Local anaesthetic for suturing
Given via s.c. injection, using a fine bore needle.
Lidocaine / Bupivacaine
+/- adrenaline to cause vasoconstriction, to reduce bleeding.
Draw back before injecting to confirm you aren’t in a blood vessel
Where should adrenaline never be used in combination with the local anaesthetic?
NEVER use adrenaline near end arteries (i.e. on fingers, toes, ears, nose, penis) as this can cause ischaemia.
Lidocaine for suturing LA
Onset = 5 mins
Duration = 1.5 hours
Dose = 3 mg/Kg
Dose with adrenaline = 7 mg/Kg
Max dose of Lidocaine is always 200mg, regardless of the patient’s weight.
Bupivacaine for suturing LA
Onset = 30 mins
Duration = 18 hours
Dose = 2 mg/Kg
Dose with adrenaline = 3 mg/Kg
Signs of Local Anaesthetic Toxicity
EARLY:
* Tinnitus
* Difficulty with visual focus
* Dizziness or lightheadedness
* Anxiety, agitation, confusion, disorientation, drowsiness
* Perioral and/or tongue numbness
* Metallic taste
LATE:
* CNS – seizures, coma
* CVS – bradycardia, hypotension, atrial and ventricular dysrhythmias, conduction blocks, cardiovascular collapse, asystole
* Respiratory – respiratory depression, apnoea.
* Methaemoglobinaemia – blue mucous membranes progressing to CNS and cardiovascular manifestations of cellular hypoxia and then death.
Causes of local anaesthetic toxicity
- Inadvertent venous or arterial injection
- Dose too high
Size of suture
0 = Very large; For the abdominal wall
3.0 = For skin
5.0 = For the face
6.0 = For vascular anastomoses
8.0 = For ophthalmology
10.0 = As small as a hair; For microvascular anastomoses
Suture removal timing
Face – 5 days
Scalp – 5-7 days
Upper limb/groin – 7 days
Chest – 7-10 days
Abdo – 10 days
Lower limb/back – 10-14 days
Types of Suture
Absorbable = broken down by the body over time by processes such as hydrolysis and enzymatic degradation; usually used under the skin or in a non-compliant patient.
Non-absorbable = remain in place until removed; usually best for the skin.
Braided = easier to tie, but increased risk of infection.
Non-braided = break more easily, but less bacterial colonisation.
What sutures are typically used for skin?
Non-absorbable, non-braided
=> Ethilon, Prolene
Suturing - BEFORE
- Clean skin with antiseptic and place drape
- Wash hands, put on sterile gloves
- Load needle holder
- Place the needle in the tip of the holder, two-thirds of the distance from the tip to the thread) - Plan the entry and exit of your suture on either side of the wound.
- The suture should lie perpendicularly across the wound with equal depth and distance from the wound edge.
Suturing - DURING
- Gently lift the skin with the forceps and pierce the skin surface with the needle perpendicular (90°) to the skin at approximately 2x the depth of the wound from the wound edge.
- Supinate your wrist so that the needle passes through the dermis and rises out of the middle of the wound.
- Use your forceps to hold the needle whilst you release your needle holder.
- Re-grasp the needle in the same place with your needle holder.
- Lift the opposing skin edge gently with your forceps.
- This time the needle has to travel perpendicularly through the dermis from inside to outside. Use the curvature of the needle and supinate your wrist to move the needle through the skin. Equal needle bites of depth and distance from the wound should be taken to allow wound edges to oppose equally and neatly.
- Again, use your forceps to grasp the needle and pull it through the skin. You should continue to follow the curvature of the needle as it travels through the skin, pulling the suture through as you go. You should now have a suture crossing perpendicularly to the wound.
Suturing - AFTER
- Dispose of sharps and clean up
- Clean area and apply dressing
- Advice:
- Keep wound dry
- Look for signs of heat/redness/oozing (infection) seek medical attention for ABX
- May need tetanus booster - Review of wound in 5-7 days and sutures removed (at GP practice by nurses) in appropriate time frame if non-absorbable.
Surgical Knot
- Move needle holder from short end to long
- Wrap long round needle holder twice
- Grasp end of short end and swap side of hands to tie knot
- Move knot to side of the wound you want the knots to be on
- Short to long
- Wrap long round needle holder once
- Grasp end of short end and swap side of hands to reinforce knot
- Short to long
- Wrap long round needle holder once
- Grasp end of short end and swap side of hands to complete knot
- Cut short and long strand to leave some spare for easy removal of suture
Prepare to do next suture at a suitable distance.
Osler’s Nodes
= Tender red nodules in the fingers due to immune complex deposition
Roth’s Spots
= Pale areas with surrounding haemorrhage on the retina.
Janeway Lesions
= Painless palmar / plantar macules
Respiratory Examination - lobectomy
Inspection
- Thoracotomy scar (or can be laparoscopic).
- Chest wall flattening on the side of surgery
Palpation
- Tracheal displacement towards the surgical site
- Reduced expansion on that side.
Percussion
- Hyper-resonant on the side of lobectomy, as the remaining lung expands to fill the cavity.
Auscultation
- Reduced air entry over the site.
Causes of clubbing
C
Cyanotic/Congenital Heart Disease
CF
L
Lung cancer / lung abscess
U
Ulcerative Colitis
B
Bronchiectasis
B
Benign Mesothelioma
I
Infective Endocarditis & Idiopathic Pulmonary Fibrosis
N
Neurogenic Tumours
G
GI disease (e.g. liver disease, Coeliac)
ECG lead position - Limb leads
aVR (R)
Right arm (wrist)
aVL (Y)
Left arm (wrist)
aVF (G)
Left Leg
Neutral (B)
Right leg
ECG lead position - chest leads
V1 4th ICS, right sternal edge.
V2 4th ICS, left sternal edge.
V3 midway between V2 and V4
V4 5th ICS, midclavicular line
V5 5th ICS, anterior axillary line
V6 5th ICS, mid-axillary line
What is the normal calibration for the ECG trace?
Amplitude (height)
=> 10mm/mV
=> 1 small square = 0.1mV
=> 1 large square = 0.5 mV
Duration (speed)
=> 25mm/s
=> 1 small square = 0.04 sec
=> 1 large square – 0.2 sec
Approach to interpreting an ECG
- Patient identification + indication for ECG
- General Impression
- Rate
- Rhythm
- Axis
- P-waves (present / absent)
- P-R Interval (normal / prolonged / shortened)
- QRS complexes (narrow / broad)
- ST segments
- T waves
- QT Interval
