Tying the knot:Basic Suturing Workshop

Megan Vernatter ARNP, PSCBoard Certified Family Nurse PractitionerAshland Emergency Medical Associates

Objectives• Discuss the physiology of wound healing.• Outline the appropriate history and physical exam indicated for

management of a simple wound.• Differentiate between different types of local anesthetics based on

pharmacology, onset of action, and duration of action.• Demonstrate administration of local anesthesia for a given wound.• Prepare a wound for repair.• Demonstrate various wound closure techniques- simple interrupted

sutures, vertical mattress sutures, wound adhesives, staples and steri-strips.

• Develop a patient education plan for a repaired wound including follow-up and suture removal.

Anatomy of the Skin and Fascia

• Comprise a complex system of organs and anatomic features

• Layer arrangement is most important for wound closure

• Layers include the epidermis, dermis, superficial fascia (subcutaneous layer), and deep fascia

Physiology of Wound Healing Hemostasis- onset within minutes of injury, this includes vessel

vasoconstriction, platelet aggregation, the clotting cascade and hemostatic coagulum.

Inflammatory Phase- once activated then chemotactic factors, which attract granulocytes to the wound are released, followed by lymphocytes, then macrophages to stimulate fibroblast reproduction and neovascularization.

Epithelialization- epithelial cells at the stratum germinativum, or basal layer of the epidermis, undergo morphological and functional changes.

Neovascularization- newly formed vessels replace the old injured network and bring oxygen and nutrients to the healing wound.

Collagen Synthesis- begin to produce new collagen fibrils by day 2. Wound Contraction and Remodeling- every wound undergoes scar

remodeling over several months.

Key Practice Points• All lacerations produce scars.• The function of a scar is to repair a wound with

collagen, not to restore the original appearance of the injured tissue.

• The tensile or breaking strength of a repaired laceration is only 5% of normal skin at the time of suture removal.

• Final scar appearance and tensile strength are not reached for several months.

• The appearance and size of a scar can vary according to the mechanism of injury, anatomic location, wound infection, poor technique, and other factors.

Key Practice Points continued• Visibly embedded grit in the epidermis must be

removed to prevent permanent tattooing.• Sutures can produce permanent marks in the skin if

left longer than 7-14 days.• Some people can react to wounds by producing

excessive, hypertrophic, or keloid, scars.• There are no chemical or surgical methods to

eliminate scars.• Current research using growth factors has shown

that regeneration of injured tissue, rather than collagen deposition, may be possible in the future.

Cosmetic Outcome

Keloid scarring Chicks dig scars

Risks in Wound Care

• Wounds account for >10 million ED visits a yr• >25% of closed malpractice claims involve

wound care• 5% of wounds become infected• Retained foreign bodies are the top reason for

lawsuits related to wound care• Treatment Goals: avoid infection and achieve

acceptable scar

Patient Safety and Comfort

. Obtain a history including the mechanism and timing of the injury

• Obtain a health, medication and allergy history• Verify and update tetanus status• Inform patient of procedure including description of

anesthesia to be used, type of closure, wound care and follow up

• Address any patient/family questions or concerns • Discuss family/parent presence during procedure• Obtain facility appropriate consent for procedure

Positioning

• Try to optimize patient and care giver comfort• Patient laying on stretcher• Caregiver sitting or adjust stretcher height to

avoid straining• Use bedside trays or tables for hand wounds • Utilize over head or portable lighting• Position equipment for easy access• Have holding assistance or utilize immobilization

if appropriate

Wound Examination

• Perform a thorough wound examination• Inspect and Document wound: • Location• Size ( length, width and depth )• Appearance ( linear, jagged, flapped )• Condition ( clean, contaminated, active bleeding)• Note any visible foreign bodies or tendon injury• Neurovascular and functional status

Indications for Consultation• Human or Animal Bite• Grossly contaminated wound, difficulty controlling

bleeding or foreign body noted• Wounds greater than 18 hours old• Open fracture or tendon injury• Vermilion border repair- (1mm of misalignment can

cause devastating cosmetic defect) • Eye lid, nose, complex facial or oral lacerations• Nail bed repair• If in doubt consult plastics, oral or general surgeon

before wound closure

Local Anesthetic Options

Esters. cocaine - (rarely used). procaine- (eg, Novocain) . benzocaine. tetracaine. chloroprocaine

Amides• lidocaine • mepivacaine • bupivacaine • prilocaine• lidocaine with epi – DO NOT

USE ON TIPS OF APPENDAGES

• Mixing lidocaine and bupivacaine has no benefit

Local AnestheticsAgent Percent Infiltration Block (min) Duration Max Dose

lidocaine 1% - 2% immediate 4-10 30-120 min 4.5mg/kg

lidocaine w/epi

1% immediate 4-10 60-240 min 7mg/kg

mepivacaine 1% - 2% immediate 6-10 90-180 min 5mg/kg

bupivacaine 0.25% -0.5% slower 8-12 240-480 min 3mg/kg

topical 5-15 min 20-30 min 2-5 ml

Local Anesthetic Allergy• True allergic response in <1% of patients• Rarely allergic to esters and amides• Alternatives :• No anesthetic for small wounds (< 3 sutures)• Ice placed directly over the wound• Use of preservative free spinal, epidural, and intravenous

anesthesia • Local infiltration with diphenhydramine 50 mg /1 ml

diluted in 4 ml of normal saline is sufficient for 20 – 30 minutes of anesthesia (except for facial wounds) then use topical anesthetics

Topical Anesthetics

LET• Combination of lidocaine,

epinephrine, and tetracaine • Effective 15 – 20 minutes

after application• Use a cotton ball to apply• Use a glove or tape to

secure over wound• Effective on face and body• Avoid tips of appendages

TAC• Combination of tetracaine,

adrenaline, and cocaine• NOT Approved by FDA• Must be mixed by

pharmacist• Expensive• Contraindicated on or near

mucosal surfaces• NOT recommended by

speaker

Topical Sprays

• Gebauer’s Pain Ease ©is an instant topical anesthetic skin refrigerant approved to temporarily control the pain associated with needle procedures or minor surgical procedures.

• It can be applied to minor open wounds and intact oral mucous membranes.

• It is non-drug, non-flammable and can be used by any licensed healthcare practitioner without the order of a physician.

Risk and Safety Information

• Published clinical trials support the use in children > 3 years of age• Do Not use on large wounds, puncture wounds or animal bites• Do Not spray in eyes• Overspraying may cause frostbite• Freezing may alter skin pigmentation• Use caution on diabetics or those with poor circulation• Apply only to intact oral mucous membranes• Do Not use on genital mucous membranes• The thawing process may be painful and freezing may lower resistance to

infection and delay healing• If skin irritation develops, discontinue use• Rx only• © Gebauer Company 2012

Technique for Wound Infiltration

Direct Technique• Insert 25,27 or 30G ½- 1 ¼”

needle through open wound into superficial fascia parallel to and just deep to dermis

• Inject a small bolus of anesthetic into wound margin and repeat at adjacent margin until all edges and corners are anesthetized (approx 3 to 5 ml for a 3-4 cm wound)

Technique for Wound Infiltration

Parallel Margin (Field Block)• Need at least 25G 1 ¼ - 2”

needle• Insert at one end of the

wound and slowly inject a “track” of anesthetic

• Reinsert needle at distal end of first track and repeat on all sides until complete infiltration has been achieved

Reducing Pain of Local Anesthetics• Buffering each 10 ml of lidocaine with 1 ml of standard

bicarbonate solution significantly reduces pain of injection

• Selecting smallest needle size decreases pain and patient anxiety

• Injecting slowly helps to decrease soft tissue expansion which stimulates pain receptors

• Injecting into wound edges rather than surrounding wound hurts less and does not increase risk of infection

• Waiting >2 minutes to allow anesthetic to take effect before cleansing wound allows for better results

Wound Cleansing

• NEVER put anything into wound that you would not put in your own eye

• Choice of antiseptic- in studies only 0.001% solution of povidone-iodine bacteriostatic without harming fibroblasts

• Avoid povidone-iodine scrub formulation which contains ionic detergent and increases infection when used on fresh wounds

• Soaking in normal saline Does Not aid healing and increases bacterial count

Wound Irrigation• Decreases bacterial load• Relatively high pressure does not force bacteria into tissue• Use a mask, shield or splatter guard• Current practice is the use of a 35ml syringe with 19G

catheter (develops 7-8 psi effective in reducing debris and bacterial contaminates)

• Avoid high powered 50-70 psi pulsatile lavage systems that can dissect wound margins

• Studies show no difference in wound infection rates comparing saline and running tap water

• Volume varies between 100-250 ml or more for contaminated wounds

Wound Hair Removal

• Close shaving causes microtrauma that acts as a portal for bacterial invasion

• Clipping hair around the wound with scissors is recommended

• Hair or clippings that are inadvertently buried in wounds can result in infection

• Hair can be cleansed with standard techniques and solutions

NEVER SHAVE AN EYEBROW – Hair growth is inconsistent

Time frame for Wound Closure. “Golden period”- because wounds are often contaminated

with bacteria, there is a time limit between the laceration and closure. It varies between 6 hours (hand and feet) and 24 hours for the vascular face.

.Primary closure- fresh wounds may be sutured up to 18 hours after injury and clean wounds may be sutured up to 4 days later

. Secondary closure – for grossly contaminated wounds debridement is critical for preventing infection and are then allowed to heal gradually without suturing

. Delayed primary closure – wound is cleansed, debrided, and observed for 96 hours then closed if infection does not develop

Methods for repair of simple wounds

• Tissue adhesives• Wound taping• Wound stapling• Suturing

Indications for Tissue Adhesives

• Fresh lacerations that are within the “golden period”

• Lacerations under low tension that are easy to approximate

• Lacerations with clean and even edges that can be closed with no gaps

• Lacerations with little or no blood oozing• Situations in which adhesive runoff can be

controlled or avoided

Adhesive Wound Closure Technique• Pat the wound dry after cleansing, debridement and bleeding has been

controlled• To decreased runoff, position the patient so that the wound is facing up

(use Trendelenburg or reverse Trendelenburg for wounds around the eye). Apply a rim of petroleum ointment around the wound and hold a gauze sponge to remove excessive adhesive quickly

• Crush the plastic applicator and squeeze until adhesive covers the applicator tip

• The wound is then gently approximated with fingers or forceps• Adhesive is layered over the wound with a margin of 5-10 mm. Finger or

forceps approximation is maintained for 30-60 seconds to allow for polymerization

• After 15-20 seconds, another layer may be applied and 3 layers are recommended to complete the closure

• It takes 2.5 minutes for adhesive to reach its full tensile strength

Adhesive Closure Aftercare• Instruct the patient to keep the wound clean

and dry for 24 hours• After 24 hours may gently cleanse wound using

caution not to disrupt the closure• If a wound dehisces, instruct the patient to

return for delayed primary closure with wound tapes or sutures

• No follow-up is needed for glue removal as it peels off on its own or with epidermal sloughing

Demonstration of Wound Closure with Adhesive

Skin tear before repair After adhesive repair

Indications for Wound Taping

• Superficial, straight lacerations under little tension. Suitable area include: forehead, chin, malar eminence, thorax, and nonjoint areas of extremities

• Flaps in which sutures might compromise vascular perfusion at the wound edges

• Lacerations with a greater-than-usual potential for infection• Lacerations in an elderly or steroid-dependent patient who has

thin, fragile skin• Support for lacerations after suture removal• Tapes do not work well on irregular wounds, wounds with active

bleeding or secretions, intertriginous areas, scalp and joint surfaces

Technique for Wound Taping • The wound is cleansed, irrigated, and debrided prn. Hemostasis has to be

complete and the surface completely dried.• Skin adhesive is applied to the surrounding skin to increase adhesion. • Tapes are cut to the desired length while they are still on the backing

sheet. Usually allow a 2-3 cm overlap on each side of the wound.• One of the perforated end tabs is gently removed to prevent deforming of

the tape ends.• Individual tapes are removed from the backing with forceps by pulling

directly away from the backing.• ½ of the tape is securely placed on one side of the midportion of the

wound and is held securely. The opposite wound edge is apposed with a finger of the opposite hand. After edge apposition, the tape is completely secured.

• Further tapes are placed evenly adjacent to the original midwound tape, and repeat until edges are completely apposed leaving a 2-3 mm gap between tapes.

• The final step is to place cross stays to prevent elevation of ends and wound tension.

Wound Taping Aftercare

• Tapes are maintained in place for at least as long as sutures would be for the anatomic area.

• A taped wound cannot be washed or moistened.

• Tapes should NEVER be wrapped around a digit circumferentially, because of constriction.

Demonstration of Wound Closure with Taping

Indications for Stapling• Linear, sharp (shearing mechanism) laceration

of the scalp, trunk, and extremities.• Is NOT recommended for hands or face.• Temporary, rapid closure of extensive

superficial lacerations in patients requiring immediate surgery for life-threatening trauma.

• Avoid in anatomic areas where studies such as CT or MRI are anticipated to avoid streak artifact.

Stapling Technique

• Forceps are used to evert the wound edges• Before triggering, the stapler should be placed

gently on the skin over the wound without indenting the skin

• The trigger is squeezed gently and evenly to advance the staple into the tissue

• Once placed a space should be visible between it and the skin

• The stapler is then “backed out” to disengage

Staple Aftercare

• Staples are kept in place for the same length of time as sutures in similar anatomic sites.

• Staple removal requires a special device that is provided by each manufacturer.

• The lower jaw is placed under the crossbar of the staple, and the upper jaw is closed to open the loop of the staple.

Demonstration of Wound Closure with Stapling

Suturing Equipment

• Mask, eye wear or face shield• Gloves- protect the clinician not the patient,

some studies recommend non-sterile gloves• Sutures – wound specific (see suggestions)• Suture kit – most are disposable and should

include needle holders, forceps, scissors, and hemostats

• Dressing supplies- wound specific (most facial lacerations may be left uncovered)

Suggested Guideline for Suture Selection

Body Region Percutaneous Deep

Scalp 5-0/4-0 monofilament 4-0 absorbable

Ear 6-0 monofilament

Eyelid 7-0/6-0 monofilament

Eyebrow 6-0/5-0 monofilament 5-0 absorbable

Nose 6-0 monofilament 5-0 absorbable

Lip 6-0 monofilament 5-0 absorbable

Oral mucosa 5-0 absorbable

Face/Forehead 6-0 monofilament 5-0 absorbable

Trunk 5-0/4-0 monofilament 3-0 absorbable

Extremities 5-0/4-0 monofilament 4-0 absorbable

Hand 5-0 monofilament 5-0 absorbable

Foot/sole 4-0/3-0 monofilament 4-0 absorbable

Penis 5-0 monofilament

Post Procedure

• Assess for symmetry, wound appearance and tension on suture line

• Now is the time to remove and replace any suture if you are not satisfied with the result

• Re-evaluate neurovascular and functional status• Re-enforce Wound Care and Discharge

Instructions • Reassure patient that oral antibiotics are not

needed unless develop signs of infection

Wound Care Instructions• May remove dressing and inspect wound in 24 hours• Use a clean cloth to gently cleanse wound with soap

and water one to three times a day • May apply topical antibacterial ointment to prevent

dressing from sticking, but does not decrease infection rate

• Re-dress with gauze or bandaid as needed to protect wound, keep it clean and the dressing dry

• Avoid swimming for 24 hours• Return for increased redness, swelling, or drainage of

wound, pain or fever uncontrolled with acetaminophen or ibuprofen

Recommended Intervals for Suture Removal

Location Days to Removal

Scalp 6-8

Face 4-5

Ear 4-5

Chest/abdomen 8-10

Back 12-14

Arm/leg 8-10

Hand 8-10

Fingertip 10-12

Foot 12-14

For joint extensor surfaces Add 2-3 days to above

Sample Documentation

• Wound cleansed with betadine & irrigated with saline then prepped & draped in sterile fashion. Anesthetized with 3 cc of 2% lidocaine. Wound probed with no visible foreign bodies, no tendon injury noted. Wound edges re-approximated with (6 ) 5-0 sutures in a simple interrupted percutaneous fashion. Antibacterial ointment & dressing applied.

• Tolerated procedure well.• Neurovasular and functional status intact post procedure.• Verbalized understanding of wound care and instructions.

Agrees to return in 10 days for suture removal.

Summary of the Goals of Wound Closure

• Hemostatis- all bleeding except oozing should be controlled before wound closure

• Anesthesia- to effectively control pain, and allow for adequate wound cleansing

• Irrigation- is the most important step in reducing potential for infection

• Wound exploration- xray and functional test do not always identify foreign bodies or tendon injuries

Goals of Wound Closure

• Removal of devitalized and contaminated tissue

• Tissue preservation – to prevent a permanent, uncorrectable, unsightly scar (all wounds scar)

• Closure tension- excessive wound constriction strangulates tissue, leading to a poor outcome

• Deep sutures- act as a foreign body and should use as few as possible

Goals of Wound Closure

• Tissue handling- rough handling with forceps can cause tissue necrosis

• Wound infection- antibiotics are no substitute for wound preparation and irrigation

• Dressings- properly applied assist in wound healing

• Follow-up- well understood verbal and written instructions for wound care, follow-up and suture removal are essential to complete care

Demonstration of Wound Closure with Suturing

Simple interrupted suture Vertical mattress sutures

Questions & Answers

Demonstration & Return Demonstration

References

• Greenberg, MI et al: Text-atlas of emergency medicine. Wound care 19:675-697, 2005

• Lex, JR: Wound management. Audio Digest 26:04, 2009

• Trott, AT: Wounds and lacerations, emergency care and closure. Saunders, Fourth edition. 2012

• Johnson & Johnson Wound closure manual, 2005