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Basic Suturing
Cynthia Durham, MSN, ANPC, RNFA
Your greatest tool is your ability to critically think: it is not your handsCharles Sherman MD
I have not received financial compensation from any pharmaceutical or suture company in preparation of this suturing course
At the end of this session the participant will be able to demonstrate:
Injection of a local anestheticSimple interrupted suture closureVertical Mattress suture closureand if mastered, thenRunning Subcuticular closure
Most important phaseTake your time Elicit much info quicklyBut in the meantime.
Direct pressure in absence of foreign bodies 5-10 minutes"Eye" cautery for smaller blood vesselsSuture ligature for larger vesselsTopical or injected agents
May be life savingAllows for proper visualization of woundEnables accurate repairPromotes wound healingDecreases scar tissue
Work either by: vasoconstriction or enhanced coagulation
Epi 1:100,000 injected along wound edge and wait 10 minutes (more to follow)
Surgicel wait 2-8 minutes absorbed in 1-2 weeks
Sharp - i.e. A knife woundUsually the cleanest and most easily repair
Blunt - i.e. Baseball bat lacUsually with underlying hematomaFrequently filled with devitalized tissue
"Golden period = ideal time to close
< 12 hours for most wounds
12 - 16 hours for facial wound
Tendon ID & fx assessment
Nerve testing
Blood supply assessment
Bone assessment
Laceration
Penetration
Amputation
1. Tidy no devitalized tissue or debris2. Untidy - + dead tissue/debris in woundConvert to tidy via irrigation and/or debridement3. Clean - little bacterial contamination of wound4. Contaminated - lots of bacteria in wound
5. Non- complex: Flat surface Right angle to skin surfaceLinear with a regular configuration away from critical anatomyParallel to skin tension lines
6. Complex woundConvexity or concavity Flexion crease At angle to normal skin crease Non-linear with skin flapsEdge irregularitiesOblique to skin surface
Must convert to non-complex configuration.
7. Simple Wound only dermis and fat lacerated
8. Compound Wound can involve nerves, ducts, tendons, major blood vessels, glands, fascia, muscle
1. Hemostasis - 3 componentsVascular spasmPlatelet aggregationCoagulation2. Inflammatory response3. Collagen formation4. Wound contracture5. Re- epithelization
AgeAnatomic locationTechnicalAssociated conditionsDrugs
Diabetes- vascular compromiseAnemia dec O2 transportRenal failure toxic metabolitesMalnutrition dec protein synthesisSystemic infection - dec inflam responseMalignancy - nutritional deficiencies
Steroids - suppress inflammation, protein synthesis, wound contraction and re-epithelializationASA - suppresses inflammationColchicine - arrests cell replication and suppresses collagen transportChemo - arrests cell replication, suppresses inflammation and protein synthesis
ChinchonaDanshenDevils clawGarlic GingkoPapaya FeverfewGingerEchinaceaVitamin E
First intention - evaluated, cleaned anesthtized sutured soon after injury
Second intention - heals by granulation
Third intention - left open for about 3 days and then sutured closed
Traumatic injuries with heavy contaminationUntidy wounds with inadequate debridementWounds entering joints+/- Wounds > 6 hours oldAnimal or human bitesCompromised host
The art of life is the avoidance of painThomas Jefferson
2 point discriminationPainLight touch ParesthesiaPressureProprioception
Esters not usually used in laceration repair short acting, more allergiesProcaine (novocaine), tetracaine (pontocaine), cocaineAmides - most widely usedLidocaine (xylocaine), bupivicaine (marcaine)
Blocks initiation and conduction of impulsesHow supplied1%, 2% Plain or w/epiOnset0.5-1 minDuration 30 - 120 min w/o epi 90-180 min w/epi Maximum dose plain 300 mgMaximum dose w/epi 500 mgPeds over 5 yo 75-100mg
Blocks conduction and generation by increasing threshold of excitationHow supplied0.25%, 0.5%Duration3-6 hrs w/o epi4-8 hrs w/epiOnset10-20 minMax dose175mg w/o epi250mg w/epiPeds dose NONE
AdvantagesVasoconstrictionDecreases bleedingDecreases toxicity
DisadvantagesIncreases BPIncreased allergic reaction +/-Tissue ischemia
Ph of tissue ~ 7.0Ph of lido 6.49Mix 1:10 stable 24 hoursPh of lido and bicarb = ~ 7.38
Packing can be used w/epi or w/o
Advantage - no needles, doesnt drag bacteria into wound, provides some hemostasis, works well in atrophic skinDisadvantages - not as precise infiltration, may need a touch upTechnique - gauze soaked with lido and packed snugly into wound
Infiltration -can be used w/epi or w/o
Advantages can direct exact amount into tissue, much more precise
Disadvatage- needle sticks
Technique inject thru lac edge not intact skin
Technique- insert needle thru lac edge not intact skin Warm the solution Inject s-l-o-w-l-y Buffer the solutionUse a small needle preferably 27-29 ga
Advantage great for people with caine allergies
Disadvantage - very short acting
Advantage - noninvasive
Disadvantage - short acting
Doesnt need to be sterile
Size based on circumference NOT strengthRange - #3, #2, #1, 0,1-0, 2-0, 3-0, 4-0, 5-0 etc to 12-07-0 = human hair circumferenceChoose finest suture capable of doing the jobSee appendix for suture size by region
Absorbable
Gut, polyglycolic acid, polylactic acid, polydioxanone.Known as Chromic, Plain, Dexon, Vicryl, PDSBreak down either by hydrolysis or proteolytic enzymesUsed for layered closure, mucous membranes or genitalia
Nonabsorbable:
Polypropylene, nylon or silk
Known as Ethilon, Silk, Dermalon, Prolene
Must be removed
Used for skin closure
Size long enough to pass thru tissue unimpededSuture boxes usually have WYSIWYG picturesSize is not standardized
4 needleholderAdson forcepsSuture scissorsSkin hook,scalpel, iris scissors
Halogens - chlorine, iodinesAlcoholBiguanidesOxidizing agentsSurfactants
Hair trimming AVOIDPacking the woundIrrigationPrep intact skin
Simple interruptedVertical mattressSubcuticular
Easiest to put in & take outCan be used almost anywhereCan be alternated with VMDoesnt always every skin edges
Best skin edge eversionCan be used anywhereTakes longer to put inCan be more difficult to take out
Used with non- and absorbable sutureNo hash marksNo visible sutureEasy & less painful to take outMore difficult to doGaps along suture linePatients like itDont use on face or hands
No deeper than laceration!!
Must have a respect for tissue below the depth of the laceration as well as laterally!!
From laceration edge
Eyelid .5-1mmNose 1.5-2mmFace 1-2mmTrunk 3-5mmExtremities 2.5-4mmScalp 7-7.5mmDorsal Hand 1-2mmVolar hand 1.5-2.5mmForehead 2-3mm
SiteAdultChildFace4-53-4Scalp6-75-6Trunk7-106-8Arm7-105-9Leg8-106-8Ext surface8-147-12Flex surface8-106-8Hand7-125-10Foot sole7-127-10
Dressings - dry vs moisture permeable
Topical agents - bacitracin vs neosporin
Wound check - timing
Suture removal - when and how
Gentle tissue handlingMeticulous hemostasisNeedle enters/exits at right angles to skinSkin edges everted NOT invertedAsk for help and refer out PRNSeek out better technique
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