Suturing in the Pediatric ED

Sujit Iyer, M.D.

Goals

• Review the fundamental history, preparation and techniques in suture repair in the ED

• Brief repair/pearls on how to make suturing more successful and less traumatic for pediatric patients

• Review discharge and follow up instructions

Checklist

• Type of Wound – Which do you close?• Wound care – Foreign body? How deep is it?• Choice of anesthetic – LET !?!• Suture type

Should you close it?

• Close only clean wounds!– Dirty wounds: MOST animal bites, contaminated wounds

you can not clean adequately • Cosmetic wounds – the face!• Wounds requiring hemostasis• New wounds: less than 12 hours old (up to 24 hours

on face)• Wounds overlying joints (knee) – make sure not

continuous with joint cavity – may need ortho consult to inject joint

Wound Care

• Irrigate it! Volume and pressure clear bacteria!– Use only saline or nontoxic surfactants

• Foreign bodies are rarely discovered unless you anticipate one! Consider using XR, CT, ultrasound when necessary– If grossly contaminated, irrigate and then XR

• Consider antibiotics for :– Contaminated wounds– Bite wounds– Crush wounds – Missile Wounds– Delayed wound closure

Irrigation technique

Wound Care Basics

• Always consider deeper damage and suture material needs:– Tendon, joint– Galea– Muscle/Fascia

l

Anesthesia

• Infiltrative anesthesia (Lidocaine) – Can be painful, ? If other painless equally effective

options (see LET) – Max dose: Without epi (4-5 mg/kg), with epi (5-7

mg/kg)– Consider nerve blocks to prevent toxicity for large

wounds

Infiltrative Anesthesia – PLEASE CONSIDER TOPICAL ANESTHESIA (LET) WHENEVER POSSIBLE

TOPICAL ANESTHESIA

• Alternative to local infiltrative anesthesia• LET gel – apply directly to wound with adhesive (i.e.,

Tegaderm) or with cotton ball and direct pressure• Advantages:

– NOT PAINFUL– May be only anesthetic needed for face or scalp– May decrease need for infiltrative anesthesia or at least

decrease pain for trunk and extremity wounds– Blanching of surrounding tissue indicates onset of

anesthesia – NO adverse side effects reported from systemic absorption

Anesthesia considerations in Pediatric laceration repair

• Anxiety equally (if not greater) component than pain. Tips to ease anxiety:– Child life consult – distraction techniques, explaining

procedure, etc..– Comfort positioning (see SLC module!)– Intranasal medicine (Versed, Fentanyl, or both)

• Use non painful anesthetics when possible (LET vs infiltrative lidocaine)

• Anxiety/pain of suture removal of non-absorbale sutures when absorbable suture equal cosmetic/functional option.

Sutures – The Basics to Consider

• Absorbable vs Non-absorbable– Absorbable: Fast absorbing gut, Chromic gut,

Vicryl, PDS– Non-absorbable: Prolene, Ethilon, Silk

• Smaller the number (“O”) the bigger the thread

• Packaging will show actual needle size • Curved needle for all ED needs

Which Suture, Where?

ABSORBABLE

• Fast Absorbing Gut– Face

• Chromic Gut– Mucous membs,

fingertip amputation• Vicryl

– Deep layers only• PDS

– Deep layers only

NON-ABSORBABLE

• Prolene– Any skin surface

• Ethilon– Any skin surface

• Silk– Rarely: suturing

tubes/lines in place

Which size; and for non-absorbable when do they come out?

Use size… Take out in…

Face 6.0, 5.0 3-5 days

Scalp 5.0 or staples 7-10 days

Trunk/extremity 4.0, 5.0 7-10 days

High tension/ back

4.0, 3.0 10-14 days

Mucous membrane

5.0 chromic gut no need

Let’s get started…

How to suture…

Discharge Instructions

• Watch for signs of infection • Topical or oral antibiotics when indicated • Suture removal timing if using non-absorbable• Tetanus? (look up if indicated)• How Do I minimize scar formation?

– Keep area clean, proper suture removal if indicated

– Sublock and Vitamin E (Scars form over the next 6 months to 1 year)