suturing basics terren trott. objectives understand basic suturing anatomy indications for suturing...

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 days

Ear 6-0 Monofilament N/A 4–5 days

Eyelid 7-0, 6-0 Monofilament N/A 4–5 days

Eyebrow 6-0, 5-0 Monofilament 5-0 Absorbable 4–5 days

Nose 6-0 Monofilament 5-0 Absorbable 4–5 days

Lip 6-0 Monofilament 5-0 Absorbable 4–5 days

Face/forehead 6-0 Monofilament 5-0 Absorbable 4–5 days

Chest/abdomen 5-0, 4-0 Monofilament 3-0 Absorbable 8–10 days

Back 5-0, 4-0 Monofilament 3-0 Absorbable 12–14 days

Arm/leg 5-0, 4-0 Monofilament 4-0 Absorbable 8–10 days

Hand 5-0 Monofilament 5-0 Absorbable 8–10 daysb

Extensor tendon 4-0 Monofilament N/A N/A

Foot/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