2019 NPO EDUCATION CONFERENCE

BEGINNING SUTURING

WORKSHOP

Mary Fey, FNP

• Avoid infection

• Hemostasis

• Esthetically Pleasing Scar

GOALS OF WOUND MANAGEMENT

Epidermis

Dermis

-indistinguishable from each other visibly

Subcutaneous Layer

-Adipose, nerve fibers, blood vessels, hair follicles

Deep Fascia

-Muscle

TISSUE LAYERS

Coagulation begins immediately-vasospasm, platelet aggregation, fibrous clot formation

Epitheliazation occurs in epidermis-complete bridging of wound occurs in 48 hours

New blood vessel growth peaks 4 days after injury

Collagen formation begins 48 hours, peaks first week, continues 12 months

Wound contraction occurs 3-4 days after injury-full wound thickness moves toward center of wound

MECHANISM OF WOUND HEALING

•Mechanism of Injury

•Age of Injury

•Possible contamination or foreign body

•Extent of the wound

•Neurovascular Compromise or tendon injury

•Need for Tetanus prophylaxis

•Risk factors that might affect healing, i.e. Diabetes, immunocompromised

WOUND ASSESSMENT

• Animal Bites

• Deep puncture Wounds

• Actively bleeding (arterial)

• Stained wounds (Grease)

CONTRAINDICATIONS OF CLOSURE

Preferably within 6 hours

Up to 18 hours if no concerns of infection (High Risk)

DiabeticContaminated Wound

May need to debride edges if greater than 6 hours

TIMING OF CLOSURE

Clean and/or Irrigate• Normal Saline• Surfactant Cleaners (ShurClens)

Debridement

WOUND PREPARATION

ANESTHESIA

Lidocaine 1% Use when need large amount

Lidocaine2%Most common

Lidocaine 2% plus EpinephrineUse UNLESS fingers, toes, penis, or nose (and earlobes)

Marcaine 0.5% (Lasts longer)Sensorcaine 0.5%

Sodium BicarbonateLessens ‘sting’ of LidocaineDo not use with Marcaine or Sensorcaine (precipitates)

EQUIPMENT

• Needle Holder

• Tissue Forcep

• Iris Scissors

• Face Shield

• 3 cc Syringe with 25-30 g. needle

Dermal Suture Material:•Needles (3/8 circle most common)

•Ethilon6-0 Face5-0 Everywhere else

•Prolene6-0 Face

COMMON SUTURE MATERIALS

Most Common and Recommended

• Evert edges of wound• Penetrate skin surface at 90 degree angle• Loop same distance at skin and base of wound• Start in center• Equal amount of sutures on both sides

INTERRUPTED SUTURE

CORRECT VS. INCORRECT

Useful for closing punch biopsy and

very small laceration

FIGURE OF 8 SUTURE

A C

D B

A C

D B

FIGURE OF 8 SUTURE

SUTURE REMOVAL

• Face/neck 3-5 days

• Scalp 7-10 days

• Trunk 7-10 days

• Joints 10-14 days

• Back/Foot 10-14 days

Great for Scalp Wounds

Good for Tension Wounds (Knee laceration)

Start at one end and advance to other end

May be able to apply with just local anesthetic if only 1-2 staples – Good for someone who is having high anxiety

STAPLES

STAPLE TECHNIQUE

DERMABOND

• Useful for small clean wounds

Works Cited

Patrick, J. (2003, Sep 14). Mt. auburn hospital emergency department: wound care. Retrieved Sep 8, 2012, from

jpatric.net: http://www.jpatrick.net/MAHFiles/orient/woundcare_manual.html

CORNER STITCH

“BOAT IN THE DOCK”

•Start suture in epidermis across from flap

•Insert needle into dermis only and come out in dermis

•Assure you have a ‘good bite’

• Exit through dermis very near insertion point

• Apply sufficient tension to pull flap into corner

•Tie knot across from corner of flap

CORNER STITCH HALF-BURIED HORIZONTAL

MATTRESS

BIBLIOGRAPHY

• Boriskin, Mitchell: “Primary Care Management of Wounds”, Nurse Practitioner 1994, pp. 38-58.

• Christoph, R.A. et al.: “Pain Reduction in Local Anesthesia Administration Through pH Buffering”, Annals of Emergency Medicine, 1988, 17:2, pp. 117/27-120/30.

• Patrick, J. (2003, Sep 14). Mt. auburn hospital emergency department: wound care. Retrieved Sep 8, 2012, from jpatric.net:http://www.jpatrick.net/MAHFiles/orient/woundcare_manual.html

• Trott, A: Wounds and Lacerations: Emergency Care and Closure, St. Louis, Mosby Year Book, Inc., 1991