1. 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 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!

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

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

4. 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

5. 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

6. Wound Care Basics Anesthesia Topical Local
LET (lidocaine, epinephrine, tetracaine)
Apply for 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

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

8. 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

9. 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 days
Moncryl
Monofilament synthetic
Superior pliability
21 days

10. 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)

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

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

13. 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

14. 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)

15. 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”.....

16. 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

17. 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

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

19. 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

20. 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

21. 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.

22. 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

23. 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.

24. 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

25. 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.

26. Horizontal Mattress Suture

27. 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.

28. Vertical Mattress Suture

29. 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.

30. 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

31. 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

32. 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 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.

33. 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

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

35. When to Consult?
Good question…

36. 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