Supervised by

DR HISHAM
Prepared by
ANWARIAH ARIS
NOOR MOHAMMAD SAFWAN

OUTLINES
Objectives
Pre-procedures
Procedures
Post-procedures
Take home messages

OBJECTIVES
To identify indications &

contraindications
To be able to perform
To be aware of complications and
how to avoid or minimalize

PRE- PROCEDURE
Informed consent:
Indications
Anatomy
Procedure ( Risks & Benefits)

PRE PROCEDURE
Aseptic technique:
Prepare equipmentMask
Apron
Gown
Hand wash
Sterile glove
Povidone

PRE PROCEDURE
Local anaesthesia:
Lidocaine/lignocaine
1% (10mg in 1ml)/2%(20mg in 1ml)
With/without epinephrine 100000u

PRE PROCEDURE
Max dose 4mg/kg
Max dose with epinephrine:7mg/kg
1% lignocaine:
Alone: 28ml in 70kg pt
With epinephrine: 49ml in 70kg pt

1.TOILET AND SUTURING

Indications:
Presence of laceration wound
Laceration wound closed by:
Primary closure in clean wound

or
Secondary closure in dirty wound

Anatomy

Equipments:
T&S set
Scalpel
Water for irrigation
Syringe
Lignocaine injection
Suture
Needle holder
Forceps

Sutures:
Type: Non-absorbable for skin, absorbable for

deep tissue
Size
Face & Scalp - 3/0
Limb & Trunk - 3/0
Lips & Ear -4/0

Needle:
Cutting edge body for skin
Rounded body for tissue

Procedure:
Clean surrounding skin with povidone
Give adequate local anaesthesia
Wound assessment
Depth
Foreign body
Sign of infection
Active bleeding
Necrotic tissue
Any structural injury

Irrigation with copious amount of saline

Remove foreign body
Debride ragged, nonviable skin edges

and necrotic tissue

Secure hemostasis:
Compressed with gauze
Suture with figure of 8

Continuous
interlocking

Ensure good bite of tissue taken

Make sure wound are free of contaminant
before closing

Timing of closure:
Primary closure: Immediate closure for
clean wounds <12 hours old (24 hours on
face)e.g. assault wound, clean cut
Secondary closure: Dirty wound e.g.

animal bite, wound contaminated with soil

Complications:
Hematoma
Wound breakdown
Infection
Scar

Post T&S
Dressing with CMC
For patient to keep wound clean and dry
Suture removal:
Face: 3-5 days
Scalp: 7-10 days
Arms: 10-14 days
Legs: 10-14 days
Trunk : 10-14 days

2.INCISION AND
DRAINAGE

Indications:

Cutaneous abscess: painful swelling at

cutaneous, indurated, tender, warm,

redness, fluctuant
If in doubt, confirm with needle
aspiration

ANATOMY

Equipment:
Scalpel
Povidone
Lignocaine injection
Artery forceps
Gauze/gamgee
Syringe
Swab for c+s

PROCEDURE
Clean and drape
Give adequate local anaesthesia
Make a cruciate incision at most fluctuant

area

PROCEDURE
Express pus (swab for C+S)
Break loci using artery forceps
Secure hemostasis with gauze compression

PROCEDURE
Copiously irrigate with sterile water
Wash with povidone + hydrogen peroxide
Packed the wound loosely with ribbon

gauze(soaked with povidone)

Dressing with gauze/gamgee

Complications:
Pain
Incomplete drainage
Scar
Bleeding

POST INCISION AND

DRAINAGE
Wound inspection: pus or slough
Daily dressingnormal saline or povidone
Pain management
Continue packing of wound until no significant

discharge
Antibiotics in presence of
Localized cellulitis
Fever or chills
In immunocompromised patient

3.WOUND DESLOUGHING &

DRESSING
Indications:
Acute

Wounds

Chronic

Wounds

Anatomy:

Proliferative
Phase
Proliferation,
Granulation
and
Contraction

ACUTE
WOUND

Remodelling
Phase

Haemostasis &
Inflammatory
Phase

Healed Wound

CHRONIC WOUND
Hemostasis
Platelet
Aggregation

Neutrophil
Immigration
Monocyte
Immigration
Granulation
Re-epithelialization
Wound Closure
Scar Formation
Remodeling

Minutes

Hours

Days

Weeks

Months

Years

Time

Wound Healing Continuum (Gray et al. 2005) have

been developed. This tool incorporates intermediate colour
combinations between the four key colours

Procedure
Equipments:
Curettage
Dressing set
Blade
Gauze
Cotton wool
Cleansing agents

Normal Saline
Hydrogen Peroxide
Povidone iodine

Post Wound Dressing &

Desloughing:
Wound Inspection
Daily desloughing or dressing
Antibiotic
Analgesia

Complications:
Excessive bleeding
Infection
Delay wound closure

4. CHEST TUBE
INSERTION
Indications:
Pneumothorax / hemothorax
Massive pleural effusion
Empyema
Post operative procedures Eg :

Thoracotomy, Cardiac surgery

Pleurodesis : Chronic, recurrent
pneumothorax or effusion

Procedure
Procedure
Equipment:
Chest tube
Child : 16-20F
Average size adult :24-32F
Large size adult : 36-40F
Underwater seal system
Accessory : Chest tube set, blade,

LA, gauze, suture

Insertion site:
Safety triangle

Lateral
border of
pectoralis
major

Mid
Axillary
Line
4th or 5th intercostal
space

Complications:
Bleeding
Lung injury
Infection
Abdominal organ injury if chest tube

inserted too low

Post Chest Tube Insertion:

Vital signs monitoring (BP, HR, T) and

Spo2 monitoring
Start analgesia & start antibiotic if
indicated
Encourage incentive spirometry
CXR
Watchout for complications of chest tube
insertion

TAKE HOME MESSAGES

1. Adequate analgesia maximum of 4mg/kg

without adrenaline or 7mg/kg with adrenaline

should be administer before invasive procedure.
2. Clearly written details of each procedure and
post procedure instructions is a must.
3. Disposal of all sharp equipment are done by the
person performing the procedure.
4. Informed consent should be taken and
explained by the person performing the
procedure.

CONT..
5. Puncture all loci to ensure complete drainage

of pus and packed adequately to ensure good

healing of the wound.
6. In toilet and suturing, make sure the wound is
clean and free of contaminant before closing.
7. Desloughing are done until we reach to the
normal tissue and evidence of bleeding seen.
8. Open method of chest tube insertion at the
safety triangle is the preferred method.

Referrences
Herbert Chan, Juan E. Sola, Keith D. Lillemoe,

Manual of Common Bedside Surgical

Procedure, 2nd ed,2000.
Henry Gray, Susan Standring, Harold Ellis,

BKB Berkovitz, Grays Anatomy and Basis

Clinical Practice, 39th ed, 2005.