1. Suture Workshop FM / Rural Clerkship

2. Competency Given a pt presenting with a laceration in an office or urgent / emergent care setting and standard supplies and equipment, treat the wound appropriately.

3. Objectives Identify the various types and sizes of suture material. Choose the proper instruments for suturing. Given a list of injectable anesthetic agents, identify the different agents and correct dosages. Determine whether a wound requires suturing. Under supervision, anesthetize, clean, and close a wound with sutures. Recommend appropriate laceration care and follow-up.

4. Suture Materials Criteria – Tensile strength – Good knot security – Workability in handling – Low tissue reactivity – Ability to resist bacterial infection

5. Suture Materials ABSORBABLE: lose their tensile strength within 60 days. NON- ABSORBABLE:

6. Absorbable Sutures PLAIN GUT: Derived from the small intestine of healthy sheep. Loses 50% of tensile strength by 5-7 days. Used on mucosal surfaces. CHROMIC GUT: Treated with chromic acid to delay tissue absorption time. 50% tensile strength by 10-14 days. Used in episiotomy repairs.

7. Polyglycolic acid (Dexon ® )Polyglycolic acid (Dexon ® ) Braided Low-memory 50% tensile strength = 25 days Sites = subcutaneous closure skin

8. Polydioxanone (PDS ® ) Monofilament 50% tensile strength = 30+ days Sites = need for prolonged strength,

9. Polyglycan 910 (Vicryl ® ) Braided, synthetic polymer 50% tensile strength for 30 days Used: subcutaneous

10. Non-absorbable Sutures Nylon (Ethilon®): of all the non- absorbable suture materials, monofilament nylon is the most commonly used in surface closures.

11. Non-absorbable Sutures Polypropylene (Prolene®): appears to be stronger then nylon and has better overall wound security. BRAIDED: includes cotton, silk, braided nylon and multifilament dacron. Before the advent of synthetic fibers, silk was the mainstay of wound closure. It is the most workable and has excellent knot security. Disadvantages: high reactivity and infection due to the absorption of body fluids by the braided fibers.

12. Suture Sizes 5-0 is small, and 2-0 is big The usual sizes = 3-0 or 4-0 Examples: – might use 5-0 on the face – 2-0 on the plantar surface of a foot

13. Surgical Needles Wide variety with different company’s naming systems 2 basic configurations for curved needles – Cutting: cutting edge can cut through tough tissue, such as skin – Tapered: no cutting edge. For softer tissue inside the body

14. Surgical Needles

15. Surgical Instruments

16. Needle Holders

17. Forceps Tissue forceps Dressing forceps

18. Iris Scissors Iris scissors are predominantly used to assist in wound debridement and revision.

19. Dissection Scissors Used for heavier tissue revision as necessary for wound undermining.

20. Suture Removal Scissors

21. Hemostats Clamping small blood vessels Hemorrhage control Grasping Exposing Exploring Visualizing

22. A Cheap Skin Hook Put a hypodermic needle on a small syringe or use a hemostat to hold the needle Bend the tip of the needle back (sterile technique) General principle: Minimize trauma in handling tissue

23. Scalpels

24. Scalpel Blades #15 blade

25. Dermabond ® A sterile, liquid topical skin adhesive Reacts with moisture on skin surface to form a strong, flexible bond Only for easily approximated skin edges of wounds – punctures from minimally invasive surgery – simple, thoroughly cleansed, lacerations

26. Anesthetic Solutions Lidocaine (Xylocaine®) – Most commonly used – Rapid onset – Strength: 0.5%, 1.0%, & 2.0% – Maximum dose: 5 mg / kg 300 mg –1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc –300 mg = 0.03 liter = 30 ml

27. Anesthetic Solutions Lidocaine (Xylocaine®) with epinephrine – Vasoconstriction – Decreased bleeding – Prolongs duration – Strength: 0.5% & 1.0% – Maximum individual dose: 7mg/kg, OR 500mg

28. Anesthetic Solutions CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: – Eyes – Ears – Nose – Fingers – Toes – Penis – Scrotum

29. Anesthetic Solutions Mepivacaine (CARBOCAINE): – Slower onset than Lidocaine – Longer duration – Strength: 1% – DOSE: maximum individual dose 5mg/kg

30. Anesthetic Solutions BUPIVACAINE (MARCAINE): – Slow onset – Long duration – Strength: 0.25% – DOSE: maximum individual dose 3mg/kg

31. Injection Techniques 25, 27, or 30-gauge needle 6 or 10 cc syringe Check for allergies Insert the needle at the inner wound edge Aspirate Inject agent into tissue SLOWLY Wait… After anesthesia has taken effect, suturing may begin

32. Complicated Wounds Wounds or lacerations with Nerve Tendon Major vessel Wounds or lacerations of the Eye Eyelids Bites Severely contaminated wounds. Wounds entering the Thoracic or abdominal cavities.

33. Wound Evaluation Time of incident Size of wound Depth of wound Tendon / nerve involvement Bleeding at site

34. Contraindications Redness Edema of the wound margins Infection Fever

35. Contraindications Puncture wounds Animal bites Tendon, verve, or vessel involvement Wound more than 12 hours old

36. Closure Types Primary closure (primary intention) Secondary closure (secondary intention) Tertiary closure (delayed primary closure)

37. Wound Preparation Most important step for reducing the risk of wound infection. Remove all contaminants and devitalized tissue before wound closure. – IRRIGATE – CUT OUT DEAD, FRAGMENTED TISSUE If not, the risk of infection and of a cosmetically poor scar are greatly increased

38. Wound Preparation Personnel Precautions

39. Wound Preparation Wound cleansing solution Wound scrubbing Irrigation – Take only the soft, flexible part from an 18 gauge IV needle (angiocath) – Put angiocath tip on 20 cc or 50 cc syringe Debridement

40. Basic Laceration Repair Principles And Techniques

41. Minimize trauma in skin handling Gentle apposition with slight eversion of wound edges – Visualize an Erlenmeyer flask Make yourself comfortable – Adjust the chair and the light Change the laceration – Debride crushed tissue

42. Definition of Terms – Bite – Throw – Percutaneous (deep) closure – Dermal closure – Interrupted closure – Continuous closure (running sutures)

43. Principles And Techniques Suture Techniques

44. Suture Procedures

45. Suturing Apply the needle to the needle driver – Clasp needle 1/2 to 2/3 back from tip Rule of halves: – Matches wound edges better; avoids dog ears – Vary from rule when too much tension across wound

46. Suturing Rule of halves

47. Suturing

48. Suturing The needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees – Visualize Erlenmeyer flask – Evert wound edges Because scars contract over time

49. Suturing Release the needle from the needle driver, reach into the wound and grasp the needle with the needle driver. Pull it free to give enough suture material to enter the opposite side of the wound. Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites.

50. Follow the needle’s arc Rotate your wrist to follow the arc of the needle. Principle: minimize trauma to the skin, and don’t bend the needle. Follow the path of least resistance.

51. Suturing Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2-inch suture strand protruding form the bites site. Release the needle from the needle driver and wrap the suture around the needle driver two times.

52. Suturing Grasp the end of the suture material with the needle driver and pull the two lines across the wound site in opposite direction (this is one throw). Do not position the knot directly over the wound edge. Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap.

53. Suturing Cut the ends of the suture 1/4-inch from the knot. The remaining sutures are inserted in the same manner

54. The trick to an instrument tie Always place the suture holder parallel to the wound’s direction. Hold the longer side of the suture (with the needle) and wrap OVER the suture holder. With each tie, move your suture-holding hand to the OTHER side. By always wrapping OVER and moving the hand to the OTHER side = square knots!!

55. Simple, Interrupted

56. Vertical Mattress Good for everting wound edges (neck, forehead creases, concave surfaces)

57. Horizontal Mattress Good for closing wound edges under high tension, And for hemostasis.

58. Suturing - finishing After sutures placed, clean the site with normal saline. Apply a small amount of Bacitracin and cover with a sterile non-adherent dressing.

59. Suturing - before you go… Need for tetanus globulin and/or vaccine? – Dirty (playground nail) vs clean (kitchen knife) – Immunization history Tell pt to return in one day for recheck, for signs of infection or complications.

60. Suture Removal Time frame for removing sutures: Average time frame is 7-10 days FACE: 4-5 days BODY & SCALP: 7 days SOLES, PALMS, BACK OR OVER JOINTS: 10 days Any suture with pus or signs of infections should be removed immediately.

61. Suture Removal 1. Clean with hydrogen peroxide to remove any crusting or dried blood 2. Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin 3. Pull the suture line through the tissue- in the direction that keeps the wound closed - and place on a 4x4

62. Suture Removal Once all sutures have been removed, count the sutures The number of sutures needs to match the number indicated in the patient's health record