Common Procedures in the Athletic Training Clinic

Larry Collins, Tiffany O’Connor and Micki Cuppett

At the completion of this chapter the reader should be able to do the following:

1. Name the limitations of the practice act pertaining to invasive procedures

2. Demonstrate use of an appropriate informed consent prior to performing any of the procedures described in this chapter

3. Employ fundamental aseptic procedures, including the use of sterile gloves and the creation of a sterile field

4. Properly unpack a sterile package and prepare for a sterile procedure

5. Compare the various types of sutures and suture needles and their specific applications

6. Describe the difference between interrupted, running, and mattress sutures and the advantages and disadvantages of each

7. Prepare the patient for injection and aspiration

Introduction

This chapter begins with a disclaimer about state practice acts. At present 47 states regulate the practice of athletic training in some fashion, whether it be by certification, licensure, or other regulation.¹ What is important to remember is that the practice act for athletic trainers as well as other health care professionals varies widely by state. Knowing and understanding the specific practice act is ultimately the responsibility of the clinician. Recognizing the limitations and following the practice act in their state will allow the athletic trainer to fully use his or her skills and knowledge base to provide appropriate health care to patients and athletes.

The techniques and procedures outlined in this chapter may be prohibited or not addressed in particular state rules and regulations. Despite this, learning new techniques will allow the practitioner to evolve with changes in the profession and revisions in state practice acts, or to adapt to new settings, if he or she moves to a state with a different set of guidelines in the practice act. With the expansion of athletic trainers in physicians’ offices and their use as physician extenders, many athletic trainers are now performing the procedures listed in this chapter in their daily practice. Even if not performing the procedures themselves, many athletic trainers are asked by the physician to assist in the preparation of the patient and the environment for invasive procedures in the athletic training clinic.

Informed Consent

Informed consent ensures an individual’s right to be an active participant in the decision-making process regarding their health care. Sufficient information should be presented to every individual so that they may make an informed decision regarding whether or not to consent to a specific treatment or procedure. Although the legal requirement to obtain informed consent rests with the physician, the physician may delegate this responsibility to another health care provider. A health care provider who is substantially involved with the patient’s care must obtain the informed consent. An example of an informed consent may be found in Figure 6-1. Informed consent should include, at a minimum, a thorough discussion of the following:

FIGURE 6-1 An informed consent form for an invasive procedure should present the nature and purpose of the procedure as well as the risks and benefits.

• The patient’s diagnosis

• The nature and purpose of a proposed treatment or procedure

• The risks and benefits of a proposed treatment or procedure

• Alternatives to the proposed treatment or procedure (regardless of the cost or the extent to which the treatment options are covered by health insurance)

• The risks and benefits of the alternative treatment or procedure

• The risks and benefits of not receiving or undergoing a treatment or procedure

Preventing Infection

As indicated in detail in Chapter 1 of this textbook, OSHA and the Centers for Disease Control and Prevention (CDC, Atlanta, GA) define universal precautions as a simple set of effective practices designed to protect health care workers and patients from infection with a range of pathogens including blood-borne viruses. These practices are used when caring for all patients regardless of diagnosis.²

Universal precautions apply to blood and other body fluids containing visible blood, semen, and vaginal secretions. Universal precautions also apply to tissues and to cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Universal precautions do not apply to feces, nasal secretions, sputum, sweat, tears, urine, and vomitus unless they contain visible blood. Universal precautions do not apply to saliva except when visibly contaminated with blood or in the dental setting where blood contamination of saliva is predictable.³

Universal precautions provide for the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear, which can reduce the risk of exposure of the health care worker’s skin or mucous membranes to potentially infective materials. It is also recommended that all health care workers take precautions to prevent injuries caused by needles, scalpels, and other sharp instruments or devices.² Box 6-1 describes numerous best practices to prevent sharps injuries in the sports medicine clinic.

BOX 6-1 PREVENTING SHARPS INJURIES

Use the following best practices for handling sharps in the medical clinic:

• Use standardized sterile field setups.

• Keep all sharps on instrument tables or trays with the points away from staff members.

• Use a neutral zone or hands-free method for passing sharps.

• Dedicate the neutral zone for sharps only (these include suture and hypodermic needles, scalpels, and other sharp instruments).

• Only one sharp at a time should be in the neutral zone.

• Avoid handling suture needles manually whenever possible. Instead, use a needle holder, forceps, or suturing assist device.

• Do not hold a sharp and any other instrument simultaneously.

• Do not use fingers to touch tissue being cut or sutured.

• Know where all sharps are throughout the procedure.

• Confine and contain all sharps in a disposable, puncture-resistant needle container.

Modified from Rothrock JC: Alexander’s care of the patient in surgery, ed 13, St. Louis, 2007, Mosby.

Asepsis and Aseptic Technique

Preventing infection and maximizing healing should be the primary goal when performing any invasive procedure. The term asepsis means the absence of infectious organisms ³ and the goal of aseptic technique is to prevent the transfer of microorganisms into the wound. Preventing site contamination requires the efforts of all trained team members to use their knowledge and experience in aseptic practices to provide their patients with optimal care resulting in positive procedural outcomes.

Whenever an invasive procedure is performed, aseptic practices must be followed:

• Assess the patient for any risk factors.

• Assess any environmental concerns.

• Ensure proper disinfection and sterilization of instruments.

• Observe the use of universal precautions.

Adherence to the principles of asepsis and observance of the boundaries established by the techniques are the responsibility of each clinician involved in the medical procedure.³

Procedures used to Close Lacerations

Caring for a laceration is a common occurrence in the athletic training clinic. Often simply cleaning the wound and applying an antibiotic ointment and an adhesive bandage are sufficient. Sometimes, however, more aggressive measures must be used to close the laceration to achieve good healing and cosmetic results. This section discusses common skin closure materials and techniques.

Adhesive Skin Tape

Adhesive skin tape is used to close small, superficial, low-tension wounds and to reinforce larger wounds closed with sutures or after removing sutures to protect the wound during the proliferation and early remodeling periods of healing (Figure 6-5, A).

FIGURE 6-5 A, Adhesive closures can be used to close minor wounds or can be used after sutures have been removed. B, Skin glue. (From Pieknik R: Suture and surgical hemostasis: a pocket guide, St. Louis, 2006, Mosby.)

Adhesive skin tape is designed to facilitate quick, simple closure of minor wounds with minimal risk. The noninvasive application technique reduces tissue trauma and is relatively pain free. In an athletic setting, they are also used to temporarily close wounds during competition before more definitive wound closure after the competition.

Application Technique

• Clean the wound.

• Inspect the wound.

• Dry the edges and surrounding skin.

• Consider an adhesive application such as tincture of benzoin or Mastisol (Ferndale Laboratories, Ferndale, MI). Both may be applied to the skin via a cotton-tipped applicator before applying tape. They may offer some degree of protection from allergy to the adhesive in the tape, and they improve the adherence of the tape. Mastisol does appear to have superior adhesion and fewer adverse reactions.⁷

• If significant swelling is anticipated, it is probably best not to apply an adhesive.

• Elastic tape may be used, but should be used with caution if swelling is anticipated as it may also cause blistering of the skin.

• Ensure that the wound edges are nicely aligned. Starting at the center of the wound, apply strips in an evenly spaced manner opposing gravity, until the edges of the wound are approximated (Figure 6-6).

FIGURE 6-6 Application of adhesive skin tape. A, Start at the center of the wound. B, Apply the strips, evenly spaced, until the edges of the wound are approximated. (From Bonewit-West K: Clinical procedures for medical assistants, ed 7, St. Louis, 2008, Saunders.)

• Do not apply too much tension across a wound that may swell, or the tape may cause blisters.

Topical Liquid Skin Adhesive

Tissue adhesives are polymers formulated to be used in place of nonabsorbable sutures for primary closure of skin wounds. Commercially available tissue adhesives include Histoacryl (B. Braun, Melsungen, Germany), Dermabond (Ethicon, Somerville, NJ), and Indermil (Syneture brand; Covidien, Dublin, Ireland).⁸ These products are approved for the closure of skin wounds and as barriers against certain bacterial infections (Figure 6-5, B).

Usage

Skin tissue adhesives may be used in place of nonabsorbable sutures for primary closure of skin wounds. For wounds that are under tension, deep sutures are recommended. These products should not be used on the oral mucosa or across joints, where repetitive movement may cause the adhesives to slough prematurely. These adhesives do not replace the necessity for appropriate wound care. Wounds still need careful examination and exploration with irrigation and debridement when appropriate. These tissue adhesives polymerize to form a firm, pliable film that bridges the edges of the wound and binds to the epithelium. The adhesives are water resistant enough to permit showering after 48 hours and the material typically sloughs off with keratinized epithelium about 5 to 10 days after applications.

If used appropriately, the adhesive will act as a strong bridge to hold well-apposed wound edges together.⁹ When necessary, deep dermal sutures (vertical mattress stitches) are used to bring the skin edges into everted apposition.⁹ Everted edges are extremely important to successful closure with tissue adhesives, because they prevent scar broadening and improve the cosmetic result. Everted skin apposition should be maintained with forceps or fingers during the application of adhesive.

The adhesive should be applied to dry tissue that is under very little tension. For best results, a thin layer should be applied over the epidermis and allowed to dry for approximately 20 to 30 seconds. This method prevents pooling and running of the tissue adhesive, and it also provides a layer of protection from the heat generated by the exothermic polymerization.¹⁰ Subsequent layers of the adhesive are then applied over the top of this initial layer.

When applying tissue adhesives, it is important to ensure that the adhesive does not leak into the wound. If leakage into the wound occurs, the adhesive acts as a barrier to epithelialization. The adhesive may also cause a foreign-body reaction and potentially increase the risk of infection if it enters the wound.11,12 It is also important to remember to use proper sterile technique and to minimize tissue trauma while applying these products. Always reduce skin tension at the site of the laceration and ensure that no dead space is present before sealing with a tissue adhesive.