Basic Suturing

1

• Basic Suturing
• Cynthia Durham, MSN, ANPC, RNFA
• Your greatest tool is your ability to critically
  think it is not your hands
• Charles Sherman MD

2
Financial Disclosure

• I have not received financial compensation from
  any pharmaceutical or suture company in
  preparation of this suturing course

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Objectives

• 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

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Assessment Of Injury

• Most important phase
• Take your time
• Elicit much info quickly
• But in the meantime.

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Initial Hemostasis

• 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

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Hemostasis

• May be life saving
• Allows for proper visualization of wound
• Enables accurate repair
• Promotes wound healing
• Decreases scar tissue

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Topical/Injected Hemostatic Agents

• Work either by
• vasoconstriction or enhanced coagulation
• Epi 1100,000 injected along wound edge and wait
  10 minutes (more to follow)
• Surgicel wait 2-8 minutes
• absorbed in 1-2 weeks

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Mechanism of Injury

• 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

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Age of Wound

• "Golden period ideal time to close
• lt 12 hours for most wounds
• 12 - 16 hours for facial wound

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Extent of Injury

• Tendon ID fx assessment
• Nerve testing
• Blood supply assessment
• Bone assessment

11
Wound Classification

• Laceration
• Penetration
• Amputation

12
Condition of Wound - 8 Terms

• 1. Tidy no devitalized tissue or debris
• 2. 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

13
Condition of Wound

• 5. Non- complex
• Flat surface
• Right angle to skin surface
• Linear with a regular configuration
• away from critical anatomy
• Parallel to skin tension lines

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Condition of Wound

• 6. Complex wound
• Convexity or concavity
• Flexion crease
• At angle to normal skin crease
• Non-linear with skin flaps
• Edge irregularities
• Oblique to skin surface
• Must convert to non-complex configuration.

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Condition of Wound

• 7. Simple Wound
• only dermis and fat lacerated
• 8. Compound Wound
• can involve nerves, ducts, tendons,
  major blood vessels,
• glands, fascia, muscle

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NORMAL WOUND HEALING 5 Phases

• 1. Hemostasis - 3 components
• Vascular spasm
• Platelet aggregation
• Coagulation
• 2. Inflammatory response
• 3. Collagen formation
• 4. Wound contracture
• 5. Re- epithelization

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Factors Affecting Wound Healing

• Age
• Anatomic location
• Technical
• Associated conditions
• Drugs

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Diseases That Affect Wound Healing

• Diabetes- vascular compromise
• Anemia dec O2 transport
• Renal failure toxic metabolites
• Malnutrition dec protein synthesis
• Systemic infection - dec inflam response
• Malignancy - nutritional deficiencies

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Effects of Drugs on Wound Healing

• 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

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Herbs That Reduce Hemostasis

• Chinchona Danshen
• Devils claw Garlic
• Gingko Papaya
• Feverfew Ginger
• Echinacea Vitamin E

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Wound Closure Terminology

• 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

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Guidelines For Antibiotics

• Traumatic injuries with heavy contamination
• Untidy wounds with inadequate debridement
• Wounds entering joints
• /- Wounds gt 6 hours old
• Animal or human bites
• Compromised host

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Local Anesthetics Sensory Modalities

• The art of life is the avoidance of pain
• Thomas Jefferson
• 2 point discrimination
• Pain
• Light touch
• Paresthesia
• Pressure
• Proprioception

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Local Anesthesia Types

• Esters not usually used in laceration repair
  short acting, more allergies
• Procaine (novocaine), tetracaine (pontocaine),
  cocaine
• Amides - most widely used
• Lidocaine (xylocaine), bupivicaine (marcaine)

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Lidocaine

• 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 mg
• Maximum dose w/epi 500 mg
• Peds over 5 yo 75-100mg

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Bupivicaine

• 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/epi
• Peds dose NONE

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Addition Of Epinephrine To Local Anesthetic

• Advantages
• Vasoconstriction
• Decreases bleeding
• Decreases toxicity
• Disadvantages
• Increases BP
• Increased allergic reaction /-
• Tissue ischemia

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Use Of Bicarbonate In Local Anesthetic

• Ph of tissue 7.0
• Ph of lido 6.49
• Mix 110 stable 24 hours
• Ph of lido and bicarb 7.38

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Administration Of Local Anesthetic- 2 Methods

• Packing can be used w/epi or w/o
• Advantage - no needles, doesnt 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

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Administration of Local Anesthesia 2 Methods

• 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

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Tips For Comfort

• 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

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Normal Saline As Local Anesthetic

• Advantage great for people with caine
  allergies
• Disadvantage - very short acting

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Ice As Local Anesthetic

• Advantage - noninvasive
• Disadvantage - short acting
• Doesnt need to be sterile

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Suture Sizes

• 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

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Choice Of Sutures

• 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

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Choice Of Sutures

• Nonabsorbable
• Polypropylene, nylon or silk
• Known as Ethilon, Silk, Dermalon, Prolene
• Must be removed
• Used for skin closure

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Choice Of Needle

• Size long enough to pass thru tissue unimpeded
• Suture boxes usually have WYSIWYG pictures
• Size is not standardized

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Choice of Needle

• 3 Tip Shapes
• 1. Taper- used for layers, internal organs
• Will Not pass thru skin
• 2. Cutting standard used for skin closure
• 3. Reverse Cutting preferred by plastic
  surgeons

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Wound Closure Instruments

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

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Antiseptics

• Halogens - chlorine, iodines
• Alcohol
• Biguanides
• Oxidizing agents
• Surfactants

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Wound Field Prep

• Hair trimming AVOID
• Packing the wound
• Irrigation
• Prep intact skin

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Suture Patterns

• Simple interrupted
• Vertical mattress
• Subcuticular

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Simple Interrupted

• Easiest to put in take out
• Can be used almost anywhere
• Can be alternated with VM
• Doesnt always every skin edges

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Vertical Mattress

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

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Subcuticular

• 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
• Dont use on face or hands

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Depth Of Tissue To Take

• No deeper than laceration!!
• Must have a respect for tissue below the depth of
  the laceration as well as laterally!!

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Width of Tissue to Take

• 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

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Suture Removal in Days

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

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After Care

• Dressings - dry vs moisture permeable
• Topical agents - bacitracin vs neosporin
• Wound check - timing
• Suture removal - when and how

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Technique Tips

• 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

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Thank YouPlease take a 15 minute break