Peds ED Top 10 Make sure you review the Epic ED environment (EMERG DEPT UNC) Review the orientation manual & contact your assigned attending Find someone (attending, upper level resident, nurse) if you feel the patient is sick Plan to spend no more than 10-15 minutes on the initial H&P Synthesize the information gathered into a prioritized differential (and plan) Consult with a specific question Follow-up on ancillary studies (labs, xrays, etc.) & keep the attending and patient/family informed Take time to have a clear disposition discussion with patients & families. Talk to the PCP if necessary. Let your attending know of anything specific learning objectives, concerns, etc. Learn & have fun!

Suturing & Wound Care William Mills, Jr., MD, MPH UNC School of Medicine Department of Pediatrics Division of Pediatric Emergency Medicine

Objectives Discuss wound care basics Review suture material Discuss commonly used wound closure techniques Review disposition and follow-up

Skin Anatomy Epidermis and dermis are tightly adhered and clinically indistinguishable Dermal approximation provides the strength and alignment of skin closure Subcutaneously layer is composed mainly of adipose tissue Also Nerve fibers Blood vessels Hair follicles Although this layer provides little strength to the repair, suture placed in the subcu layer may decrease wound tension and improve cosmesis Deep fascial layer Intermixed with muscle Occasionally requires deep repair in deep lacerations

Wound Care Basics Irrigate with copious normal saline Rule of thumb: 100 mL per cm of laceration Use a 60 mL syringe to obtain adequate psi Clean edges with Betadine Closure Dressing Antibiotic ointment No antibiotic ointment for Dermabond Bandage/Band-aid Tetanus status? Splint? For lacerations over joints to prevent flexion

Wound Care Basics Anesthesia Topical Local LET (lidocaine, epinephrine, tetracaine) Apply for 15-30 minutes, may repeat Local 1% lidocaine +/- epinephrine 1% = 10 mg/mL Toxic dose: 5mg/kg or 7mg/kg (with epi) Consider sodium bicarbonate (Neut) In a 10 mL syringe draw up 9 mL of lidocaine and 1 mL of bicarb Inject into the wound edges (not intact skin) Sedation Intranasal fentanyl, midazolam Procedural

Suture Material Generally categorized by three characteristics: Absorbable vs. non-absorbable Natural vs. synthetic Monofilament vs. multifilament

Absorbable Suture Degraded and eventually eliminated in one of two ways: Via inflammatory reaction utilizing tissue enzymes Via hydrolysis Examples: “Catgut” Chromic gut Vicryl Monocryl PDS

Tensile Strength Duration Absorbable Suture Type Advantages Tensile Strength Duration Chromic gut Coated with chromic salts Good for oral mucosa, less optimal for dermal and muscle closures due to increased tissue reactivity 10-14 days Fast absorbing gut Heat-treated to accelerate loss of tensile strength Ideal for facial lacerations 5-7 days Vicryl Braided synthetic Excellent handling and smooth tie-down properties 3-4 weeks, complete absorption in 60-90 days Moncryl Monofilament synthetic Superior pliability 21 days

Non-absorbable Suture Not degraded, permanent Examples: Prolene Nylon Stainless steel Silk* (*not a truly permanent material; known to be broken down over a prolonged period of time — i.e. years)

Natural Suture Biological origin Cause intense inflammatory reaction Examples: “Catgut” – purified collagen fibers from intestine of healthy sheep or cows Chromic – coated “catgut” Silk

Synthetic Suture Synthetic polymers Do not cause intense inflammatory reaction Examples: Vicryl Monocryl Polydiaxanone (PDS) Prolene Nylon

Monofilament Suture Grossly appears as single strand of suture material; all fibers run parallel Minimal tissue trauma Resists harboring microorganisms Ties smoothly Requires more knots than multifilament suture Possesses memory Examples: Monocryl, PDS, Prolene, Nylon

Multifilament Suture Fibers are twisted or braided together Greater resistance in tissue Provides good handling and ease of tying Fewer knots required Examples: Vicryl (braided) Chromic (twisted) Silk (braided)

Suture Size Smaller -------------------------------------Larger Sized according to diameter with “0” as reference size Numbers alone indicate progressively larger sutures (“1”, “2”, etc) Numbers followed by a “0” indicate progressively smaller sutures (“2-0”, “4-0”, etc) Smaller -------------------------------------Larger .....”3-0”...”2-0”...”1-0”...”0”...”1”...”2”...”3”.....

Guidelines for Suture Material, Size and Removal Body Region Size (for superficial lacerations) (for deep lacerations) Duration (days) Scalp 5-0 or 4-0 or staples 4-0 7-14 Face 6-0 or 5-0 5-0 3-5 Eyelid 7-0 or 6-0 -- Eyebrow Trunk 5-0 or 4-0 3-0 5-7 Extremities 7 Joint surface 7-10 Hand Sole of foot 4-0 or 3-0

Needle Holder Technique Arming the needle holder Grasp the needle with the tip of the needle holder about 1/3 of the way down from the eye The needle tip should point at about a 90-degree angle from the needle holder

Needle Holder Technique Proper Needle Holder Technique #1: Classic thumb-ringer finger needle holder grip #2: Thenar needle holder grip

Wound Closure Basic suturing techniques: Simple sutures Mattress sutures Flap suture Subcuticular sutures Goal: “approximate, not strangulate” For proper healing, the edges of the wound must be everted Needle should penetrate the skin at 90° angle to its surface

Simple Sutures Simple interrupted sutures Single stitches, individually knotted Keep all knots on one side of wound Used for uncomplicated laceration repair and wound closure

Simple Sutures Simple interrupted sutures Tissue bites should be evenly placed Wound edges meet at the same level to minimize the possibility of mismatched wound-edge heights (i.e., stepping) Rule of thumb: Distance between sutures is equal to the bite distance from the wound edge The bottom right picture shows a flask-shaped stitch, which maximizes eversion.

Simple Sutures Different techniques for placing sutures Start at one end and move sequentially Start in the middle and the place next sutures halfway to the ends

Simple Sutures Simple interrupted sutures The bites taken can be deliberately varied by modifying Distance of the needle insertion site from the wound edge Distance of the needle exit site from the wound edge Depth of the bite taken The use of differently sized needle bites on each side of the wound can correct preexisting asymmetry in edge thickness or height Small bites can be used to precisely approximate wound edges Large bites can be used to reduce wound tension Proper tension is important to ensure precise wound approximation while preventing tissue strangulation The bottom right picture shows a flask-shaped stitch, which maximizes eversion.

Deep Sutures Deep sutures Absorbable buried sutures are used as part of a layered closure in wounds under moderate-to-high tension Buried sutures provide support to the wound and reduce tension on the wound edges Allow for better epidermal approximation of the wound Help eliminate dead space ** Buried knots away from the skin surface helps avoid interference with epidermal healing. Needle directed toward the skin surface Exits at the dermal-epidermal junction, then insert into the opposite side of the wound directly across from the point of exit. Loop completed in the dermis at the level where the needle was initially place Knot tied

Horizontal Mattress Suture Horizontal mattress sutures The 2 lines of suture lie parallel to one another in a horizontal plane The needle enters on the far side of the wound and exits on the near side Then, the pattern is reversed: The needle enters on the near side of the wound and exits on the far side of the wound The suture is tied normally Advantages -- The horizontal mattress suture allows for excellent eversion of the skin edges Time saving, as a single horizontal mattress stitch can take the place of two simple ties. This suture is less likely to rip through the skin Disadvantages -- Puckering may occur if too much pressure is exerted. There is less control than with other types of sutures.

Horizontal Mattress Suture

Vertical Mattress Suture Vertical mattress sutures Involves placing a double line of suture material across the wound The skin is entered and exited twice The result is that two lines of suture lie one above the other “Far, far. Near, near.” Enter and exit the wound at a generous distance from the wound edge Reenter the skin about 1-2 mm from the wound edge Tie the suture normally Advantages – Ensures wound edge eversion. This type of suture is useful in areas where the wound edges have a tendency to invert. Disadvantages -- There are twice as many suture marks as with simple sutures as vertical mattress sutures require four points of skin entry and exit.

Vertical Mattress Suture

Flap Closure Flap suture/Corner stitch Used primarily to position the corners and tips of flaps The corner stitch may allow for increased blood flow to flap tips Lowers the risk of necrosis and improves aesthetic outcomes The half-buried horizontal suture or tip stitch begins on the side of the wound on which the flap is to be attached. The suture is passed through the dermis of the wound edge to the dermis of the flap tip. The needle is passed laterally in the same dermal plane of the flap tip, exits the flap tip, and reenters the skin to which the flap is to be attached. The needle is directed perpendicularly and exits the skin; then, the knot is tied.

Flap Closure Flap sutures Begins on the side of the wound on which the flap is to be attached The suture is passed through the dermis of the wound edge to the dermis of the flap tip The needle is passed laterally in the same dermal plane of the flap tip, exits the flap tip, and reenters the skin to which the flap is to be attached The needle is directed perpendicularly and exits the skin; then, the knot is tied

Subcuticular Sutures Usually a running stitch, but can be interrupted Intradermal horizontal bites Allow suture to remain for a longer period of time without development of crosshatch scarring

Tissue Adhesive Dermabond (2-octyl cyanoacrylate) Liquid monomer that undergoes an exothermic reaction after exposure to moisture (skin surface) Primarily used to close facial lacerations in the ED Lasts 5-10 days Avoid excessive moisture Not recommended for mucosal (high moisture) surfaces or hands, feet, joints since repetitive motion may cause the bond to break. Apply, let dry for 30-40 seconds, then repeat 3-4 times. Wound closure strength can be enhanced by extending the application 5-10mm beyond the wound margin. Avoid applying within the wound. Can be degraded by antibiotic ointment or petroleum jelly. OK to get splashed wet, not “swimming pool” wet.

Steri-strips Sterile adhesive tapes Available in different widths Frequently used with subcuticular sutures May be used following staple or suture removal Can be used for delayed closure

Staples Rapid closure of wound Easy to apply Evert tissue when placed properly In the ED setting, primarily use for scalp lacerations

When to Consult? Good question…

Home Care Leave dressing in place about 24 hours Clean with soapy water followed by application of antibiotic ointment 1-2 times a day (keep dry if Dermabond) Acetaminophen or ibuprofen for pain Keep out of the sun Follow-up with PCP for removal Return for signs of infection, other concerns