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Basic Suturing
Cynthia Durham, MSN, ANPC, RNFA
Your greatest tool is your ability to critically think: it is not your handsCharles Sherman MD
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I have not received financial compensation from any pharmaceutical or suture company in preparation of this suturing course
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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
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Most important phaseTake your time Elicit much info quicklyBut in the meantime.
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Direct pressure in absence of foreign bodies 5-10 minutes"Eye" cautery for smaller blood vesselsSuture ligature for larger vesselsTopical or injected agents
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May be life savingAllows for proper visualization of woundEnables accurate repairPromotes wound healingDecreases scar tissue
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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
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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
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"Golden period = ideal time to close
< 12 hours for most wounds
12 - 16 hours for facial wound
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Tendon ID & fx assessment
Nerve testing
Blood supply assessment
Bone assessment
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Laceration
Penetration
Amputation
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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
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5. Non- complex: Flat surface Right angle to skin surfaceLinear with a regular configuration away from critical anatomyParallel to skin tension lines
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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.
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7. Simple Wound only dermis and fat lacerated
8. Compound Wound can involve nerves, ducts, tendons, major blood vessels, glands, fascia, muscle
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1. Hemostasis - 3 componentsVascular spasmPlatelet aggregationCoagulation2. Inflammatory response3. Collagen formation4. Wound contracture5. Re- epithelization
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AgeAnatomic locationTechnicalAssociated conditionsDrugs
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Diabetes- vascular compromiseAnemia dec O2 transportRenal failure toxic metabolitesMalnutrition dec protein synthesisSystemic infection - dec inflam responseMalignancy - nutritional deficiencies
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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
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ChinchonaDanshenDevils clawGarlic GingkoPapaya FeverfewGingerEchinaceaVitamin E
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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
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Traumatic injuries with heavy contaminationUntidy wounds with inadequate debridementWounds entering joints+/- Wounds > 6 hours oldAnimal or human bitesCompromised host
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The art of life is the avoidance of painThomas Jefferson
2 point discriminationPainLight touch ParesthesiaPressureProprioception
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Esters not usually used in laceration repair short acting, more allergiesProcaine (novocaine), tetracaine (pontocaine), cocaineAmides - most widely usedLidocaine (xylocaine), bupivicaine (marcaine)
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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
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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
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AdvantagesVasoconstrictionDecreases bleedingDecreases toxicity
DisadvantagesIncreases BPIncreased allergic reaction +/-Tissue ischemia
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Ph of tissue ~ 7.0Ph of lido 6.49Mix 1:10 stable 24 hoursPh of lido and bicarb = ~ 7.38
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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
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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
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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
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Advantage great for people with caine allergies
Disadvantage - very short acting
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Advantage - noninvasive
Disadvantage - short acting
Doesnt need to be sterile
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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
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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
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Nonabsorbable:
Polypropylene, nylon or silk
Known as Ethilon, Silk, Dermalon, Prolene
Must be removed
Used for skin closure
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Size long enough to pass thru tissue unimpededSuture boxes usually have WYSIWYG picturesSize is not standardized
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4 needleholderAdson forcepsSuture scissorsSkin hook,scalpel, iris scissors
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Halogens - chlorine, iodinesAlcoholBiguanidesOxidizing agentsSurfactants
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Hair trimming AVOIDPacking the woundIrrigationPrep intact skin
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Simple interruptedVertical mattressSubcuticular
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Easiest to put in & take outCan be used almost anywhereCan be alternated with VMDoesnt always every skin edges
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Best skin edge eversionCan be used anywhereTakes longer to put inCan be more difficult to take out
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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
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No deeper than laceration!!
Must have a respect for tissue below the depth of the laceration as well as laterally!!
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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
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SiteAdultChildFace4-53-4Scalp6-75-6Trunk7-106-8Arm7-105-9Leg8-106-8Ext surface8-147-12Flex surface8-106-8Hand7-125-10Foot sole7-127-10
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Dressings - dry vs moisture permeable
Topical agents - bacitracin vs neosporin
Wound check - timing
Suture removal - when and how
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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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