swallow identified Staphylococcus, Streptococcus, Eikenella, Pasturella, Proteus, Klebsiella, Hemophilus, Enterobacter, Capnocytophaga carnivorous (DF-2) and Bacteroides species as being frequent contaminants of living creature bite wounds and such wounds must receive divvy upful antiseptic treatment prior to suturing. (Morgan M et al. 2007)One definitive study on the subject of whether prophylactic antibiotics are important everywhere and above standard wound cleaning and debridement found that a great number of forbearings evolveed wound infections if they did not receive prophylactic antibiotics with duskyer wounds being more likely to develop infection than superficial ones.( Dire D J 2001).In broad terms, suturing must be carried out with rigorous aseptic technique. By defini tion, this refers to the absence of pathogenic organisms. It may well be that the wound to be treated is already infected by its nature (viz. an animal bite or a dirty wound) but the aseptic technique is key to ensuring that no further infection is introduced into the wound. The main principles of an aseptic technique acknowledgeKeeping the exposure of sensitized sites to a minimumEnsuring bewitch sight decontamination prior to the procedureUsing gloves (sterile or non-sterile, depending on the nature of the susceptible site)Ensuring that all fluids and materials recitationd are sterileChecking that all packs used are sterile and show no evidence of damageEnsuring that contaminated and non-sterile items are not placed in the sterile fieldNot reusing single-use items cut down staff and/or bystander activity (wherever possible) in the immediate vicinity of the plain in which the procedure is to be performed.(HCAI 2008)In any discussion of infection risks, one must not overlook the possibility of the reverse infection of healthcare professionals becoming infected by coming into contact with tissue fluids from the patient. Scrupulous attention to the Health Depts published guidance on protection against infection with blood-borne viruses for healthcare professionals in 1998 (UKHD 1998) should help to minimise the risk of blood-borne virus transmission to health care workers from patients. Suturing always carries the accompaniment risk of a needle prick injury even in the most experienced hands. An unexpected move from the patient, a sudden withdraw break of even inattention, can easily choose major repercussions if it results in a stick wound to the operator. (Bosch X 2003)Pros and cons of suturing.The purpose of a suture is to hold the edges of a wound together in good abiding apposition until the natural healing cropes are sufficiently well launch to make the support provided by the suture material unnecessary and redundant.There is a distinct dif ference however, betwixt the results from good and bad suturing. For example, if sutures are made excessively tight, the tissue becomes ischaemic from the pressure. This encourages persistence of infection and tissue necrosis. Too many sutures will also make a wound ischaemic. Materials which are multifilament or braided can allow bacteria to defer the wound (by wick action) but can exclude phagocytes. It is on that pointfore appropriate to draw distinctions between the results obtained from optimal suturing and poor suturing.Sutures are not the only mechanism available for achieving wound closure. Synthetic and natural tissue glues, surgical staples and flexible non-tensile tapes all have their place in maintaining wound edge apposition. Choice of technique is dependent on the anatomy of the area to be closed, whether it is going to be exposed to movement stresses, as well as the type and depth of the wound itself. Criteria for the choice of closure is a vast subject and beyond the scope of a modest essay, but decisions for optimum means of wound closure have great implications for triple-crown healing and good aesthetic results. (Spotnitz W D et al. 1997)Training compound to enable medical staff to perform suturing.Training staff to suture requires a combination of a knowledge of the physiology of the healing processes, anatomy and clinical experience. There are a number of teaching aids commercially available for suture training.It is not simply a matter of development how to suture, but the motor skills are also capable of considerable sweetening once the basic techniques are acquired. (Judkins T N et al. 2008)Suturing v non suturing of wounds. Are there benefits to these alternative methods?Suturing has been tried and well-tried with modern materials for many years. It does have the downside that, in inexperienced hands it can have sub-optimal effects with poor aesthetic and functional results, wound ischemia if done too tightly and raises the p ossibility of pathogens entering the wound along the suture line.Alternative methods of skin closure have been developed over the last 40 years including various glues and sealants. The majority are fibrin / thrombin based. The modern commercially available glues are bacteriologically and virally sterile (which contrasts to the biologically derived early varieties). Glues have the downside that they are not good in sites that are under considerable tensile stress. Full thickness wounds, particularly those that involve the deeper structures need deep sutures to minimise stresses in the skin. Glues are best for minor skin wounds. (Mintz P D et al. 2001)Adhesive strips are used for minor wounds and have the advantages that they have less of an inflammatory reaction than sutures, lower infection rates and no risk of abscess development at suture locations. They also have greater tensile strength when used late in the healing process and are cheap.Staples are used for wound closure prim arily in surgical situations. They require considerable practice and expertness in use for optimal results. Some authorities advocate their use in the pre-hospital setting (particularly on the sports field) to minimise blood contamination and to allow suturing at a later stage. ( orchard J W 2004)Paramedics suturing skills within pre hospital setting.There are a number of studies which have been done which deliver that, within the hospital setting, to use paramedics for suturing duties can reduce the number of patients who are waiting to see a medical practitioner by up to 25%. This study also noted a patient satisfaction rate that was superior to having to wait to see a restore or nurse. There was no difference in the morbidity rates after one month. Those who object in principle to this use of a paramedic on the grounds that it would require training beyond the expertise of the practitioner would find the argument hard to support when one considers that paramedics are currently trained in more sophisticated skills such as intubation, cardiac resuscitation and critical patient assessment.Hale presented a prospective fork-like blind trial to determine if Paramedics could determine which wounds could be safely repaired in the pre-hospital situation and found a very high correlation (almost degree Celsius%) between emergency specialists and paramedics in the wounds that were excluded from pre- hospital repair. The paramedics tended to be slightly more cautions than the emergency specialists in identifying which wounds should be brought into the hospital setting. (Hale D et al. 2000)Different types of sutures and there pros and cons, number of days that sutures should be in situ for.Even a outline overview of available suture materials would extend to many pages. In general terms therefore one has to consider the two major categories of Absorbable and Non-absorbable suture material. In general terms, absorbable sutures are to be preferred unless there is a n eed to fixate an anatomical structure. These two categories can be further subdivided into the braided group (which have properties of tissue drag and a capillary filling effect but handle well) and the monofilament group which semivowel easily but can be more difficult to bear a knot.Of the absorbable varieties, the modern synthetic types undergo hydrolysis in the tissues, begin minimal tissue reaction and their degradation products are CO 2 and H2O. Examples are Polyglycolic acid, Polydioxanon and PolylactateStudies show that all three retain their tensile strength until clinical tissue healing is complete with Polyglycolic acid being 60% cloaked within 21 days and Polylactates being 75% absorbed in 14 days. (Hsiao W C et al. 2000)Non-absorbable suture materials include silk, linen and cotton with synthetic varieties including nylon and Dacron and wire.References Bosch X. Second case of doctor-to-patient HIV transmission. The Lancet infective Diseases 2003 3 261.Dire D J (200 1) Cat bite wounds risk factors for infection. Ann Emerg Med 2001 Sep 20 (9) 973 9.Hale D, Sipprell K (2000) Ability Of Paramedics to determine which wounds can be repaired in the field. Pre-Hospital Emergency Care. Volume 4, Number 3, July September 2000 , pp. 245 249 (5)HCAI and Cleanliness section Ambulance staff . Reducing infection through effective practice in the pre-hospital environment. Dept. of Health Publication HMSO London 18th June 2008Hsiao W C, Young K C, Wang S T, Lin P W. (2000) Incisional hernia after laparotomy randomised comparison between early-absorbable and late-absorbable suture materials. World J Surg 2000 24 747 751.Judkins T N, Oleynikov D, Stergiou N. et al. (2008) Enhanced Robotic surgical Training Using Augmented Visual Feedback. Surgical Innovation, Vol. 15, No. 1, 59 68 (2008)Mintz P D, Mayers L, Avery N, Flanagan H L, Burks S G, Spotnitz W D.(2001) Fibrin Sealant clinical Use and the Development of the University of Virginia Tissue Adhes ive Center. Annals of Clinical science laboratory Science 31 108 118 (2001)Morgan M, Palmer J. (2007) Dog bites. BMJ. 2007 Feb 24 334 (7590) 413 7.Moy R L, Waldman B, Hein D W. (2002) A review of sutures and suturing techniques. J Dermatol Surg Oncol. Sep 2002 18 (9) 785 95Orchard J W (2004) Video illustration of staple gun use to rapidly repair on-field head laceration. Br J Sports Med 2004 38 e 7Scott M. (1993) 32,000 years of sutures. N Engl J Med. . May 1993 20 ( 5) 15 27.Spotnitz W D, Falstrom J K, Rodeheaver G T. (1997) The role of sutures and fibrin sealant in wound healing. Surg Clin North Am. Jun 1997 77 (3) 651 69.UKHD (1998) UK Health Departments. Guidance for clinical health care workers protection against blood-borne viruses. London Department of Health, 1998.12.12.2008 Word count 2,259 PDG