Suture and Staples removal

SUTURE/ STAPLES REMOVAL

• IN MOST CASES, sutures and staples applied to surgical wounds are removed in 7 to 10 days.

• Inform patient that they might feel slight discomfort, such as a pulling sensation or stinging.

• Wear clean gloves and remove the dressing.

• Inspect the wound for edge approximation and signs of infection 

1. If after the longest adequate time, wound hasn’t approximated, it means it never will until underlying cause for the same is treated and so, sutures are removed nevertheless.

2. Serous discharge from a wound is generally not problematic

• Remove the gloves, wash your hands, and put on sterile gloves. 

• Clean the suture line with an antimicrobial solution before and after suture or staple removal.

• Always first remove alternate sutures/ staples. Assess the wound for dehiscence; if none occurs, remove the remaining sutures.

To remove a plain interrupted suture

REQUIREMENTS: Sterile gauze piece, Ethanol, Blade and Forceps

•  

  
  

• Gently grasp the knot with forceps (by your non-dominant hand) and raise it slightly.  

  Place the curved tip of the suture scissors/ blade (in dominant hand) directly under the knot as close as possible to the skin 

• Gently cut the suture and pull it out with the forceps with the direction of pull being ‘over’ the wound rather than ‘away’ from the wound (to prevent any tension on the wound).

  
  

  

• Forceps may not be available (not recommended but it may sometimes be the case) so hold the knot up with one hand and cut the suture directing the force such that the sharp edge faces away from your other hand (to prevent injury to self).

To remove staples

REQUIREMENTS: Staple remover, Sterile gauze piece, Ethanol

• Place the lower jaw of the remover under a staple. Squeeze the handles by depressing your thumb completely to close the device. This bends the staple in the middle and pulls the edges out of the skin.

  
  

  
  
  

  
  

  
  

• Do not pull up the staple removal device.

• Gently move the staple away from the incision site when both ends are visible. Hold the staple remover over a gauze piece or sharps container relax pressure on the handles, and let the staple drop into the container.

After suture or staple removal

• Count the number of sutures/ staples removed and re-confirm with patient (to ensure none is left).

• Apply sterile wound strips to prevent dehiscence. 

NOTE:

• If dehiscence occurs, cover the wound with sterile gauze saturated with sterile 0.9% sodium chloride solution and immediately notify a senior.

• Don’t remove remaining sutures or staples if dehiscence occurs.

   

  REFERENCE VIDEO LINKS:

• Removal of plain interrupted suture: https://youtu.be/Hg-bSb1FLTA 

• Removal of surgical staples: https://youtu.be/OatwWz1k2s8 (** DO NOT HOLD THE REMOVED STAPLES IN YOUR HAND)

Written by our guest authors - Anveshi Nayan and Neha Kumari

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN

 

Plaster Removal

 PLASTER REMOVAL

GENERAL GUIDELINES: 

Reassure patient and inform that the saw blade may get hot.

1. Support and position limb.

2. The noise of the electric cutter frightens some children, and so shears may be used.

3. A plastic skin protector strip may be inserted between the cast lining and a patient’s limb in the area where cutting will occur to protect the skin.

4. Cut steadily and smoothly while conversing with the patient to divert attention.

REMOVAL OF PLASTER CAST WITH STILLE’S PLASTER SHEARS:

1. Draw guidelines down the side of the cast making sure that the line does not run directly over any bony prominences. 

2. Insert the blade between the plaster and the padding wool, parallel to the skin with the handle held steadily in the vertical position. The other blade cuts through the cast from above, its handle should be parallel to the cutting line at rest. 

This is the starting position, and if the blades are incorrectly aligned, the lower blade will press into the flesh causing bruises or even lacerations.

3. After each cut, the blades should be realigned before the next cut is made. This prevents the skin wrinkling in front of the shears. 

4. Use the plaster benders to open out the cast.

5. Use scissors to cut the guaze padding. 

REMOVAL OF PLASTER CAST WITH ELECTRIC CUTTER (MORE COMMONLY DONE):

1. The electric cutter must only be used to cut completely padded casts.

2. Position the blade at the start of the guideline, apply gentle pressure and move the cutter smoothly along the line. 

   
   

3. The electric cutter should always be used carefully especially near bony prominences such as the medial border of the foot leading to the big toe. 

4. Rest of the procedure is same as above.

CARE OF THE PART AFTER CAST REMOVAL:

• Examine for any injury.

• Instructions for the patient:

1. Wash and dry the part.

2. Gentle massage with oil, or cream, may help to restore normal nutrition and elasticity to the skin.

3. Some swelling of the limb is expected after a period of immobilization, especially in the lower limbs.Excessive swelling may be managed by elastic wrapping or intermittent limb elevation.

4. Continue exercises as advised and resume normal activity gradually, resting the part at regular intervals.

Practical tips and tricks:

1. Never try to cut around corners. Always remove the blades and cut from the opposite end of the line to meet the end of the cut already made.

2. When using shears, keep the elbows relatively still and apply the cutting force from the shoulder girdle and chest muscles. This gives a more controlled power and saves energy.

REFERENCE VIDEO LINK:

Plaster cutting with electric cutter: https://youtu.be/3yW_-Aq0O0Q 

Written by our guest author - Rishabh Rawat

Illustrations by Anveshi Nayan

#Ae(ONE)INTERN

 

Thoracocentesis

THORACOCENTESIS 

REQUIREMENTS:  

Written Informed Consent, Sterile gloves, povidone iodine solution, aspiration needle, 3 way stop cock, one 5 mL (for LA) and one 20 mL or 50 mL syringe, a reservoir (empty plastic bottle), one non-collapsible tube (iv set can be used for this), injection lignocaine and sterile dressing

PROCEDURE:

1. Check the vitals of the patient.

2. Position of the patient

(Sitting leaning forward with hands on the table)

• If no table is available, ask the patient to cross their arms in front of their chest.
• If the patient is unable to sit up, the lateral recumbent or supine position may be used. 

 

2. IV access should be established before procedure in most cases. 

3. Atropine should be on hand in case of profound vaso-vagal response and supplemental O2 should be administered throughout the procedure. It is given as IM routinely pre-procedure. 

4. Confirm the side by looking at the chest radiograph or sonography report) 

5. The skin at the puncture site will be cleansed with an antiseptic solution like povidone iodine. 

6. SITE: 7th or 8th intercostal space between the inferior angle of scapula (Aspiration site is determined by USG when done electively or by percussion when done during emergency.)  

7. Give local anesthesia. Infiltrate the skin and subcutaneous tissue and the parietal pleura over the chosen space at the upper border of the lower rib.   

8. The needle has to be inserted near the upper border of lower rib in the intercoastal space.

9. Insert the needle with the stop cock in closed position piercing the skin, subcutaneous tissue and the pleura. A 20 or 50 mL syringe is connected to the end of the stop cock and by turning the stop cock to on position, fluid is aspirated gently with the syringe (figure 1). The stop cock is turned on to the side channel and the fluid is pushed out from the syringe to the reservoir (usually a plastic bottle) via the side channel (figure 2). The process of aspiration is then repeated by turning the stop cock to on position. 

NEVER OPEN THE SIDE PORT ATTACHED TO TUBE DIRECTLY TO PLEURAL SPACE. (To avoid pneumothorax)

                                                

Figure 1- Showing the position of the 3-way during aspiration of pleural fluid

Figure 2- Showing the position of the 3-way while pushing out the fluid into reservoir

Not more than 1000 mL of fluid from pleural cavity is removed within first 30 minutes if done for therapeutic purpose (to prevent re-expansion pulmonary edema). 40-50 mL fluid is sufficient if done for diagnostic purposes. The fluid may be sent to a laboratory for testing (pleural fluid analysis). 

Place a small sterile dressing over the site of puncture.

  

10. Post-procedure X-ray to evaluate the fluid level.

VIDEO LINK:

https://youtu.be/2FviyY_XrEU

 

 

Written by our guest authors - Aishwarya Bagade and Ayushi Gupta 

Illustration by Anveshi Nayan 

#Ae(ONE)INTERN

 

 

CARDIOPULMONARY RESUSCITATION (CPR)

 CARDIOPULMONARY RESUSCITATION (CPR)

OUTSIDE HOSPITAL CPR

PRE- CPR PROCEDURE:

1. First, check the scene for factors that could put you in danger, such as traffic, fire, or falling masonry.

2. Next, check the person. Tap their shoulder and shout, "Are you OK?”. If they are not responding, call for help and call 108. If available, ask a near-by person to bring AED machine.

3. 
   

Remove any obstruction (food or vomitus) seen, only if it is loose. 

(If it is not loose, trying to grasp it may push it farther into the airway.)

• Check for breathing and feel for pulse (Brachial artery in infant, Carotid or femoral in a child and Carotid in adults) within 10 seconds:

  
  

  

  
  

1. No breathing, or occasional gasps + No pulse           Begin CPR

2. No breathing or occasional gasps + Pulse felt         Give 10-12 breaths/ minute

3. Unconscious but still breathing, do not perform CPR. Instead, place them in:

Keep monitoring the patient. Start CPR if the person stops breathing.

CPR

4. Perform chest compressions at the rate of 100-120/ min:

5. Open airway using triple maneuver: 

6. Give rescue breaths:

Pinch the nose while giving a breath mouth-to-mouth and look for chest rise.

If their chest does not rise with the first breath, tilt their head.

If their chest still does not rise with a second breath, the person might be choking. 

7. Try to synchronize the breaths with any voluntary breathing activity of the patient that might be present.

8. Repeat the cycle of 30 chest compressions and two rescue breaths until the person starts breathing or help arrives. If an AED arrives, carry on performing CPR until the machine is set up and ready to use. 

FOR CHILDREN (STEPS AS ABOVE WITH FOLLOWING MODIFICATIONS)

For children, give compressions using one hand only, between the nipples and press down around 2 inches.

For infants, give compressions using both the thumbs or index and middle fingers and press down approximately 1.5 inches.

If two rescuers present, try give 15 compressions followed by 2 rescue breaths and so on.

INSIDE HOSPITAL CPR

1. Recognize cardiac arrest and activate emergency team.

2. Start CPR as above (except that now, the person administering CPR should stand by the side of patient). 

3. Instead of using mouth-to-mouth for rescue breaths (may not feasible in case of infectious diseases), bag and mask ventilation is done and the patient is ventilated with a compression to ventilation ratio of 30:2

For Bag and mask ventilation, tilt the head of patient backwards.

Then, form a tight seal with the mask around the nose and mouth of patient forming letters E by fingers and thumb of one hand and C by the other.

Squeeze the AMBU bag and look for chest rise.

4. Airway may be secured by following methods while making sure that this process doesn’t compromise on the chest compressions.

• Combitube

• Laryngeal Mask Airway

• Endo-tracheal intubation (See document titled ‘ENDOTRACHEAL INTUBATION’)

Once advanced airway is secured give 1 breath every 6 seconds.

ADULT ALGORITH FOR MANAGEMENT OF CARDIAC ARREST

In brief:

• Shockable rhythm - ALWAYS Shock 

• Non- shockable rhythm – CPR with epinephrine (keeping approximately 4-minute interval between 2 epinephrine injections)

• Shock 🡪 CPR gain i.v. access + Inject Epinephrine 🡪Shock 🡪 CPR + Inject Amiodarone 🡪 Shock 🡪 CPR + Epinephrine 🡪 and so on...

• Time between 2 assessments/ 2 shocks/ time for which CPR is performed while injecting drugs = 2 mins

DEFIBRILLATION

For pediatric patients:

1st shock: 2-4 J/kg 

Subsequent 4J/kg (but not more than 10 J)

For adults:

Biphasic defibrillators: 100-120 J 

Monophasic defibrillators: 360 J

Placement of leads:

EPINEPHRINE:

1 mg 1:10000 i.v./ i.o. every 3-5 mins 

AMIODARONE:

1st Dose: 300 mg bolus dilute in 20-30 ml

2nd Dose: 150 mg bolus

VIDEO LINK:

ADVANCED CARDIAC LIFE SUPPORT (ACLS) ADULTS:

(2) ACLS Megacode - YouTube

Written by our guest authors - Hemant Kadam, Jignesh Bhadarka, Anveshi Nayan 

Illustrations by Anveshi Nayan and Devi Bavishi

#Ae(ONE)INTERN