1. Rene Ramirez, MD UCSF - Fresno Dept. of EM Intern Boot Camp 6/19/2015
Suturing Workshop
Rene Ramirez, MD
UCSF - Fresno Dept. of EM
Intern Boot Camp 6/19/2015

2. Objectives
Wound Healing
Options
Materials
Technique
Practice

3. Layers Epidermis, dermis, subcutaneous layer, and deep fascia
Skin: Epidermis & dermis- Tightly adhered, clinically indistinguishable
Dermal approximation: Strength/alignment of skin closure
SubQ: <Adipose tissue; Nerve, vessels, & hair follicles
Little repair strength; ↓tension ↑cosmesis
Deep fascia: Muscle

5. Wound Healing Coagulation: Immediate
Vasospasm, platelets, fibrinous clot, Inflammation
Epithelialization: Epidermis- regeneration
<48 hours: Complete bridging
Four days: New blood vessel growth
Collagen formation: 48 hrs – 1year; 1 wk (peak)
Wound contraction: 3-4 days

6. Wound Assessment Mechanism Timing/Age of wound
Contamination/Foreign body
Extent of the wound
Neurovascular/Tendon
Tetanus prophylaxis
RF affecting healing

7. Closure Types
UptoDate

8. Contraindications Concern for wound infection
Contaminated , retained FB, infected, noncosmetic wounds
Secondary intention
RF: IC, PAD, DM- t/c delayed primary closure
Age (>6hr) & Location (Hands/Feet)
Animal bites, deep puncture wounds øeffectively irrigate
Too much tension across the suture line
Secondary intention w/scar revision
Active bleeding
Arterial (øscalp wounds)
Hemostasis: SubQ hematoma- infection, øhealing
Superficial wounds 

9. Wound Preparation
Irrigation, FB removal, & necrotic tissue debridement
Surfactant cleaners (ShurClens)
Not antibacterial
↓Trauma & ↓bacterial load/incidence of infection
High-porosity sponge (Optipore)
Road rash or burns

10. Closure Options

11. Dermabond Cyanoacrylate adhesive 50% strength of 5-0 suture
FDA approved since 1998
50% strength of 5-0 suture
Small, superficial wounds, not under tension
Cheap, less pain, no increased risk of infection, slightly increased risk of dehiscence
$22.44

12. Dermabond Clean & dry wound
Not on mucous membranes
Immediately after crushing the glass ampule
Approximate edges & apply in 2 thin layers
Dry for 30 seconds between applications
Approximate 60 seconds after final layer
Duration: 5-10 days

13. Staples Scalp; Trunk and extremities
Fast, cheap, low rates of infection
CT artifact, unable to MRI
Typically removed in 7-10 days
$6.66

14. Instruments
PPSNS

15. Needle Holder/Scissors

16. Needle Grip

17. Forceps

18. Forceps

19. Suture Selection

20. Polyglycolic acid (Dexon * ) Mono Synthetic polymer 20% in 15d; 5% 28d
Absorbable
Gut
Plain
Mammalian collagen
7 to 10 days
Chromic
21 to 28 days
Polyglycolic acid (Dexon * )
Mono
Synthetic polymer
20% in 15d; 5% 28d
Polydioxanone (PDS)
Polyester polymer
70% 14 d, 50% 28 d
Polyglactic acid (Vicryl)
Braided
Coated polymer
60% 14 d, 30% 21 d
Polyglyconate (Maxon)
PoIyester
81% 14 d, 59% 28 d
Nonabsorbable
Cotton
Twisted fibers
Cotton fiber
50% 6 mo, 30% in 2yrs
Silk
Silkworm spun fiber
Gone in one year
Steel
Alloy Fe-Ni-Cr
Indefinite
Nylon (Ethilon, Dermalon)
Loses 20% a year
Polyester (Mersilene)
Polyester
Polypropylene (Prolene )

21. Needles Cutting – Two opposing cutting edges
Skin sutures: pass through dense, irregular, thick dermal connective tissue.
Conventional cutting – Third cutting edge inside concave curvature
Prone to cutout of tissue because the inside cutting edge cuts toward the edges of the incision or wound.
Reverse cutting –Third cutting edge outer convex curvature
Theoretically reduces the danger of tissue cutout
Thick skin: Palm & soles

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

24. Anesthesia Lidocaine (Xylocaine®) with epinephrine
Vasoconstriction (↑Duration), ↓bleeding
Strength: 0.5% & 1.0%
Maximum individual dose:
7mg/kg, or 500mg
Caution 2/2 vasoconstrictive properties
Eyes, Ears, Nose
Fingers, Toes
Penis, Scrotum

25. Anesthesia BUPIVACAINE (MARCAINE): Slow onset, long duration
Strength: 0.25%
DOSE: maximum individual dose 3mg/kg

26. Techniques Simple interrupted for most uncomplicated wounds
Edges of the wound must be everted
Penetrate skin surface at a 90 degree angle
Suture loop as wide at base as skin surface
Width & depth
Both sides of the wound
Similar to thickness of dermis
Number of sutures varies: length, shape, & location
Face: 2–3 mm from edge & 3–5 mm apart
Elsewhere: 3–4 mm from edge & 5–10 mm apart

27. The proper technique for everting the edges of a wound is illustrated in the panels on the left. A) The needle has been inserted at a 90 degree angle. B) The suture loop is as wide at the base as it is at the skin surface. The width and depth of the suture loop are the same on both sides of the wound. In the panels on the right, improper technique has resulted in inversion of the wound edges, which will interfere with wound healing. C) The needle has entered the skin at an angle. D) The base of the wound is narrower than the skin surface.
UptoDate

28. Instrument Tie

30. Interrupted and Continuous Sutures
Individually placed & tied
Concerned about cleanliness of the wound
Easily removed w/o disrupting entire closure
Takes more time
Continuous sutures: Not individually tied
Clean & edges easy to approximate
Help stop bleeding
Scalp laceration

32. Mattress Tension & tend to invert Horizontal Vertical
Acts as a deep and superficial closure
Animal studies: ↑ischemia continuous, interrupted

33. Vertical Mattress

34. Buried Intradermal

35. Corner Stitch

36. Two Handed Knot

37. One Handed Knot

38. Guidelines for Consultation
Large defects more practical of OR/grafting
Severely contaminated
Tendon, nerve or vessel
Open fractures, amputations, and joint penetrations
Laceration over fx site
Compression btwn two rollers (eg, washing machine, industrial)
Delayed, extensive soft tissue/muscle damage
Paint and grease gun injuries
Strong concern about cosmetic outcome by either the patient or family

39. Suture Removal

40. Aftercare
Cover w/abx ointment & nonadhesive dressing immediately after laceration repair
A trial of 426 patients with wounds that received care within 12 hours found that treatment with topical Bacitracin or combination ointment containing neomycin sulfate, bacitracin zinc, and polymyxin B sulfate significantly reduced the rates of wound infection when compared to a petroleum ointment control (5 to 6 percent versus 18 percent)
A crossover trial in four adults evaluated reepithelialization for wounds to the upper dermis on the inner aspect of the arm. Occluded wounds had 1.4 to 3.8 times increased new skin growth at five days. All wounds were 100 percent reepithelialized at seven days
A crossover trial in 10 adults evaluated epithelial coverage in full thickness wounds to the lower extremity between occluded and air exposed sites. Occluded wounds had significantly increased epithelial coverage than air exposed wounds at seven days (62 versus 39 percent), but there was no difference in coverage at 14 days

41. Discharge Instructions
Keep dry for hours
Don’t submerge
Return precautions or infection
When to have the sutures taken out
Stay out of sun