1. Tying the knot: Basic Suturing Workshop
Megan Vernatter ARNP, PSC
Board Certified Family Nurse Practitioner
Ashland Emergency Medical Associates

2. 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.

3. 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

4. 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.

5. 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.

6. 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.

7. Cosmetic Outcome
Keloid scarring
Chicks dig scars

8. 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

9. 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

10. 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

11. 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

12. 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

14. Local Anesthetic Options
Esters
Amides
. cocaine - (rarely used) . procaine- (eg, Novocain) . benzocaine . tetracaine . chloroprocaine
lidocaine
mepivacaine
bupivacaine
prilocaine
lidocaine with epi – DO NOT USE ON TIPS OF APPENDAGES
Mixing lidocaine and bupivacaine has no benefit

15. Local Anesthetics Agent Percent Infiltration Block (min) Duration
Max Dose
lidocaine
1% - 2%
immediate
4-10
min
4.5mg/kg
lidocaine w/epi 1%
min
7mg/kg
mepivacaine
6-10
min
5mg/kg
bupivacaine
0.25% -0.5%
slower
8-12
min
3mg/kg
topical
5-15 min
20-30 min
2-5 ml

16. 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

17. Topical Anesthetics LET TAC
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
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

18. 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.

19. 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

20. 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)

21. 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

22. 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

23. 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

24. 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 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 ml or more for contaminated wounds

25. 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

26. NEVER SHAVE AN EYEBROW – Hair growth is inconsistent

27. 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

28. Methods for repair of simple wounds
Tissue adhesives
Wound taping
Wound stapling
Suturing

29. 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

30. 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 seconds to allow for polymerization
After 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

31. 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

32. Demonstration of Wound Closure with Adhesive
Skin tear before repair
After adhesive repair

33. 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

34. 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.

35. 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.

36. Demonstration of Wound Closure with Taping

37. 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.

38. 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

39. 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.

40. Demonstration of Wound Closure with Stapling

41. 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)

42. 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
Lip
Oral mucosa
Face/Forehead
Trunk
3-0 absorbable
Extremities
Hand
5-0 monofilament
Foot/sole
4-0/3-0 monofilament
Penis

43. 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

44. 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

45. Recommended Intervals for Suture Removal
Location
Days to Removal
Scalp
6-8
Face
4-5
Ear
Chest/abdomen
8-10
Back
12-14
Arm/leg
Hand
Fingertip
10-12
Foot
For joint extensor surfaces
Add 2-3 days to above

46. 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.

47. 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

48. 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

49. 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

50. Demonstration of Wound Closure with Suturing
Simple interrupted suture
Vertical mattress sutures

51. Demonstration & Return Demonstration
Questions & Answers
Demonstration & Return Demonstration

52. References
Greenberg, MI et al: Text-atlas of emergency medicine. Wound care 19: , 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