basic suturing cynthia durham, msn, anpc, rnfa “your greatest tool is your ability to critically...

Basic Suturing

Cynthia Durham, MSN, ANPC, RNFA

Your greatest tool is your ability to critically think: it is not your handsCharles Sherman MD

I have not received financial compensation from any pharmaceutical or suture company in preparation of this suturing course

At the end of this session the participant will be able to demonstrate:

Injection of a local anestheticSimple interrupted suture closureVertical Mattress suture closureand if mastered, thenRunning Subcuticular closure

Most important phaseTake your time Elicit much info quicklyBut in the meantime.

Direct pressure in absence of foreign bodies 5-10 minutes"Eye" cautery for smaller blood vesselsSuture ligature for larger vesselsTopical or injected agents

May be life savingAllows for proper visualization of woundEnables accurate repairPromotes wound healingDecreases scar tissue

Work either by: vasoconstriction or enhanced coagulation

Epi 1:100,000 injected along wound edge and wait 10 minutes (more to follow)

Surgicel wait 2-8 minutes absorbed in 1-2 weeks

Sharp - i.e. A knife woundUsually the cleanest and most easily repair

Blunt - i.e. Baseball bat lacUsually with underlying hematomaFrequently filled with devitalized tissue

"Golden period = ideal time to close

< 12 hours for most wounds

12 - 16 hours for facial wound

Tendon ID & fx assessment

Nerve testing

Blood supply assessment

Bone assessment

Laceration

Penetration

Amputation

1. Tidy no devitalized tissue or debris2. Untidy - + dead tissue/debris in woundConvert to tidy via irrigation and/or debridement3. Clean - little bacterial contamination of wound4. Contaminated - lots of bacteria in wound

5. Non- complex: Flat surface Right angle to skin surfaceLinear with a regular configuration away from critical anatomyParallel to skin tension lines

6. Complex woundConvexity or concavity Flexion crease At angle to normal skin crease Non-linear with skin flapsEdge irregularitiesOblique to skin surface

Must convert to non-complex configuration.

7. Simple Wound only dermis and fat lacerated

8. Compound Wound can involve nerves, ducts, tendons, major blood vessels, glands, fascia, muscle

1. Hemostasis - 3 componentsVascular spasmPlatelet aggregationCoagulation2. Inflammatory response3. Collagen formation4. Wound contracture5. Re- epithelization

AgeAnatomic locationTechnicalAssociated conditionsDrugs

Diabetes- vascular compromiseAnemia dec O2 transportRenal failure toxic metabolitesMalnutrition dec protein synthesisSystemic infection - dec inflam responseMalignancy - nutritional deficiencies

Steroids - suppress inflammation, protein synthesis, wound contraction and re-epithelializationASA - suppresses inflammationColchicine - arrests cell replication and suppresses collagen transportChemo - arrests cell replication, suppresses inflammation and protein synthesis

ChinchonaDanshenDevils clawGarlic GingkoPapaya FeverfewGingerEchinaceaVitamin E

First intention - evaluated, cleaned anesthtized sutured soon after injury

Second intention - heals by granulation

Third intention - left open for about 3 days and then sutured closed

Traumatic injuries with heavy contaminationUntidy wounds with inadequate debridementWounds entering joints+/- Wounds > 6 hours oldAnimal or human bitesCompromised host

The art of life is the avoidance of painThomas Jefferson

2 point discriminationPainLight touch ParesthesiaPressureProprioception

Esters not usually used in laceration repair short acting, more allergiesProcaine (novocaine), tetracaine (pontocaine), cocaineAmides - most widely usedLidocaine (xylocaine), bupivicaine (marcaine)

Blocks initiation and conduction of impulsesHow supplied1%, 2% Plain or w/epiOnset0.5-1 minDuration 30 - 120 min w/o epi 90-180 min w/epi Maximum dose plain 300 mgMaximum dose w/epi 500 mgPeds over 5 yo 75-100mg

Blocks conduction and generation by increasing threshold of excitationHow supplied0.25%, 0.5%Duration3-6 hrs w/o epi4-8 hrs w/epiOnset10-20 minMax dose175mg w/o epi250mg w/epiPeds dose NONE

AdvantagesVasoconstrictionDecreases bleedingDecreases toxicity

DisadvantagesIncreases BPIncreased allergic reaction +/-Tissue ischemia

Ph of tissue ~ 7.0Ph of lido 6.49Mix 1:10 stable 24 hoursPh of lido and bicarb = ~ 7.38

Packing can be used w/epi or w/o

Advantage - no needles, doesnt drag bacteria into wound, provides some hemostasis, works well in atrophic skinDisadvantages - not as precise infiltration, may need a touch upTechnique - gauze soaked with lido and packed snugly into wound

Infiltration -can be used w/epi or w/o

Advantages can direct exact amount into tissue, much more precise

Disadvatage- needle sticks

Technique inject thru lac edge not intact skin

Technique- insert needle thru lac edge not intact skin Warm the solution Inject s-l-o-w-l-y Buffer the solutionUse a small needle preferably 27-29 ga

Advantage great for people with caine allergies

Disadvantage - very short acting

Advantage - noninvasive

Disadvantage - short acting

Doesnt need to be sterile

Size based on circumference NOT strengthRange - #3, #2, #1, 0,1-0, 2-0, 3-0, 4-0, 5-0 etc to 12-07-0 = human hair circumferenceChoose finest suture capable of doing the jobSee appendix for suture size by region

Absorbable

Gut, polyglycolic acid, polylactic acid, polydioxanone.Known as Chromic, Plain, Dexon, Vicryl, PDSBreak down either by hydrolysis or proteolytic enzymesUsed for layered closure, mucous membranes or genitalia

Nonabsorbable:

Polypropylene, nylon or silk

Known as Ethilon, Silk, Dermalon, Prolene

Must be removed

Used for skin closure

Size long enough to pass thru tissue unimpededSuture boxes usually have WYSIWYG picturesSize is not standardized

4 needleholderAdson forcepsSuture scissorsSkin hook,scalpel, iris scissors

Halogens - chlorine, iodinesAlcoholBiguanidesOxidizing agentsSurfactants

Hair trimming AVOIDPacking the woundIrrigationPrep intact skin

Simple interruptedVertical mattressSubcuticular

Easiest to put in & take outCan be used almost anywhereCan be alternated with VMDoesnt always every skin edges

Best skin edge eversionCan be used anywhereTakes longer to put inCan be more difficult to take out

Used with non- and absorbable sutureNo hash marksNo visible sutureEasy & less painful to take outMore difficult to doGaps along suture linePatients like itDont use on face or hands

No deeper than laceration!!

Must have a respect for tissue below the depth of the laceration as well as laterally!!

From laceration edge

Eyelid .5-1mmNose 1.5-2mmFace 1-2mmTrunk 3-5mmExtremities 2.5-4mmScalp 7-7.5mmDorsal Hand 1-2mmVolar hand 1.5-2.5mmForehead 2-3mm

SiteAdultChildFace4-53-4Scalp6-75-6Trunk7-106-8Arm7-105-9Leg8-106-8Ext surface8-147-12Flex surface8-106-8Hand7-125-10Foot sole7-127-10

Dressings - dry vs moisture permeable

Topical agents - bacitracin vs neosporin

Wound check - timing

Suture removal - when and how

Gentle tissue handlingMeticulous hemostasisNeedle enters/exits at right angles to skinSkin edges everted NOT invertedAsk for help and refer out PRNSeek out better technique

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