Suturing

Wounds that require sutures

• wounds through the dermis and are likely to scar excessively if not closed with edges opposed

  • More than 0.25 inch deep, 0.75 inch long

• Wounds that continue to bleed after 15 minutes

Contraindications to Sutures

Abscess or cellulitis, high contamination, deep puncture or stab, wound that cannot be irrigated adequately, significant delay in presentation (>24 hours), most animal and human bites

Need to check what patient history for sutures

tetanus immunization status (within last 10 years = need Tdap)

• high tetanus prone wounds = soil (garden hoe)

clean

• cutting breakfast food

contaminated

• garden dirt

“golden period” - 6 to 8 hrs

• increased chance of infection after 8 hours

Delay

• Body - 12 hrs (max time for body lacerations to be repaired)

• Face - 24 hrs (have more time d/t increased blood supply)

Bite wounds management

Copious irrigation (always use saline)

tetanus immunizations

assess for rabies exposure

suturing not recommended in most cases (few to no sutures for minor cases not to lock infection in)

sterility vs clean gloves

same outcomes in both

— here in US standard practice to use sterility

Best practice for clean wounds

meticulous cleansing and copious irrigation

Goals of wound care

Eliminate complications

Restore Functioning

Reduce Scarring

• (proline sutures = most common used by plastic surgeons)

• avoid sun/sunscreen or tape over scar

• scar reducing cream (me derma)

Chance of foreign body in laceration?

get Xray before suturing

• Glass shows up well on xray

• if wood may need ultrasound

Scalp Laceration

careful examination

if white area on laceration of scalp feel it with gloved hand to see if it feels like tendon or bone

• Galea = tendon sheath of scalp that connects frontal muscle to the occipital muscle

• IF IT FEELS LIKE BONE = then galea is cut and separated - MUST BRING BACK TOGETHER WITH ABSORABLE SUTURES BEFORE REPAIRING SKIN

  • If you don’t fix it with cause cosmetic deformity from frontal muscles and increase risk for osteomyelitis of skull

Hand Considerations

• know hand dominance

Check motor and sensory function

• Radial, ulnar, median nerves

  • Dorsiflex, abduct, oppose (make OK sign with hand)

NO deep or buried sutures in hand (may hit tendon)

extensor and flexor tendons

• if extensor tendon lacerated it does not retract (send to ortho for repair)

• flexor tendon

Image of extensor tendons

How to test Motor and flexor tendons in hand

Superficial = bend finger at PIP while holding other three fingers down

Profundus = isolated PIP and bend at DIP joint

• D = bend at DIP joint which is distal

Sensory function of hand

Dog bites

crushing injury

irrigate copiously and prophylactic antibiotic

10-15% of dog bites become infected

• Pasteurella species

Cat Bites

• treacherous fangs (bite goes deep and sometimes closes)

• 50% of bites become infected Pasteurella species

• infection risk increases by double if over 8 hours

Dog bite wound repair

keep sutures loose not to trap infection

Abx for bites

Augmentin #1

Doxycycline or Bactrim (2nd options)

Animals that carry rabies

dogs, cats, ferrets, racoons, skunks, foxes, and bats (most large animals besides bats)

How to do Rabies immunizations

Four doses of rabies vaccine

• 1mL in IM deltoid

• Day 0,3,7,14

Rabies Immunoglobulin 20 units/kg

• Give day 0

• administer into wound and remainder in IM deltoid

Leg and Foot Considerations

• Less vasculature over tibia and higher tension

  • KEEP EXTERMITY ELEVATED

• Foot

  • forefoot is more prone to complications

  • Plantar surface puncture wounds

    • 2-8% complications

    • Rubber soled shoe - pseudomonas (must cover patient with fluroquinolone if through rubber shoe)

What are to inject anesthesia in skin

B/w dermis and subcutaneous layers

Interferes with neural depolarization & transmission of impulses along axons

1% lidocaine (amide)

• Blocks pain stimuli

• Leaves pressure & touch sensation intact

• Duration: local, 20-30 min

2% lidocaine

• Blocks all awareness of stimuli, including press and touch

• No longer recommended due to increased risk for toxicity with minimal benefit

What hair color does not take up lidocaine well

red

Maximal single doses

Lidocaine (Xylocaine) 1% and 2%

Avg 70 kg adult = 30 mL

4.5 mg/kg

2% = 15 mL max dose

Maximal single dose

Lidocaine with epi 1%

avg 70 kg adult = 50 mL

7 mg/kg

Maximal single dose

Bupivacaine, Marcaine, Sensorcaine 0.25-0.5%

LONG ACTING

avg 70 kg adult = 70mL

3 mg/kg of 0.25%

Topical anesthesia dose

2-5 mL of mixture

Guidelines for local anesthetic

• Don’t allow patient to view injection

• Aspirate before injection if near vessel

• Begin with topical dripping of med

  • drip medication over wound to help numb it

• inject withing wound

Lidocaine burning buffer

Lidocaine is an acid pH 4.05-6.49

ADD 1mL of Na bicarb to 10 mL of 1% lidocaine to help neutralize and reduce burning sensation

slow injection

room temp

When to use epinephrine with Lidocaine

To decrease bleeding

• Scalp, cheek, forehead

Prolong duration (lidocaine lasts longer)

DO NOT inject epi in terminal vasculature areas:

• tips of fingers, toes, penis, nose, ears

Alternatives if lidocaine is not available

inject something to dilate vessels (sterile normal saline)

1% Benadryl = 50mg/mL Benadryl in 4 mL NSS

Local ice

When and where to use topical anesthesia

LET = lidocaine/epi/tetracine

DO NOT use on mucous membranes

Wick into wounds

Occlusive dressing and pressure are helpful

• it is ready when blanced

20-to-30-minute wait time

Pain Ease

very inexpensive

spray for 10 seconds and lasts for 60 seconds

approved for minor open wounds

good when stapling scalp

Preparing and cleansing wound

1ST aestheticize wound then clean

Cleaning inside wound = normal saline

Cleaning around wound:

betadine = bactericidal for gram + & -

Hibiclens (CHG) - antibacterial agent for gram + (do not use in open wounds)

Hydrogen peroxide - oxygen bubbles remove new cells from granulation tissue and delays healing (not recommended)

Steps to wound irrigation

NSS 100-300 mL

use splash shield or 4×4 gauze

high pressure (5-70 psi) of saline superior to low-pressure streams such as bulb syringe (0.5-1 psi)

Considerations for healing wound

all wounds leave a scar

sunscreen for at least 1 year

history of keloid formation (always use proline for sutures to avoid keloid formation)

aged & long-term corticosteroid use

• frail thin skin

Most common suture material

nylon ($1.30 / package) cheap

Best suture material

proline but $9 / package

Must align landmarks

• Natural creases, Vermilion border, eyebrows

  • never shave eyebrows

lacerations along skin tension lines

heal easier

Gelfoam

used to repair avulsive laceration (won’t stop bleeding)

apply to wound and hold pressure for several minutes; observe for 5 to 10 minutes (if still bleeding add more on top of one another)

keep gelfoam on for 7-10 days and let fall off naturally

• DO NOT soak off

• expensive / package

When to use Strei-stips

good for surface lacerations, nonmotion areas

avoid areas of bending or prone to getting wet

can use with both sutures or Dermabond

use benzoin or mastisol for additional adhesion

when to use steri strips

helpful on skin tears for thin frail skin

Tissue glue (Dermabond)

KEY POINT: thin to win

Cleanse and dry wound area

Apply two to three thin layers of tissue glue

avoid oozing into wound

dry between each layer to bond skin edges (5-10 sec dry time)

bonding strength is 2.5” = 7 days of sutures

Dermabond Safety in eye lacerations

Low tension, < 4 cm

Moist gauze over eye

Trendelenburg position

Antibiotic ointment over lashes (ointment dissolves glue)

Comes in prepared vials

Spontaneously peels in 5-10 days

ProPen no longer available

Staples

great for scalp

do not use in hands, feet, face

proper alignment = ½ cm

warn patient about noise

do not press into wound; line arrow up with wound laceration

always pull trigger all the way back until you hear a click

Removing Staples

go in center of staples

use rocking motion

Helpful hints for suture placement

comfortable position

adequate lighting

sew towards yourself

go into flap first if present

three instruments for sutures

suture with needle

needle holders

scissors

(possibly forceps if available)

best technique for sutures

good supination

How to select size of suture

Small needles — fine repairs, e.g., face

Larger needles — bigger bites

More zeros (6-0) — smaller, thin suture

Smaller suture — less tensile strength

Types of suture needles

Two basic configurations:

• Tapered (round) - used in surgery

• Cutting (reverse cutting) - what we will use

Letters

• FS — For skin

• CE — Cutting edge

• P — Plastic

Absorbable Suture names and locations

Chromic, Dexon, Vicryl •

Below the skin •

Special areas — inside the mouth •

Situations in which later removal difficult •

Eliminate trauma of suture removal

NON absorbable sutures

Nylon-Ethilon

Prolene - for hairy or keloid areas

Silk

What size needle/thread on area of body?

5-0 anywhere on the body

4-0 on a larger joint

6-0 on face

Scalp = 4-0 or staples

Face = 6-0

Joints = 4-0

Extremities = 4-0 or 5-0

KEY PRINCIPLE wound eversion vs inversion

Correct = eversion

• enter skin at 90 degree angle

• wound edges should slightly evert

How to have best cosmetic results

smallest size needle

good wound eversion

prolene suture

Why do you want knots all to one side of wound?

bacterial grow in knots so you want to move knots away from wound

When to remove sutures

face/neck = 3-5 days

scalp/body = 7-10 days

joints = 10-14 days

Key steps in suture placement

2-1-1-1

move hands in opposite directions:

• pull the needle holder toward you, then push the needle holder away

Wrap the long thread toward the tail

Aftercare for suture placement

Keep clean & dry for 24-48 hours

Gently wash with mild soap and water

Keep covered when ‘out’

Sparing use of antibiotic ointment

Suture removal as scheduled

• 5 days face

• 7-10 days body

• 10-14 days large joint