suture workshop fm / rural clerkship. competency given a pt presenting with a laceration in an...

Suture WorkshopSuture Workshop

FM / Rural Clerkship

CompetencyCompetency

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

ObjectivesObjectives

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.

Suture MaterialsSuture Materials

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

Suture MaterialsSuture Materials

ABSORBABLE:

lose their tensile strength within 60 days.

NON-ABSORBABLE:

Absorbable SuturesAbsorbable 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.

•Polyglycolic acid (DexonPolyglycolic acid (Dexon®®))

Braided

Low-memory

50% tensile strength = 25 days

Sites = subcutaneous closure skin

Polydioxanone (PDSPolydioxanone (PDS®®))

Monofilament50% tensile strength = 30+ daysSites = need for prolonged strength,

Polyglycan 910 (VicrylPolyglycan 910 (Vicryl®®))

Braided, synthetic polymer50% tensile strength for 30 daysUsed: subcutaneous

Non-absorbable SuturesNon-absorbable Sutures

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

Non-absorbable SuturesNon-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.

Suture SizesSuture Sizes

5-0 is small, and 2-0 is bigThe usual sizes = 3-0 or 4-0Examples:

– might use 5-0 on the face– 2-0 on the plantar surface of a foot

Surgical NeedlesSurgical 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

Surgical NeedlesSurgical Needles

Surgical InstrumentsSurgical Instruments

Needle Holders

Forceps Forceps

Tissue forceps Dressing forceps

Iris ScissorsIris Scissors

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

Dissection ScissorsDissection Scissors

Used for heavier tissue revision as necessary for wound undermining.

Suture Removal ScissorsSuture Removal Scissors

Hemostats

Clamping small blood vesselsHemorrhage controlGraspingExposingExploringVisualizing

A Cheap Skin HookA 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

ScalpelsScalpels

Scalpel BladesScalpel Blades

#15 blade

DermabondDermabond®®

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

Anesthetic SolutionsAnesthetic 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

Anesthetic SolutionsAnesthetic Solutions

Lidocaine (Xylocaine®) with epinephrine– Vasoconstriction– Decreased bleeding– Prolongs duration – Strength: 0.5% & 1.0%– Maximum individual dose:

7mg/kg, OR 500mg

Anesthetic SolutionsAnesthetic Solutions

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

Anesthetic SolutionsAnesthetic Solutions

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

Anesthetic SolutionsAnesthetic Solutions

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

Injection TechniquesInjection 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

Complicated WoundsComplicated Wounds

Wounds or lacerations withNerveTendonMajor vessel

Wounds or lacerations of theEyeEyelidsBitesSeverely contaminated wounds.

Wounds entering the

Thoracic

or abdominal cavities.

Wound EvaluationWound Evaluation

Time of incidentSize of woundDepth of woundTendon / nerve involvementBleeding at site

ContraindicationsContraindications

RednessEdema of the wound marginsInfectionFever

ContraindicationsContraindications

Puncture woundsAnimal bitesTendon, verve, or vessel involvementWound more than 12 hours old

Closure TypesClosure Types

Primary closure (primary intention)

Secondary closure (secondary intention)

Tertiary closure (delayed primary closure)

Wound PreparationWound 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

Wound PreparationWound Preparation

Personnel Precautions

Wound PreparationWound Preparation

Wound cleansing solutionWound scrubbingIrrigation

– Take only the soft, flexible part from an 18 gauge IV needle (angiocath)

– Put angiocath tip on 20 cc or 50 cc syringe

Debridement

Basic Laceration RepairBasic Laceration Repair

Principles And Techniques

Principles And TechniquesPrinciples And Techniques

Minimize trauma in skin handlingGentle 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

Definition of TermsDefinition of Terms

– Bite– Throw– Percutaneous (deep) closure – Dermal closure – Interrupted closure – Continuous closure (running sutures)

Principles And TechniquesPrinciples And Techniques

Suture Techniques    

Suture ProceduresSuture Procedures

SuturingSuturing

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

SuturingSuturing

Rule of halves

SuturingSuturing

Rule of halves

SuturingSuturing

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

SuturingSuturing

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.

Follow the needle’s arcFollow 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.

SuturingSuturing

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.

SuturingSuturing

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.

SuturingSuturing

Cut the ends of the suture 1/4-inch from the knot.

The remaining sutures are inserted in the same manner

The trick to an instrument tieThe 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!!

Simple, InterruptedSimple, Interrupted

Vertical MattressVertical Mattress

Good for everting wound edges (neck, forehead creases, concave surfaces)

Horizontal MattressHorizontal Mattress

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

Suturing - finishingSuturing - finishing

After sutures placed, clean the site with normal saline.

Apply a small amount of Bacitracin and cover with a sterile non-adherent dressing.

Suturing - before you go…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.

Suture RemovalSuture Removal

Time frame for removing sutures:Average time frame is 7-10 days

FACE: 4-5 daysBODY & SCALP: 7 daysSOLES, PALMS, BACK OR OVER JOINTS:

10 days

Any suture with pus or signs of infections should be removed immediately.

Suture RemovalSuture 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

Suture RemovalSuture 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