Welcome To:Welcome To:Introduction to suturing for the Non-Introduction to suturing for the Non-

clinician/Pre-hospital Provider who may clinician/Pre-hospital Provider who may be required to suture a laceration in the be required to suture a laceration in the

austere environment of the Fire-line, austere environment of the Fire-line, Disaster Site or other area not normally Disaster Site or other area not normally suited for said procedure due to non-suited for said procedure due to non-

sterile conditions resulting from a sterile conditions resulting from a declared or non-declared disasterdeclared or non-declared disaster

OR

Presented byGarth Gilmer MICP*

*Chief dummy

OBJECTIVES:OBJECTIVES:

1. Learn different suture materials and appropriate choice for wound location

2. Describe choice of suture size

3. Learn procedure for wound preparation

4. Describe choices of local anesthetic

5. Learn how to anesthetize wounds

6. Learn the simple interrupted suture technique

7. Learn the “Instrument Tie”

8. Describe how long sutures need to stay in place

9. Sew up some pig’s feet

Types of SutureTypes of Suture

• Absorbable– Dexon, Vicryl, Plain Gut, Chromic Gut, PDS

• Lose their tensile strength within 60 days

• Used in many of the internal tissues of the body

• Used for “buried knots”• Degrades via inflammatory response

Types of Suture (cont.)Types of Suture (cont.)

• Non-absorbable– Silk, Ethilon®/Dermalon (nylon), Prolene

(Polyproylene), Mersiline (polyester)• Does not dissolve, must be removed

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

Monofilament

• Single strand of suture material

• Minimal tissue trauma

• Smooth tying but needs more knots

• Harder to handle due to memory

• Ethilon is your friend

Considerations Before SuturingConsiderations Before Suturing

How long ago did wound happen?– No greater that 12hrs on body, 24hrs on

face

Last tetanus shot?– More than 10yrs needs a booster, more than

5yrs if dirty wound

Contamination/Foreign body?– Don’t want to sew FB into wound

What What NotNot to Suture to Suture

• Puncture wounds• Animal bites• Tendon, nerve, or vessel involvement

– Must assess before suturing

• Wound more than 12 hours old• Redness• Edema of the wound margins• Infection• Fever

STEPS:STEPS:

1. Assess

2. Gather materials

3. Anesthetize

4. Irrigate

5. Prep

6. Suture

7. Bandage

ASSESSASSESS

• Serious blood loss?

• Motor and sensory function– Did they cut a tendon?

• Circulation

• Note size and depth of laceration

• Foreign body? Contamination?

• Fracture?

Gather Ye MaterialsGather Ye Materials

• Irrigation solution/supplies• Sterile gloves, eye protection• Drape if available• Needle driver or straight hemostat• Suture material• Forceps• Suture scissors• Sterile 4x4’s • Try for good lighting

What size suture?What size suture?

• Scalp 4-0 or 5-0, staples

• Face, ear, nose, lip,

forehead 6-0

• Eyelid 6-0 or 7-0

• Eyebrow 5-0 or 6-0

• Trunk or extremity

3-0, 4-0, or 5-0• Plantar foot 3-0 or

4-0• Hand 5-0

AnesthetizeAnesthetizeLocal anesthetics available:

– Plain Lidocaine (1%, 2%)• 1% Lidocaine will probably work for most wounds

– Lidocaine with epi (1%, 2%)• Lidocaine with epi

– Vasoconstriction

– Decreased bleeding– Prolongs duration – NEVER use on eyes, ears, fingers, toes, nose and “one of

those” (penis)

– Bupivicaine– Topical

Local Anesthetics Local Anesthetics Lidocaine

– Rapid onset • 2-5 minutes

– Short duration • 1-2 hours

Bupivicaine (Marcaine)

– Slower Onset

• 4-8 minutes – Longer duration

• 4-8 hours

OK, So letOK, So let’s numb ‘em up…’s numb ‘em up…

• 25, 27, or 30-gauge needle

• 6 or 10 cc syringe• Check for allergies• Insert the needle at

the inner wound edge inject from within the wound margins

• Aspirate• Inject agent into

tissue SLOWLY; look for skin blanching

• Wait…• After anesthesia has

taken effect, suturing may begin

What About Bicarb?What About Bicarb?

Sodium Bicarbonate can be added to Lidocaine to reduce pain of infiltration.– 9 parts lidocaine to 1 part bicarb.

Or….

you can just warm the lidocaine solution to body temp and warn the patient that this is gonna hurt a little.

IRRIGATIONIRRIGATIONVery important!

– Most important step for reducing the risk of wound infection.

– Removes foreign bodies– 100cc of fluid for every cm of wound length– Must be under pressure

• About 15psi

– Tap water works just as well as sterile saline

– Can use a 30-60cc syringe with 18g angiocath• Cover your eyes!

PrepPrep1. Sterile drapes/towels if you have them2. Suture open and on the tray

• If you can, open an extra suture pack

1. Good light/Good body position2. Instruments out before you put on sterile

gloves3. Check the wound for foreign bodies and

remove them4. Cut out dead, fragmented tissue (make it

pretty)

SutureSutureaka Go For It!aka Go For It!

Basic Suturing Techniques:

• Simple interrupted

• Subcuticular or continuous

• Vertical or horizontal mattress

The simple interrupted technique is the The simple interrupted technique is the predominate form of basic wound closure predominate form of basic wound closure

and can close 90% of woundsand can close 90% of wounds

So that’s what we’re going to learn

Suture PearlsSuture Pearls

• Approximate don’t strangulate!

• Avoid leaving a dead space

• Gentle apposition with slight eversion of wound edges

• Don’t poke yourself

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

• The needle enters the skin with a 1/4-inch bite from the wound edge at 90 degrees– Evert wound edges

• Because scars contract over time

SuturingSuturing

Rule of halves

SuturingSuturing

Rule of halves

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).– You can get a preview of your stitch this way

• 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.– Place the needle holder/hemostat in the “V” of the

suture.

SuturingSuturing

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

• The remaining sutures are inserted in the same manner

• Question: What’s the only stitch that you can’t take out?– Answer: There ain’t one. When in doubt, take

it out

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 or surgeon’s knot

Simple, Interrupted*Simple, Interrupted*

*don’t worry, you’ll see this when you practice

BandageBandage

• After sutures placed, clean the site with normal saline.

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

• Do they need a tetanus shot?

Suture RemovalSuture RemovalTime frame for removing sutures:

Average time frame is 7-10 daysFace: 4-5 days (longer is NOT better)Body & Scalp: 7-10 daysHand: 10 daysTrunk, arms or legs: 10 days

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

Other Methods of Wound ClosureOther Methods of Wound Closure

Dermabond®

• 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

DermabondDermabond®®

1. Crack ampoule or applicator tip up; invert

2. Hold skin edges approximated horizontally

3. Gently and evenly apply at least two thin

layers on the surface of the edges with a

brushing motion with at least 30 seconds

between each layer and hold for 60 sec

after last layer until not tacky

Skin StaplerSkin Stapler

• Consider staples for linear lacerations not involving the face or other cosmetically sensitive areas

• Frequently used for scalp, trunk, or extremity lacerations

• Optimally, two operators perform this procedure

Skin StaplerSkin Stapler

Pearls for Adjunctive ClosuresPearls for Adjunctive ClosuresStaplesStaples

• With the stapler centered over the wound, press it gently but firmly against the wound and depressed the trigger

• This is a common mistake. People often apply no pressure and end up with partially applied “floating staples”

• Properly applied staples naturally evert the wound edges

Questions?Questions?

Look out piggies, here we come