Basic Suturing

Cynthia Durham, MSN, ANPC, RNFA

“Your greatest tool is your ability to critically think: it is not your hands” Charles 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 anesthetic Simple interrupted suture closure Vertical Mattress suture closure

and if mastered, then Running 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 vessels

Suture ligature for larger vessels Topical or injected agents

May be life saving Allows for proper visualization of wound Enables accurate repair Promotes wound healing Decreases 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 wound◦Usually the cleanest and most easily repair

Blunt - i.e. Baseball bat lac◦Usually with underlying hematoma◦Frequently 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 wound

◦Convert to tidy via irrigation and/or debridement

3. Clean - little bacterial contamination of wound

4. 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 components◦Vascular spasm◦Platelet aggregation◦Coagulation

2. Inflammatory response3. Collagen formation4. Wound contracture5. Re- epithelization

Age Anatomic location Technical Associated conditions Drugs

Diabetes- vascular compromiseAnemia – dec O2 transportRenal failure – toxic metabolitesMalnutrition –dec protein synthesisSystemic infection - dec inflam response

Malignancy - nutritional deficiencies

Steroids - suppress inflammation, protein synthesis, wound contraction and re-epithelialization

ASA - suppresses inflammation Colchicine - arrests cell replication and suppresses collagen transport

Chemo - arrests cell replication, suppresses inflammation and protein synthesis

Chinchona Danshen Devil’s claw Garlic Gingko Papaya Feverfew Ginger Echinacea Vitamin 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 contamination

Untidy wounds with inadequate debridement

Wounds entering joints +/- Wounds > 6 hours old Animal or human bites Compromised host

“The art of life is the avoidance of pain” Thomas Jefferson

2 point discrimination Pain Light touch Paresthesia Pressure Proprioception

Esters – not usually used in laceration repair – short acting, more allergies◦Procaine (novocaine), tetracaine (pontocaine), cocaine

Amides - most widely used◦Lidocaine (xylocaine), bupivicaine (marcaine)

Blocks initiation and conduction of impulses

How supplied 1%, 2% Plain or w/epi Onset 0.5-1 min Duration 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 excitation

How supplied 0.25%, 0.5% Duration 3-6 hrs w/o epi

4-8 hrs w/epi Onset 10-20 min Max dose 175mg w/o epi

250mg w/epiPeds dose NONE

Advantages◦Vasoconstriction◦Decreases bleeding◦Decreases toxicity

Disadvantages◦Increases BP◦Increased allergic reaction +/-◦Tissue ischemia

Ph of tissue ~ 7.0 Ph of lido 6.49 Mix 1:10 stable 24 hours Ph of lido and bicarb = ~ 7.38

Packing – can be used w/epi or w/o

◦Advantage - no needles, doesn’t drag bacteria into wound, provides some hemostasis, works well in atrophic skin

◦Disadvantages - not as precise infiltration, may need a touch up

◦Technique - 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 solution Use a small needle – preferably 27-29 ga

Advantage – great for people with “caine” allergies

Disadvantage - very short acting

Advantage - noninvasive

Disadvantage - short acting

Doesn’t need to be sterile

Size based on circumference NOT strength

Range - #3, #2, #1, 0,1-0, 2-0, 3-0, 4-0, 5-0 etc to 12-0

7-0 = human hair circumference Choose finest suture capable of doing the job

See appendix for suture size by region

Absorbable

Gut, polyglycolic acid, polylactic acid, polydioxanone.

Known as – Chromic, Plain, Dexon, Vicryl, PDS

Break down either by hydrolysis or proteolytic enzymes

Used 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 unimpeded

Suture boxes usually have WYSIWYG pictures

Size is not standardized

4” needleholder Adson forceps Suture scissors Skin hook,scalpel, iris scissors

Halogens - chlorine, iodines Alcohol Biguanides Oxidizing agents Surfactants

Hair trimming – AVOID Packing the wound Irrigation Prep intact skin

Simple interrupted Vertical mattress Subcuticular

Easiest to put in & take out Can be used almost anywhere Can be alternated with VM Doesn’t always every skin edges

Best skin edge eversion Can be used anywhere Takes longer to put in Can be more difficult to take out

Used with non- and absorbable suture No “hash marks” No visible suture Easy & less painful to take out More difficult to do Gaps along suture line Patients like it Don’t 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 .5-1mm Nose 1.5-2mm Face 1-2mm Trunk 3-5mm Extremities 2.5-4mm Scalp 7-

7.5mm Dorsal Hand 1-2mm Volar hand 1.5-2.5mm Forehead 2-3mm

Site Adult ChildFace 4-5 3-4Scalp 6-7 5-6Trunk 7-10 6-8Arm 7-10 5-9Leg 8-10 6-8Ext surface 8-14 7-12Flex surface 8-10 6-8Hand 7-12 5-10Foot sole 7-12 7-10

Dressings - dry vs moisture permeable

Topical agents - bacitracin vs neosporin

Wound check - timing

Suture removal - when and how

Gentle tissue handling Meticulous hemostasis Needle enters/exits at right angles to skin Skin edges everted NOT inverted Ask for help and refer out PRN Seek out better technique