Carotid Massage

Carotid Massage

Simplify version:
1.First auscultate over the carotids for any bruit, which is produced by atheromatous plaque, which may dislodge and causes stroke if massage if given.
2.If no bruit, give massage over the carotid area so that the carotid body gets compressed over vertebral body.Give the massage for 5 sec and ask pt to do valsalva maneuver at the same time and stop both suddenly at the same time.Give massage on the other sides for 2-3 times.

Carotid Massage

Proper Explanation:

Carotid sinus massage involves rubbing the large part of the arterial wall at the point where the common carotid artery, located in the neck, divides into its two main branches(dilated area superior to the bifurcation of the common carotid at the level of the superior border of thyroid cartilage).

Carotid sinus massage will slow the heart rate during episodes of atrial flutter, fibrillation, and some tachycardias. It has been known to stop the arrhythmia completely. If the procedure is being done to help diagnose angina pectoris, massaging the carotid sinus may make the discomfort go away.

The patient will be asked to lie down, with the neck fully extended and the head turned away from the side being massaged. While watching an electrocardiogram monitor, the doctor will gently touch the carotid sinus. If there is no change in the heart rate on the monitor, the pressure is applied more firmly with a gentle rotating motion. After massaging one side of the neck, the massage will be repeated on the other side. Both sides of the neck are never massaged at the same time.
Doctor must be sure there is no evidence of blockage in the carotid artery before performing the procedure. Massage in a blocked area might cause a clot to break loose and cause a stroke.


Absolute contraindications to carotid sinus massage include myocardial infarction, transient ischemic attack or stroke within the preceding three months. A history of ventricular fibrillation or tachycardia, or a previous adverse reaction to carotid sinus massage are also absolute contraindications. A relative contraindication is the presence of carotid bruits, which should be evaluated by Doppler ultrasonography before proceeding with massage. If the ultrasound shows stenosis or atheroma, the patient should understand the risks and benefits of the procedure.

Carotid sinus massage should be discontinued immediately if the ECG shows asystole for more than three seconds. If asystole is prolonged, a chest blow should be administered. If neurologic complications occur, the procedure should be stopped, aspirin should be given if not contraindicated, and the patient should be closely observed. Symptoms of pre-syncope or syncope should be recorded and compared with the original symptoms for which the patient is being evaluated. The procedure is then repeated on the left side with the patient in the supine position, and then on both sides with the patient in the erect position. The diagnostic rate increases when the carotid sinus massage is repeated in the upright position. The baseline values should return before the next step of the procedure is begun. After the procedure, the patient should be observed in the supine position for at least 10 minutes before discharge.



Valsalva Maneuver

The Valsalva  manoeuvre is performed by moderately forceful attempted exhalation against a closed airway, usually done by closing one's mouth, pinching one's nose shut while pressing out as if blowing up a balloon. Variations of the maneuver can be used either in medical examination as a test of cardiac function and autonomic nervous control of the heart, or to clear the ears and sinuses by equalize pressure between them when ambient pressure changes, as in diving, hyperbaric oxygen therapy, or air travel.

By Lakdhes. 

Smoking Cessation

I'm blogging after sometime..Hope the grammar is readable.Today i would like to write about smoking cessation.Many try to stop smoking but eventually failed after sometime.It's not your fault solely..It's due to the real  culprit,nicotine.

Bupropion is a drug primarily used as an 
atypical antidepressant and smoking cessation aid. 
also widely used to reduce nicotine cravings by people who are trying to quit smoking.It used  an aid for smoking cessation where it reduces the severity of nicotine cravings and withdrawal symptoms.

A typical bupropion treatment course lasts for seven to twelve weeks, with the patient halting the use of tobacco about ten days into the course. Bupropion approximately doubles the chance of quitting smoking successfully after three months. One year after treatment, the odds of sustaining smoking cessation are still 1.5 times higher in the bupropion group than in the placebo group.

The evidence is clear that bupropion is effective at reducing nicotine cravings. Whether it is more effective than other treatments is not as clear, due to a limited number of studies.Other than bupropion,Varenicline also can be used for smoking cessation but it has a greater amount of side effects.

Other than drug therapy ,Nicotine replacement therapy  is the remedial administration of nicotine to the body by means other than tobacco, usually as part of smoking cessation. Common forms of nicotine replacement therapy are nicotine patches(which transdermally administers nicotine) and nicotine gum (which orally administers nicotine). 

The primary benefit of nicotine replacement therapy is that it prevents cravings in a smoker whilst allowing him to abstain from tobacco—and thus avoid the harmful effects of smoking. Nicotine replacement therapy enables the easier overcoming of nicotine addiction because it reduces the craving to smoke.
The use of nicotine replacement therapy increases the success of initially quitting smoking by 50 to 70%. So before trying any of those,see a doctor and do as directed by the physician.


Thank you.
by Lakdhes..

Bodybuilding

Boxing Day

LaSt wEEk-Endotracheal Intubation and Intravenous cannulation

·   Endotracheal intubation

·       Indicated in cardiac arrest, serious head injury, certain acute respiratory and trauma settings, and prior to many surgical operations

• Effective bag and mask ventilation is better than multiple attempts at endotracheal intubation in the arrest setting.
• Except in a dire emergency endotracheal intubation should not be performed without expert supervision.

Equipment:

• 10mL syringe.

• Endotracheal tube (ET; size 8-9 for females and 9-11 for         males).

• Laryngoscope.

• Ribbon to secure tube; lubricating jelly

Steps:

• Pre-oxygenate the patient.

• Ensure that the laryngoscope and ET cuff are        functioning.

• Remove any dentures, and suction excess saliva and secretions.

• Extend the neck.

• Insert the laryngoscope pushing the tongue to the left.

• Advance the scope anterior to the epiglottis and pull gently but firmly upwards to expose the        vocal cords. Take care not to lever on the upper teeth with the  scope.

• Insert the lubricated ET tube between the cords into the trachea.

• Confirm correct positioning of the tube by observing chest movements, and listening over lung    bases and stomach.

• Progressively inflate the cuff and attach ventilation equipment.

• Confirm correct cuff inflation by listening for whistling or bubbling in the larynx suggesting air  leak and secure the tube in place with ribbon.

• * Patients not in cardiac arrest or who maintain a gag reflex will need anesthetizing prior to  oropharyngeal intubation, i.e. administration of inducing agent plus muscle relaxant.

• * The best setting to learn intubation is preoperatively in the anesthetic room of a theater with  good supervision in controlled conditions.

                                                

and .....

Intravenous cannulation

A similar skill to that of simple venepuncture but needs plenty of practice to become competent. If having difficulty, observe a few experts in action.

Indications

Venous access for administration of IV fluids, blood, or IV drugs.

Equipment

• Tourniquet.

• Cannula: 20G or 18G.

• Adhesive dressing/tape.

• Alcohol swabs.

• 5mL syringe containing 0.9% saline or heparinized      saline.

• IV fluid bag with giving set, if necessary.

Preparation

Apply tourniquet above or below the elbow and inspect the arm for suitable engorged veins.

Method

• Clean the skin thoroughly at the site of access.

• Identify a suitable vein.

• Tether the skin distal to the proposed site of puncture.

• Pass the cannula obliquely through the skin at a point approximately 1cm distal to the point at which you wish to enter the vein.

• Advance the cannula smoothly until the vein is entered: a flashback  seen in the hub of the cannula.

• Hold the hub of the needle with one hand and advance the cannula into the vein, while maintaining skin fixation until the cannula is well into the vein.

• Remove the tourniquet and press on the vein proximal to the cannula as the needle is removed. Apply the screw cap to the end of the cannula.

• Secure the cannula in place with a dressing.

• If the cannula is not going to be used immediately, flush with heparinized saline

Tips 

• Poor veins. If the patient is cold and the samples non-urgent, place the arm in warm water and this may aid venous dilatation. Veins on the dorsum of the hand may be the only ones readily available-try using a smaller or butterfly needle to obtain samples.
• Obese patients. Try the dorsum of the hand or the radial aspect of the wrist; access may be easier here.
• Failed attempts. Repeated failed attempts will distress the patient and demoralize the doctor! Ask someone to help. If the samples are extremely urgent, a femoral stab may be the best option for obtaining blood samples, e.g. during cardiac arrest.
• IV cannulae. If blood samples and IV access are needed, a sample can be taken immediately after inserting the cannula. However, do not use a peripheral cannula for routine samples; they can be haemolysed, contaminated by IV fluids, and unreliable.

• Agitated or fitting patients. Try not to place the cannula over a joint, as these tend to become easily dislodged
• Secure the cannula. Cannulas are all too easily dislodged because of poor fixation to the skin. Use of two cannula dressings (one placed above and one below) and a bandage is often needed.
• Hairy arm. Shaving the skin at the planned cannula site seems tedious but will allow the cannula to be secured adequately.
• Non-dominant hand. Placing the cannula in the non-dominant hand, if possible, will allow the patient a little bit more freedom and may prevent the cannula becoming dislodged easily.
• Fragile veins. This tends to be a problem in elderly or debilitated patients. Try using a smaller cannula: the dorsum of the hand is often an ideal site.
• Poor peripheral access. In some patients with multiple collapsed or damaged veins alternative cannula sites may have to be considered, e.g. feet. If peripheral cannulation becomes impossible, a central line will have to be considered.
• Blood transfusion. If blood is being given IV then an 18G or 16G cannula will be needed.

Size and function of different cannulae

Colour Size   Flow mL/min Use Blue 22G 31 Small fragile veins, paediatrics Pink 20G 55 IV drugs and fluid/slow transfusion Green 18G 90 IV fluids, drugs White 17G 135 Grey 16G 170 Rapid IV fluids, in emergencies Brown 14G 265

before I end this post..
Last Week:

Wonder how this happen.(.it is a button)

This made to go back that day..

 missing them..

during free time..

by Lakdhes..

Heel Pain Management

Heel Pain Management  

heel pain/foot pain/feet pain/leg pain 

Well. I'm blogging after quite long gap..Nothing much too say,just can't find the proper time to write.Life here is so hectic.Most of the time ,some idiots out there having rally and strikes.I really don't know what's the point.because this, most of the time,no internet connection,yet I still have to pay for it..and my fucking college life..Everyday have to go and stand there like a chicken,don't understand a single word.Then why they said this is an English medium.So.let me come the point.The topic I'm going to write today is foot pain.I'm sure many of you having the same problem.(even my mum having this pain).

Plantar fascitis , also known as Plantar Heel Pain (PHP) is a painful inflammatory process of the plantar fascia, the connective tissue or ligament on the sole (bottom surface) of the foot. It is often caused by overuse of the plantar fascia, increases in activities, weight or age. It is a very common condition and can be difficult to treat if not looked after properly.

Longstanding cases of plantar fasciitis often demonstrate more degenerative changes than inflammatory changes, in which case they are termed plantar fasciosis. Since tendons and ligaments do not contain blood vessels, they do not actually become inflamed. Instead, injury to the tendon is usually the result of an accumulation over time of microscopic tears at the cellular level.

The plantar fascia is a thick fibrous band of connective tissue originating on the bottom surface of the calcaneus (heel bone) and extending along the sole of the foot towards the toes. It is commonly associated with long periods of weight bearing and much more prevalent with hyper-pronation (flat feet). Among non-athletic populations, it is associated with a high body mass index. The pain is usually felt on the underside of the heel and is often most intense with the first steps of the day. Another symptom is that the sufferer has difficulty bending the foot so that the toes are brought toward the shin (decreased dorsiflexion of the ankle). A symptom commonly recognized among sufferers of plantar fasciitis is an increased probability of knee pains, especially among runners

An incidental finding associated with this condition is a heel spur, a small bony calcification on the calcaneus heel bone, in which case it is the underlying plantar fasciitis that produces the pain, and not the spur itself. The condition is responsible for the creation of the spur; the plantar fasciitis is not caused by the spur.

Sometimes ball-of-foot pain is mistakenly assumed to be derived from plantar fasciitis. A dull pain or numbness in the metatarsal region of the foot could instead be metatarsalgia, also called capsulitis. Some current studies suggest that plantar fasciitis is not actually inflamed plantar fascia, but merely an inflamed flexor digitorum brevis muscle (FDB) belly. Ultrasound evidence illustrates fluid within the FDB muscle belly, not the plantar fascia.

Treatment

Physical treatments

Based on current research, recommendations for immediate relief and reduction of inflammation include heel and foot stretching exercises as can be tolerated, microcurrent treatment, rest, wearing shoes with good support and cushions. Other steps to relieve pain include: applying ice or ice-heat-ice, and/or using night splints to stretch the injured fascia. Customized functional foot orthotics can offer a decrease in the pain associated with plantar fasciitis and may provide an additional benefit in terms of increased functional ability in patients with the condition.

Some evidence shows that stretching of the calf and plantar fascia may provide up to 2–4 months of benefit. One study has shown improvement over a four-month period with stretching. One study has shown high success rates with a stretch of the plantar fascia, but has been criticized because it was not blinded, and contained a bias because the analysis did not use the intention to treat method. Because it is impractical to do double-blind experiments involving stretching, such studies are vulnerable to placebo effects.

Pain with the first steps of the day can be markedly reduced by stretching the plantar fascia and Achilles tendon before getting out of bed. Night splints can be used to keep the foot in a dorsi-flexed position during sleep to improve calf muscle flexibility and decrease pain on waking. These have many different designs. The type of splint has not been shown to affect outcomes.

Surgery 

Surgery carries the risk of nerve injury, infection, rupture of the plantar fascia, and failure to improve the pain.This allows more space for the inflamed muscle belly, thus, relieving pain/pressure. An ultrasound-guided needle fasciotomy can be used as a minimally invasive surgical intervention for plantar fasciitis. A needle is inserted into the plantar fascia and moved back and forwards to disrupt the fibrous tissue.Coblation surgery  has been used successfully in the treatment of recalcitrant plantar fasciitis. This procedure utilizes radiofrequency ablation and is a minimally invasive procedure.

Medication 

To relieve pain and inflammation, nonsteroidal anti-inflammatory drugs (NSAIDs) such as aspirin and ibuprofen are often used but are of limited benefit.Dexamethasone 0.4 % or acetic acid 5% delivered by iontophoresis(Iontophoresis is a physical process in which ions flow diffusively in a medium driven by an electric field  to treat of excessive sweating of the hands and feet )    combined with low Dye strapping and calf stretching has been shown to provide short term pain relief and increased function.

Local injection of corticosteroids often gives temporary or permanent relief, but may be painful, especially if not combined with a local anesthetic and injected slowly with a small-diameter needle.(Injecting dexamethasone and lidocaine ,but dont try yourself).Recurrence rates may be lower if injection is performed under ultrasound guidance.Repeated steroid injections may result in rupture of the plantar fascia.

by Lakdhes..

Methods of Surgical Suturing

Suture Material

Many different suture materials are available. The main classifications are absorbable or nonabsorbable. A more subtle subclassification is whether the suture material is braided or nonbraided. Unless there is a dire emergency, never use regular thread for sutures because of the risk of infection.

 Nonabsorbable Sutures
Nonabsorbable sutures remain in place until they are removed. Because they are not dissolved by the body, they are less tissue-reactive and therefore leave less scarring as long as they are removed in a timely fashion. They are best used on the skin. 

Absorbable Sutures 
Absorbable sutures are dissolved by the body's tissues. The great advantage is that the sutures do not need to be removed. However, absorbable sutures tend to leave a more pronounced scar when used as skin sutures. Absorbable sutures are primarily used under the skin, where they are well hidden. It is sometimes difficult to get patients to return for suture removal. If this is a concern, use an absorbable suture for skin closure. You should warn the patient that absorbable sutures probably will result in a more noticeable scar than nonabsorbable sutures with later removal. Because it is often difficult to remove stitches from children (because of their crying and difficulty in staying still), absorbable materials should be used when suturing their wounds.

 Braided Sutures 
Braided sutures are made up of several thin strands of the suture material twisted together. Braided sutures are easier to tie than nonbraided sutures. However, braided sutures have little interstices in the suture material, which can be a place for bacteria to hide and grow, resulting in an increased risk of infection. 

Nonbraided Sutures 
Nonbraided sutures are simply a monofilament, a single strand. They are not made up of the little subunits found in a braided suture. Nonbraided sutures are recommended for most skin closures, especially wounds that may be at risk for infection



Suturing Techniques

When suturing the edges of a wound together, it is important to evert the skin edges—that is, to get the underlying dermis from both sides of the wound to touch. For the wound to heal, the dermal elements must meet and heal together. If the edges are inverted (the epidermis turns in and touches the epidermis of the other side), the wound will not heal as quickly or as well as you would like. The suture technique that you choose is important to achieve optimal wound healing.

Instruments Needed

Needle holder:

used to grab onto the suture needle.


 Forceps:

used to hold the tissues gently and to grab the needle 


Suture scissors:

used to cut the stitch from the rest of the suture material




How to Hold the Instruments
Whenever you use sharp instruments, you face the risk of accidentally sticking yourself. Needlesticks are especially hazardous because of the risk of serious infection (hepatitis, human immunodeficiency virus). 
To prevent needlesticks, get in the habit of using the instruments correctly. Never handle the suture needle with your fingers. 

1.Scissors-Place your thumb and ring finger in the holes. It is best to cut with the tips of the scissors so that you do not accidentally injure any surrounding structures or tissue (which may happen if you cut with the center part of the scissors). 

2.Needle Holder-Place your thumb and ring finger in the holes. When using the needle holder, be sure to grab the needle until you hear the clasp engage, ensuring that the needle is securely held. You grab the needle at its half-way point, with the tip pointing upward. Try not to grab the tip; it will become blunt if grabbed by the needle holder. Then it will be difficult to pass the tip through the skin.

3.Forceps-Hold the forceps like a writing utensil. The forceps is used to support the skin edges when you place the sutures. Be careful not to grab the skin too hard, or you will leave marks that can lead to scarring. Ideally, you should grab the dermis or subcutaneous tissue—not the skin—with the forceps, but this technique takes practice. For suturing skin, try to use forceps with teeth, which are little pointed edges at the end of the forceps.



Placing the Sutures
For most areas of the body, except the face ,the sutures should be placed in the skin 3–4 mm from the wound edge and 5–10 mm apart. Sutures placed on the face should be approximately 2–3 mm from the skin edge and 3–5 mm apart. 
Sutures placed elsewhere on the body should be approximately 3–4 mm from the skin edge and 5–10 mm apart.Start on the side of the wound opposite and farthest from you to ensure that you are always sewing toward yourself. By sewing toward yourself, the suturing process is made easier from a biomechanical standpoint.

Simple Sutures Indication.

This technique is the easiest to perform. It is used for most skin suturing. 
Technique
1.Start from the outside of the skin, go through the epidermis into the subcutaneous tissue from one side, then enter the subcutaneous tissue on the opposite side, and come out the epidermis above. 
2.To evert the edges, the needle tip should enter at a 90°angle to the skin. Then turn your wrist to get the needle through the tissues. 3.You can use simple sutures for a continuous or interrupted closure.


Interrupted Sutures
 •Interrupted sutures are individually placed and tied.
•They are the technique of choice if you are worried about the cleanliness of the wound.
 •If the wound looks like it is becoming infected, a few sutures can be removed easily without disrupting the entire closure.
•Interrupted sutures can be used in all areas but may take longer to place than a continuous suture.

Continuous Closure
 •Place the sutures again and again without tying each individual suture.
•If the wound is very clean and it is easy to bring the edges together, a continuous closure is adequate and quicker to perform. •Continuous closure is the technique of choice to help stop bleeding from the skin edges, which is important, for example, in a scalp laceration.


Mattress Sutures Indication.
Mattress sutures are a good choice when the skin edges are difficult to evert. Sometimes you may want to close a wound with a few scattered mattress sutures and place simple sutures between them. It is a bit more technically challenging to place mattress sutures, but it is often worth the effort because good dermis-to-dermis contact is achieved

Technique
1.Start like a simple suture, go from the outside of the skin through the epidermis into the subcutaneous tissue from one side, then enter the subcutaneous tissue on the opposite side, and come out the epidermis above. 
2.Turn the needle in the opposite direction and go from outside the skin on the side that you just exited and come out the dermis below. Then enter the dermis on the opposite side and come out of the epidermis above. 
3.Your suture is now back on the side on which you started.

Buried Intradermal Sutures
Indication-
This technique is useful for wide, gaping wounds and when it is difficult to evert the skin edges. When buried intradermal sutures are placed properly, they make skin closure much easier. The purpose of this stitch is to line up the dermis and thus enhance healing. The knot needs to be as deep into the tissues as possible (hence the term buried) so that it does not come up through the epidermis and cause irritation and pain.
Technique
1.Use a cutting needle and absorbable material.
2.Start just under the dermal layer and come out below the epidermis. You are going from deep to more superficial tissues
3.Now the technique becomes a bit challenging. You need to enter the skin on the opposite side at a depth similar to where you exited the skin on the first side, just below the epidermis. To do so, you should position the needle with the tip pointing down and pronate your wrist to get the correct angle. It will help to use the forceps (in the other hand) to hold up the skin. The needle should come out of the tissues below the dermis. Try to get as little fat in the stitch as possible; it does not contribute to the suture. 
4.Tie the suture.


Figure-of-eight Sutures
 Indication.This technique is useful for bringing together underlying tissues such as muscle, fascia, or extensor tendons. It is not commonly used for skin closure.
 Technique
 1.Usually a tapered needle and absorbable sutures are used.
 2.Start on the side opposite from you. Go through the full thickness of tissues on that side, then finish the first half of the stitch by going from bottom to top on the opposite side. Advance just a little farther (1.0–1.5 cm) along the tissue. The needle should now be back on top of the tissue. 
3.Now enter the first side (going from top to bottom) just across from the suture on the other side. Again go through the full thickness of the tissue and come out on the undersurface of the tissue. 
4.Now enter the undersurface of the other side even with the first suture and come out on top.
5.The suture can now be easily tied.

Tying the Suture
 The simplest way to tie the suture is by doing an “instrument tie".

Simple Sutures
1.Pull the suture through the skin so that just a short amount of suture material (a few centimeters) is left out. 
2.Take the needle out of the needle holder. 
3.Place your needle holder in the center between the skin edges parallel to the wound. One end of the suture should be on each side of the wound without crossing in the middle.
 4.Wrap the suture that is attached to the needle once or twice around the needle holder in a clockwise direction. 
5.Grab the short end of the suture with the needle holder.
 6.Pull it through the loops, and have the knot lie flat. The short end of the stitch should now be on the opposite side. 
7.Let go of the short end. 
8.Bring the needle holder back to the center, parallel to the wound edges. 
9.Repeat steps 4–8 at least one or two times more. 
10.Cut the suture ends about 1 cm from the knot

Mattress Sutures
1.Pull the suture through the skin so that just a short amount of suture material (a few centimeters) is left out. 
2.Take the needle out of the needle holder. 
3.Both ends of the suture are on the same side. Place your needle holder between the ends of the suture. 
4.Wrap the suture that is attached to the needle once or twice around the needle holder in a clockwise direction. 
5.Grab the short end with the needle holder. 
6.Pull it through the loops, and have the knot lie flat. The short end of the stitch should now be on the opposite side. 
7.Let go of the short end.
8.Bring the needle holder back to the center, between the suture ends. 
9.Repeat steps 4–8 at least one or two times more. 
10.Cut the suture ends about 1 cm from the knot.

 Continuous Suture 
1.Do not pull the next to-the-last stitch all the way through; leave it as a loop. 
2.Place your needle holder between the loop and the suture attached to the needle. The needle holder should be almost perpendicular to the wound. 
3.Wrap the suture that is attached to the needle once or twice around the needle holder in a clockwise direction. 
4.Grab the loop with the needle holder.
5.Pull it through, and have the knot lie flat. The short loop should now be on the opposite side.
6.Let go of the loop. 
7.Bring the needle holder back to the center between the loop and the suture end. 
8.Repeat steps 3–7 at least one or two times more. 
9.Cut the suture ends about 1 cm from the knot.


Suture Removal
If the sutures are taken out within 7–10 days, suture removal is usually easy and should not cause more than a pinching sensation to the patient.

 Simple Sutures-
1.Cut the suture where it is exposed, crossing the wound edges. 2.Remove the entire stitch by grabbing the knot with a clamp or forceps and pulling gently.

 Mattress Sutures -
Removal of mattress sutures can be a little more difficult. 
1. Grab the knot and try to lift it up a little; this should allow you to see a space between the suture strands
2.Cut one strand of the suture under the knot. 
3.Remove the entire stitch by grabbing the knot with a clamp or forceps and pulling gently. This suture will be a little harder to remove than a simple suture. 
4.If you accidentally cut both ends of the suture, you will leave suture material behind.
 5.Look on the opposite side of the skin for the suture. Grab it with a clamp or forceps, and gently remove the remaining suture material.

 Continuous Sutures-
 1.Cut the suture in several places where it is exposed, crossing the wound edges. 
2.Remove portions of the stitch by grabbing an end with a clamp or forceps and pulling gently. 
3.The sutures to the knot must be cut in several places for removal.

by Lakdhes..