Suturing BasicsTerren Trott
Objectives
• Understand Basic Suturing Anatomy • Indications for Suturing• Materials and Preparation• Suturing Techniques
Options to Sutures• Dermabond
– Superficial lacerations– Facial lacerations
• Staples– Commonly used on the scalp or huge lacerations– Faster, lower infection, reduced inflammation– Greater tensile strength– CI: face, joints, hands
• Steristrips• Healing by Secondary Intention
– If wound has been open for more than 6 hours
Suture Anatomy
• Absorbable– Plain gut, FAST gut,
vicryl, monocryl• Non-absorbable– Ethilon (Nylon)– Silk– Polypropylene
(Prolene)• Monofilament Vs
Polyfilament
Suturing Preparation
• Hemostasis• Anesthetic• Irrigation• Exploration• Draping• Suture selection
Hemostasis
• Direct pressure and elevation• Blood Pressure Cuff• Lidocaine with Epinephrine• Figure-8 stitch
AnestheticName Onset Duration Max Dosing
Lidocaine 1 – 5 minutes 1.5 – 2 hours 4mg/kg
Lidocaine with Epi 1 – 5 minutes 2 – 3 hours 7mg/kg
Mepivacaine 1 – 5 minutes 3 hours 5mg/kg
Mepivacaine with Epi 1 – 5 minutes 4 – 5 hours 7mg/kg
Bupivacaine 10 – 15 minutes ~4 hours 2.5mg/kg
Bupivacaine with Epi 10 – 15 minutes ~8 hours 3mg/kg
Anesthetic PearlsEpinephrine vasoconstricts
Amides: have two ‘I’s in the name, esters have one ‘I’Infiltrate with anesthetic slowly to reduce the burn
Consider digital blocksBicarb can be used to buffer lidocaine and reduce burning
Withdraw on the syringe to make sure you’re not in a vessel
What does lidocaine toxicity look like?
• Early symtoms– Headache, nausea/vomiting, AMS
• Late Symptoms– Seizures– Cardiac Arrythmias: PEA, vtach, torsades
• Tx: Sodium Bicarb, IV Lipids
Irrigation
IRRIGATIONIRRIGATIONIRRIGATIONIRRIGATIONIRRIGATIONIRRIGATIONIRRIGATION
Exploration
• Radiograph/Ultrasound for foreign bodies• Digital exploration of scalp lacerations for skull
fractures• Tendon injuries must be examined through
entire course of anatomical range• Missed foreign objects are a common source
of Emergency Department litigation
Anatomic Site Skin Deep DurationScalp 5-0, 4-0 Monofilament 4-0 Absorbable 6–8 daysEar 6-0 Monofilament N/A 4–5 daysEyelid 7-0, 6-0 Monofilament N/A 4–5 daysEyebrow 6-0, 5-0 Monofilament 5-0 Absorbable 4–5 daysNose 6-0 Monofilament 5-0 Absorbable 4–5 daysLip 6-0 Monofilament 5-0 Absorbable 4–5 daysFace/forehead 6-0 Monofilament 5-0 Absorbable 4–5 daysChest/abdomen 5-0, 4-0 Monofilament 3-0 Absorbable 8–10 daysBack 5-0, 4-0 Monofilament 3-0 Absorbable 12–14 daysArm/leg 5-0, 4-0 Monofilament 4-0 Absorbable 8–10 daysHand 5-0 Monofilament 5-0 Absorbable 8–10 daysb
Extensor tendon 4-0 Monofilament N/A N/AFoot/sole 4-0, 3-0 Monofilament 4-0 Absorbable 12–14 days
Suture Technique Pearls• “Approximate, Don’t Strangulate”• For proper wound eversion, the needle should enter the dermis at 90
degrees• Exit the wound equidistant from the entry site• Reduce tension with deep sutures• No matter how small the laceration, use universal blood precautions• Antibiotics are no substitute for thorough irrigation and cleaning• Shaving hair is a relative contraindication• Use only the minimum number of sutures, excess sutures provide a
nidus for infection• Grasp needle ¾ of distance from tip• Use the forceps to grasp under the dermis to prevent crush injury
Knot Tying Pearls
• Knot throwing: throw as many knows as size suture material• 6-0 throw 6 knots
• Knots are tied in opposite directions• Hand tie vs. instrument tie
Simple Interrupted
• Most commonly used technique to close skin• Attempt to keep all knots on one side• For uncomplicated wound closure
Vertical Mattress• Large bite 1 – 1.5 cm from
wound edge, cross equidistant to other wound edge.
• Reverse the needle• Enter the dermalepi-
dermal junction, 2 – 3mm from wound edge
• Advantages: acts as both deep and superficial closure, reducing wound tension
Horizontal Mattress
• All entry and exit points are equidistant
• Advantages: distribution of tension across greater area, improved wound eversion
Corner Stitch
• Advantages: approximation of corners and stellate lacerations without capillary compromise of the corner
Running
• Advantages: Faster• Disadvantages: one compromised stitch
compromises entire suture
Deep Sutures
• To decrease tension and approximate tissues
• Enter the tissue low and exit high so that the knot ties to the bottom
References
• http://www.jpatrick.net/WND/woundcare.html