Suturing Workshop

Rene Ramirez, MDUCSF - Fresno Dept. of EM

Intern Boot Camp 6/19/2015

Objectives

• Wound Healing• Options• Materials• Technique• Practice

Layers

• Epidermis, dermis, subcutaneous layer, and deep fascia

• Skin: Epidermis & dermis- Tightly adhered, clinically indistinguishable– Dermal approximation: Strength/alignment of skin

closure• SubQ: <Adipose tissue; Nerve, vessels, & hair

follicles– Little repair strength; ↓tension ↑cosmesis

• Deep fascia: Muscle

Wound Healing• Coagulation: Immediate– Vasospasm, platelets, fibrinous clot, Inflammation

• Epithelialization: Epidermis- regeneration– <48 hours: Complete bridging

• Four days: New blood vessel growth• Collagen formation: 48 hrs – 1year; 1 wk (peak)• Wound contraction: 3-4 days

Wound Assessment

• Mechanism• Timing/Age of wound• Contamination/Foreign body• Extent of the wound• Neurovascular/Tendon• Tetanus prophylaxis • RF affecting healing

Closure Types

UptoDate

Contraindications• Concern for wound infection• Contaminated , retained FB, infected, noncosmetic wounds

– Secondary intention• RF: IC, PAD, DM- t/c delayed primary closure

– Age (>6hr) & Location (Hands/Feet)• Animal bites, deep puncture wounds øeffectively irrigate• Too much tension across the suture line

– Secondary intention w/scar revision• Active bleeding

– Arterial (øscalp wounds)– Hemostasis: SubQ hematoma- infection, øhealing

• Superficial wounds

Wound Preparation

• Irrigation, FB removal, & necrotic tissue debridement

• Surfactant cleaners (ShurClens)– Not antibacterial– ↓Trauma & ↓bacterial load/incidence of

infection– High-porosity sponge (Optipore)• Road rash or burns

Closure Options

Dermabond

• Cyanoacrylate adhesive – FDA approved since 1998

• 50% strength of 5-0 suture• Small, superficial wounds, not under tension• Cheap, less pain, no increased risk of

infection, slightly increased risk of dehiscence

Dermabond

• Clean & dry wound – Not on mucous membranes

• Immediately after crushing the glass ampule• Approximate edges & apply in 2 thin layers– Dry for 30 seconds between applications

• Approximate 60 seconds after final layer• Duration: 5-10 days

Staples

• Scalp; Trunk and extremities• Fast, cheap, low rates of infection• CT artifact, unable to MRI• Typically removed in 7-10 days

Instruments

Needle Holder/Scissors

Needle Grip

Forceps

Forceps

Suture Selection

AbsorbableGut Plain Mammalian collagen 7 to 10 days

Gut Chromic Mammalian collagen 21 to 28 days

Polyglycolic acid (Dexon * ) Mono Synthetic polymer 20% in 15d; 5% 28d

Polydioxanone (PDS) Mono Polyester polymer 70% 14 d, 50% 28 d

Polyglactic acid (Vicryl) Braided Coated polymer 60% 14 d, 30% 21 d

Polyglyconate (Maxon) Mono PoIyester 81% 14 d, 59% 28 d

NonabsorbableCotton Twisted fibers Cotton fiber 50% 6 mo, 30% in 2yrs

Silk Braided Silkworm spun fiber Gone in one year

Steel Mono Alloy Fe-Ni-Cr IndefiniteNylon (Ethilon, Dermalon) Mono Synthetic polymer Loses 20% a year

Polyester (Mersilene) Braided Polyester Indefinite

Polypropylene (Prolene ) Mono Synthetic polymer

Needles• Cutting – Two opposing cutting edges– Skin sutures: pass through dense, irregular, thick

dermal connective tissue.• Conventional cutting – Third cutting edge inside

concave curvature– Prone to cutout of tissue because the inside cutting

edge cuts toward the edges of the incision or wound.• Reverse cutting –Third cutting edge outer convex

curvature– Theoretically reduces the danger of tissue cutout – Thick skin: Palm & soles

Anesthesia

• Lidocaine (Xylocaine®) – Most commonly used, Rapid onset – Strength: 0.5%, 1.0%, & 2.0% – Maximum dose:• 5 mg / kg, or• 300 mg

– 1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc– 300 mg = 0.03 liter = 30 ml

Anesthesia

• Lidocaine (Xylocaine®) with epinephrine– Vasoconstriction (↑Duration), ↓bleeding – Strength: 0.5% & 1.0%– Maximum individual dose:• 7mg/kg, or 500mg

• Caution 2/2 vasoconstrictive properties– Eyes, Ears, Nose – Fingers, Toes– Penis, Scrotum

Anesthesia

• BUPIVACAINE (MARCAINE):– Slow onset, long duration– Strength: 0.25%– DOSE: maximum individual dose 3mg/kg

Techniques

• Simple interrupted for most uncomplicated wounds– Edges of the wound must be everted

• Penetrate skin surface at a 90 degree angle• Suture loop as wide at base as skin surface• Width & depth – Both sides of the wound– Similar to thickness of dermis

• Number of sutures varies: length, shape, & location• Face: 2–3 mm from edge & 3–5 mm apart• Elsewhere: 3–4 mm from edge & 5–10 mm apart

Instrument Tie

• http://www.youtube.com/watch?v=-smZKFnC-U8

Interrupted and Continuous Sutures

• Individually placed & tied• Concerned about cleanliness of the wound– Easily removed w/o disrupting entire closure

• Takes more time

• Continuous sutures: Not individually tied• Clean & edges easy to approximate• Help stop bleeding– Scalp laceration

Mattress

• Tension & tend to invert

• Horizontal

• Vertical– Acts as a deep and superficial closure– Animal studies: ↑ischemia continuous,

interrupted

Vertical Mattress

Buried Intradermal

Corner Stitch

Two Handed Knot

• http://www.youtube.com/watch?v=_lvQ2YJ0RjQ&feature=related

One Handed Knot

• http://www.youtube.com/watch?v=HTxT60u2Lj0

Guidelines for Consultation• Large defects more practical of OR/grafting• Severely contaminated• Tendon, nerve or vessel• Open fractures, amputations, and joint penetrations• Laceration over fx site• Compression btwn two rollers (eg, washing machine,

industrial)– Delayed, extensive soft tissue/muscle damage

• Paint and grease gun injuries• Strong concern about cosmetic outcome by either the patient

or family

Suture Removal

Aftercare• Cover w/abx ointment & nonadhesive dressing immediately after

laceration repair– A trial of 426 patients with wounds that received care within 12 hours

found that treatment with topical Bacitracin or combination ointment containing neomycin sulfate, bacitracin zinc, and polymyxin B sulfate significantly reduced the rates of wound infection when compared to a petroleum ointment control (5 to 6 percent versus 18 percent)

– A crossover trial in four adults evaluated reepithelialization for wounds to the upper dermis on the inner aspect of the arm. Occluded wounds had 1.4 to 3.8 times increased new skin growth at five days. All wounds were 100 percent reepithelialized at seven days

– A crossover trial in 10 adults evaluated epithelial coverage in full thickness wounds to the lower extremity between occluded and air exposed sites. Occluded wounds had significantly increased epithelial coverage than air exposed wounds at seven days (62 versus 39 percent), but there was no difference in coverage at 14 days

Discharge Instructions

• Keep dry for 24-48 hours• Don’t submerge• Return precautions or infection• When to have the sutures taken out• Stay out of sun