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Suturing Basics Terren Trott. Objectives Understand Basic Suturing Anatomy Indications for Suturing Materials and Preparation Suturing Techniques.

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Presentation on theme: "Suturing Basics Terren Trott. Objectives Understand Basic Suturing Anatomy Indications for Suturing Materials and Preparation Suturing Techniques."— Presentation transcript:

1 Suturing Basics Terren Trott

2 Objectives Understand Basic Suturing Anatomy Indications for Suturing Materials and Preparation Suturing Techniques

3 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

4 Suture Anatomy Absorbable – Plain gut, FAST gut, vicryl, monocryl Non-absorbable – Ethilon (Nylon) – Silk – Polypropylene (Prolene) Monofilament Vs Polyfilament

5 Suturing Preparation Hemostasis Anesthetic Irrigation Exploration Draping Suture selection

6 Hemostasis Direct pressure and elevation Blood Pressure Cuff Lidocaine with Epinephrine Figure-8 stitch

7 Anesthetic NameOnsetDurationMax Dosing Lidocaine1 – 5 minutes1.5 – 2 hours4mg/kg Lidocaine with Epi1 – 5 minutes2 – 3 hours7mg/kg Mepivacaine1 – 5 minutes3 hours5mg/kg Mepivacaine with Epi1 – 5 minutes4 – 5 hours7mg/kg Bupivacaine10 – 15 minutes~4 hours2.5mg/kg Bupivacaine with Epi10 – 15 minutes~8 hours3mg/kg Anesthetic Pearls Epinephrine vasoconstricts Amides: have two ‘I’s in the name, esters have one ‘I’ Infiltrate with anesthetic slowly to reduce the burn Consider digital blocks Bicarb can be used to buffer lidocaine and reduce burning Withdraw on the syringe to make sure you’re not in a vessel

8 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

9 Irrigation IRRIGATION

10 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

11 Anatomic SiteSkinDeepDuration Scalp5-0, 4-0 Monofilament4-0 Absorbable6–8 days Ear6-0 MonofilamentN/A4–5 days Eyelid7-0, 6-0 MonofilamentN/A4–5 days Eyebrow6-0, 5-0 Monofilament5-0 Absorbable4–5 days Nose6-0 Monofilament5-0 Absorbable4–5 days Lip6-0 Monofilament5-0 Absorbable4–5 days Face/forehead6-0 Monofilament5-0 Absorbable4–5 days Chest/abdomen5-0, 4-0 Monofilament3-0 Absorbable8–10 days Back5-0, 4-0 Monofilament3-0 Absorbable12–14 days Arm/leg5-0, 4-0 Monofilament4-0 Absorbable8–10 days Hand5-0 Monofilament5-0 Absorbable 8–10 days b Extensor tendon4-0 MonofilamentN/A Foot/sole4-0, 3-0 Monofilament4-0 Absorbable12–14 days

12 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

13 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

14 Simple Interrupted Most commonly used technique to close skin Attempt to keep all knots on one side For uncomplicated wound closure

15 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

16 Horizontal Mattress All entry and exit points are equidistant Advantages: distribution of tension across greater area, improved wound eversion

17 Corner Stitch Advantages: approximation of corners and stellate lacerations without capillary compromise of the corner

18 Running Advantages: Faster Disadvantages: one compromised stitch compromises entire suture

19 Deep Sutures To decrease tension and approximate tissues Enter the tissue low and exit high so that the knot ties to the bottom

20 References ml ml


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