Simple suturing technique

Basic suturing principles

Many varieties of suture material and needles are available to the cutaneous surgeon. The choice of sutures and needles is determined by the location of the lesion, the thickness of the skin in that location, and the amount of tension exerted on the wound. Regardless of the specific suture and needle chosen, the basic techniques of needle holding, needle driving, and knot placement remain the same.

• Needle construction

  • The needle has 3 sections. The point is the sharpest portion and is used to penetrate the tissue. The body represents the mid portion of the needle. The swage is the thickest portion of the needle and the portion to which the suture material is attached.
  • In cutaneous surgery, 2 main types of needles are used: cutting and reverse cutting. Both needles have a triangular body. A cutting needle has a sharp edge on the inner curve of the needle that is directed toward the wound edge. A reverse cutting needle has a sharp edge on the outer curve of the needle that is directed away from the wound edge, which reduces the risk of the suture pulling through the tissue. For this reason, the reverse cutting needle is used more often than the cutting needle in cutaneous surgery (see image below).
    Diagram of a needle.
    
• Suture placement

  • A needle holder is used to grasp the needle at the distal portion of the body, one half to three quarters of the distance from the tip of the needle, depending on the surgeon's preference. The needle holder is tightened by squeezing it until the first ratchet catches. The needle holder should not be tightened excessively because damage to both the needle and the needle holder may result. The needle is held vertically and longitudinally perpendicular to the needle holder (see image below).
    
     
    The needle is placed vertically and longitudinally perpendicular to the needle holder.
    
  • Incorrect placement of the needle in the needle holder may result in a bent needle, difficult penetration of the skin, and/or an undesirable angle of entry into the tissue. The needle holder is held by placing the thumb and the fourth finger into the loops and by placing the index finger on the fulcrum of the needle holder to provide stability (see first image below). Alternatively, the needle holder may be held in the palm to increase dexterity (see second image below).
    The needle holder is held through the loops between the thumb and the fourth finger, and the index finger rests on the fulcrum of the instrument.
    
    The needle holder is held in the palm, allowing greater dexterity.
    
  • The tissue must be stabilized to allow suture placement. Depending on the surgeon's preference, toothed or untoothed forceps or skin hooks may be used to gently grasp the tissue. Excessive trauma to the tissue being sutured should be avoided to reduce the possibility of tissue strangulation and necrosis. Forceps are necessary for grasping the needle as it exits the tissue after a pass. Prior to removing the needle holder, grasping and stabilizing the needle is important. This maneuver decreases the risk of losing the needle in the dermis or subcutaneous fat, and it is especially important if small needles are used in areas such as the back, where large needle bites are necessary for proper tissue approximation.
  • The needle should always penetrate the skin at a 90° angle, which minimizes the size of the entry wound and promotes eversion of the skin edges. The needle should be inserted 1-3 mm from the wound edge, depending on skin thickness. The depth and angle of the suture depends on the particular suturing technique. In general, the 2 sides of the suture should become mirror images, and the needle should also exit the skin perpendicular to the skin surface.
• Knot tying

  • Once the suture is satisfactorily placed, it must be secured with a knot. The instrument tie is used most commonly in cutaneous surgery. The square knot is traditionally used. First, the tip of the needle holder is rotated clockwise around the long end of the suture material for 2 complete turns. The tip of the needle holder is used to grasp the short end of the suture. The short end of the suture is pulled through the loops of the long end by crossing the hands, such that the 2 ends of the suture material are situated on opposite sides of the suture line. The needle holder is rotated counterclockwise once around the long end of the suture. The short end is grasped with the needle holder tip, and the short end is pulled through the loop again.
  • The suture should be tightened sufficiently to approximate the wound edges without constricting the tissue. Sometimes, leaving a small loop of suture after the second throw is helpful. This reserve loop allows the stitch to expand slightly and is helpful in preventing the strangulation of tissue because the tension exerted on the suture increases with increased wound edema. Depending on the surgeon's preference, 1-2 additional throws may be added.
  • Properly squaring successive ties is important. That is, each tie must be laid down perfectly parallel to the previous tie. This procedure is important in preventing the creation of a granny knot, which tends to slip and is inherently weaker than a properly squared knot. When the desired number of throws is completed, the suture material may be cut (if interrupted stitches are used), or the next suture may be placed (see image below).
    
    Knot tying.

Foley catheter insertion (male and female)

Indications
By inserting a Foley catheter, you are gaining access to the bladder and its contents. Thus enabling you to:
 drain bladder contents,
decompress the bladder,
 obtain a specimen,
and introduce a passage into the GU tract.

This will allow you to treat urinary retention, and bladder outlet obstruction.

Urinary output is also a sensitive indicator of volume status and renal perfusion (and thus tissue perfusion also).

In the emergency department, catheters can be used to aid in the diagnosis of GU bleeding.

In some cases, as in urethral stricture or prostatic hypertrophy, insertion will be difficult and early consultation with urology is essential.

Contraindications
Foley catheters are contraindicated in the presence of urethral trauma.
 Urethral injuries may occur in patients with multisystem injuries and pelvic factures, as well as straddle impacts. If this is suspected, one must perform a genital and rectal exam first. If one finds blood at the meatus of the urethra, a scrotal hematoma, a pelvic fracture, or a high riding prostate then a high suspicion of urethral tear is present. One must then perform retrograde urethrography (injecting 20 cc of contrast into the urethra).

Nasogastric tube insertion

Indications
By inserting a nasogastric tube, you are gaining access to the stomach and its contents.
This enables you to:
 drain gastric contents,
 decompress the stomach,
 obtain a specimen of the gastric contents,
 or introduce a passage into the GI tract.

 This will allow you to treat gastric immobility, and bowel obstruction.

 It will also allow for drainage and/or lavage in drug overdosage or poisoning.

 In trauma settings, NG tubes can be used to aid in the prevention of vomiting and aspiration, as well as for assessment of GI bleeding.

 NG tubes can also be used for enteral feeding initially.

Contraindications
Nasogastric tubes are contraindicated in the presence of severe facial trauma
(cribriform plate disruption), due to the possibility of inserting the tube intracranially.
In this instance, an orogastric tube may be inserted.

Cannula and Peripheral IV line insertion

Contraindications

Absolute Contraindications: None

Relative Contraindications:

    Avoid extremities that have massive edema, burns, or injury; in these cases other IV sites need to be accessed.

    Avoid going through an area of cellulitis; the area of infection should not be punctured with a needle because of the risk of inoculating deeper tissue or the bloodstream with bacteria.

    Avoid extremities with an indwelling fistula; it is preferable to place the IV in another extremity because of changes in vascular flow secondary to the fistula.

    An upper extremity on the same side of a mastectomy should be avoided, particularly if an axillary node dissection was carried out, because of concerns of previous lymphatic system damage and adequate lymphatic flow.

    Very short procedures performed on pediatric patients, like placement of ear tubes

    Bleeding diathesis

    Medication administration that will take longer than 6 days (preference is then for a peripherally inserted central catheter)

    Type of fluid to be administered through peripheral IV is too caustic; hypertonic solutions and some therapeutic agents should not be infused in a peripheral IV.

Central line placement

Indications:

• Placement of venous access line when other peripheral sites are unavailable
• Placement of a large-bore venous catheter in an emergent situation to deliver a high flow of fluid or blood products (the flow rate is determined by the caliber and length of the catheter, shorter and greater caliber catheters delivering greater volumes over equivalent amounts of time)
• Central venous pressure measurement
• Administration of sclerosing agents such as chemotherapeutic agents, hyperalimentation fluids, etc.
• As an alternative to repetitive venous cannulations
• For placement of pulmonary wedge catheters
• For placement of trans venous pacemakers
• For performance of hemodialysis or plasmapheresis

Contraindications:

• Infection over the insertion site
• Distortion of landmarks from any reason
• Suspected injury to the superior vena cava (eg., SVC syndrome)
• Coagulopathies including anticoagulation therapy
• Pneumothorax or hemothorax on the contralateral side
• Inability to tolerate pneumothorax on the ipsilateral side
• Uncooperative patients
• Patients unable to tolerate a Trendelenberg position
• Prior injury to that vein (choose the one on the other side)
• Morbid obesity
• Recently discontinued subclavian catheter at the same location
• Planned mastectomy on the side of subclavian insertion
• Patients receiving ventilatory support with high end expiratory pressures (temporarily reduce the pressures)
• Patients with vigorous, ongoing cardiopulmonary resuscitation
• Children less than 2 years (higher complication rates)
• Fracture or suspected fracture of ipsilateral upper ribs or clavicle

Complications, Prevention and Management:

·        Pneumothroax

o       Prevention: Remove patient from ventilator before advancing the needle, choose the right side rather than left, avoid multiple attempts when possible

o       Management: Check postprocedure x-ray, if pneumothorax arrange for thorcostomy depending on the size of the pneumothorax

• Hemothorax - as above
• Bilateral Iatrogenic complications

o       Prevention: If attempted catheterization is unsuccessful, try the ipsilateral internal jugular or subclavicular approach before trying contralateral subclavian catheterization

• Catheter embolization

o       Prevention: Never withdraw a catheter past a needle bevel which might shear off the catheter

o       Management: x-ray the patient and contact specialist who can remove the embolized catheter

• Infection

o       Prevention: Never choose an insertion site that goes through infected tissue; use antimicrobial-impregnated catheters; avoid the use of antibiotic ointments (increase of fungal contamination and antibiotic resistant bacteria)

• Cardiac dysrhythmia

o       Prevention: if available, have someone watch monitor for dysrhythmia while the catheter is advanced (this comes from direct contact of the catheter tip with the myocardium of the right atrium)

o       Management: reposition the catheter; treat dysrhythmia according to ACLS protocols.

• Air embolism

o       Prevention: Maintain a Trendelenberg position, ask the patient to exhale while you are advancing the catheter, maintain a "closed system

o       Management: Place the patient in a left lateral decubitis, head down position to minimize the chances of an air embolism to the brain.

Digital block

Digital nerve blocks are important tools for the emergency medicine clinician. Injuries or infections of the digits are extremely common. Adequate analgesia is essential to properly address the presenting condition and to minimize the patient's discomfort. Digital blocks are useful in many scenarios in which local infiltration of an anesthetic would require several injections into the already painful site of injury. Furthermore, local infiltration around the wound may create increased swelling, making the repair more difficult. Several techniques are available for performing digital blocks.

Indications

Digital blocks are indicated for any minor surgery or procedure of the digits. These include, but are not limited to, the following:

    Large irregular lacerations
    Lacerations involving the nail or the nail bed
    Ingrown nails
    Felon or paronychia
    Trephination of subungual hematoma
    Digit dislocations or fractures

Contraindications

    Compromised digit circulation
    Infected injection site
    Known allergy to anesthetic

Arterial Blood Gas Sampling

ABG sampling provides valuable information on the acid-base balance at a specific point in the course of a patient's illness. It is the only reliable determination of ventilation success as evidenced by CO2 content. It constitutes a more precise measure of successful gas exchange and oxygenation. ABG sampling is the only way of accurately determining the alveolar-arterial oxygen gradient (see the A-a Gradient calculator).

Indications

Indications for ABG sampling include the following:

    Identification of respiratory, metabolic, and mixed acid-base disorders, with or without physiologic compensation, by means of pH ([H+]) and CO2 levels (partial pressure of CO2)

    Measurement of the partial pressures of respiratory gases involved in oxygenation and ventilation

    Monitoring of acid-base status, as in patient with diabetic ketoacidosis (DKA) on insulin infusion; ABG and venous blood gas (VBG) could be obtained simultaneously for comparison, with VBG sampling subsequently used for further monitoring
    Assessment of the response to therapeutic interventions such as mechanical ventilation in a patient with respiratory failure
    Determination of arterial respiratory gases during diagnostic evaluations[2, 3] (eg, assessment of the need for home oxygen therapy in patients with advanced chronic pulmonary disease)
    Quantification of oxyhemoglobin, which, combined with measurement of arterial oxygen tension (PaO2), provides useful information about the oxygen-carrying capacity of the patient
    Quantification of the levels of dyshemoglobins (eg, carboxyhemoglobin and methemoglobin)
    Procurement of a blood sample in an acute emergency setting when venous sampling is not feasible (many blood chemistry tests could be performed from an arterial sample[4] )

Contraindications

Absolute contraindications for ABG sampling include the following:

    An abnormal modified Allen test (see below), in which case consideration should be given to attempting puncture at a different site

    Local infection or distorted anatomy at the potential puncture site (eg, from previous surgical interventions, congenital or acquired malformations, or burns)

    The presence of arteriovenous fistulas or vascular grafts, in which case arterial vascular puncture should not be attempted

    Known or suspected severe peripheral vascular disease of the limb involved

Relative contraindications include the following:

    Severe coagulopathy

    Anticoagulation therapy with warfarin, heparin and derivatives, direct thrombin inhibitors, or factor X inhibitors; aspirin is not a contraindication for arterial vascular sampling in most cases

    Use of thrombolytic agents, such as streptokinase or tissue plasminogen activator

Ingrown Toe Nail Removal

Surgery for Ingrown Toenails

If an infection is present, then surgical removal of either part of the nail or the whole nail and drainage of the abscess will be needed. This is performed in the doctor's office or in the emergency department. The extent of the procedure will depend on the severity of the infection, any other medical problems, and if this is a recurring problem.

    How ingrown toenails are surgically removed

        A tetanus immunization will be given if it has been longer than five years since the last one. With an ingrown toenail, there is a chance the open wound could develop tetanus.

        Sometimes a pre-operative X-ray will be taken to make sure that the infection hasn't spread to the bone (osteomyelitis)

        The doctor will inject anesthetic medicine at the point where the toe joins with the foot. This will make the entire toe numb.

        The doctor will then drain the infection from the end of the toe or remove the extra tissue that has grown around the end of the nail.

        At this point, the doctor will remove a portion of the nail so that the skin or infection can heal without the nail pushing on it.

        The doctor may decide to destroy some of the cells that make the nail grow back by applying a chemical (phenol or sodium hydroxide) to the skin under the nail. Adding phenol at the end of the procedure decreases recurrence rates but can be associated with increased infections. Some alternative methods of ablating the cells include lasers, electrocautery, or extreme cold. This is performed so that the edge of the nail that caused the problem will not return, which is more likely with severe or recurring infections.

        For very severe or recurrent cases that have already failed traditional surgery, a complete excision of the nail bed can be done.

        A lateral matricectomy is a procedure that surgically removes a portion of the nail bed and is usually performed by a specialist. It is considered the usual treatment for chronic or recurrent ingrown nails.

        There are several newer types of surgery that don't alter the nail bed at all, instead they removes a portion of the soft tissue beside and/or underneath the nail in order to make more room for the nail to grow out. These types of surgery have shown promise but are not yet the standard of care, as they are still being studied. A flexible tube can also be slid along the side of the nail after removal of the extra tissue to help it heal properly.

        Antibiotics are usually not prescribed for this problem because draining the abscess will take care of the infection.

        The toe will then be covered with ointment and gauze.

Lumbar Puncture

Lumbar Puncture

A lumbar puncture (also called a spinal tap) is a procedure to collect and look at the fluid (cerebrospinal fluid, or CSF) surrounding the brain and spinal cord.

During a lumbar puncture, a needle is carefully inserted into the spinal canal low in the back (lumbar area). Samples of CSF are collected. The samples are studied for color, blood cell counts, protein, glucose, and other substances. Some of the sample may be put into a special culture cup to see if any infection, such as bacteria or fungi, grows. The pressure of the CSF also is measured during the procedure.
Why It Is Done

A lumbar puncture is done to:

    Find a cause for symptoms possibly caused by an infection (such as meningitis), inflammation, cancer, or bleeding in the area around the brain or spinal cord (such as subarachnoid hemorrhage).
    Diagnose certain diseases of the brain and spinal cord, such as multiple sclerosis or Guillain-Barr� syndrome.
    Measure the pressure of cerebrospinal fluid (CSF) in the space surrounding the spinal cord. If the pressure is high, it may be causing certain symptoms.

A lumbar puncture may also be done to:

    Put anesthetics or medicines into the CSF. Medicines may be injected to treat leukemia and other types of cancer of the central nervous system.
    Put a dye in the CSF that makes the spinal cord and fluid clearer on X-ray pictures (myelogram). This may be done to see whether a disc or a cancer is bulging into the spinal canal.

In rare cases, a lumbar puncture may be used to lower the pressure in the brain caused by too much CSF.

Modified Radical Mastectomy

When doctors treat breast cancer, their goal is to remove all of the cancer -- or as much of it as possible. Surgery is one of the mainstays of treatment, and today a procedure called modified radical mastectomy (MRM) has become a standard surgical treatment for early-stage breast cancers.

Modified radical mastectomy is especially helpful for early-stage breast cancer that has spread to the lymph nodes. Studies show that MRM is just as effective as radical mastectomy, but not nearly as disfiguring.  MRM spares one or both of the chest muscles, preventing an unsightly hollow in the chest that is common after a traditional radical mastectomy.

What Is Modified Radical Mastectomy?

During a modified radical mastectomy, the surgeon removes the breast (including the skin, breast tissue, areola, and nipple) and most of the lymph nodes under the arm. The lining over the large muscle in the chest called the pectoralis major is also removed. However, this surgery spares the pectoralis major muscle itself.

MRM surgery tries to preserve enough healthy tissue and skin for a surgeon to perform breast reconstruction surgery in women who want to have it done.

What to Expect During an MRM

A modified radical mastectomy takes about two to four hours. The surgery might take longer if you have breast reconstruction surgery done immediately afterward.

While you are under general anesthesia, the surgeon will make a single incision across one side of the chest. The skin will be pulled back. Then the doctor will remove the entire breast tissue, the lining over the pectoralis major, as well as some of the lymph nodes under your arm.  Finally, the doctor will close the incision.

The goal is to remove the cancer while preserving as much of the skin and tissue as possible so that you can have breast reconstruction. The surgeon also will try to avoid damaging nearby blood vessels and nerves.

Although research has found modified radical mastectomy to be generally safe and effective, like all surgical procedures it can have risks, which include:

    Bleeding
    Infection
    Swelling of the arm
    Pockets of fluid forming underneath the incision (seromas)
    Risks from general anesthesia

Some people experience numbness in the upper arm, which is caused by damage to small nerves in the area where the lymph nodes are removed. There is a good chance that you will regain most of the feeling in your arm over time.

The lymph nodes that are removed will be sent to a lab for examination to determine whether the cancer has spread.

After a Modified Radical Mastectomy

Once your surgery is complete, you will need to stay in the hospital for one or two nights. Thin plastic tubes will be placed in your breast area to drain off any fluid. These drains are attached to small suction devices. The drains will be removed about a week after your surgery. The hospital staff will show you how to care for the tubes until they are removed.

Tracheostomy

What is a tracheostomy?

A tracheostomy is a surgically created opening in the neck leading directly to the trachea (the breathing tube). It is maintained open with a hollow tube called a tracheostomy tube.

Why is a tracheostomy performed?

A tracheostomy is usually done for one of three reasons:
(1) to bypass an obstructed upper airway (an object obstructing the upper airway will prevent oxygen from the mouth to reach the lungs);
(2) to clean and remove secretions from the airway; and
(3) to more easily, and usually more safely, deliver oxygen to the lungs.

What are risks and complications of tracheostomy?

It is important to understand that a tracheostomy, as with all surgeries, involves potential complications and possible injury from both known and unforeseen causes. Because individuals vary in their tissue circulation and healing processes, as well as anesthetic reactions, ultimately there can be no guarantee made as to the results or potential complications. Tracheostomies are usually performed during emergency situations or on very ill patients. This patient population is, therefore, at higher risk for a complication during and after the procedure

The following complications have been reported in the medical literature. This list is not meant to be inclusive of every possible complication. It is listed here for information only in order to provide a greater awareness and knowledge concerning the tracheostomy procedure.

    Airway obstruction and aspiration of secretions (rare).
    Bleeding. In very rare situations, the need for blood products or a blood transfusion.
    Damage to the larynx (voice box) or airway with resultant permanent change in voice (rare).
    Need for further and more aggressive surgery
    Infection
    Air trapping in the surrounding tissues or chest. In rare situations, a chest tube may be required
    Scarring of the airway or erosion of the tube into the surrounding structures (rare).
    Need for a permanent tracheostomy. This is most likely the result of the disease process which made the a tracheostomy necessary, and not from the actual procedure itself.
    Impaired swallowing and vocal function
    Scarring of the neck

Obviously, many of the types of patients who undergo a tracheostomy are seriously ill and have multiple organ-system problems. The doctors will decide on the ideal timing for the tracheostomy based on the patient's status and underlying medical conditions.