Suture workshop

Suture Workshop

Key Points to understand when closing a wound

  1. Patient History
    1. Blood Loss
    2. Contamination & Mechanism (puncture through tennis shoe? Or Animal bite?)
    3. Time
    4. Co-morbidities (DM,HIV, CA…)
Laceration  Time Treatment
Extremity Less than 12 hrs Suture
Extremity Greater than 12 hrs Irrigate, Td, and let heal by 2 or 3 closure. If cosmesus or function are an issue discuss with specialist
Face Less than 24 hrs Suture (unless grossly infected)

 

  1. Td or Abx?
  2. Films or no Films (underlying fracture, FB…)
  3. Complete Physical Exam (pulses, ROM, Strength, Sensation, Visualize base of wound) May need good pain control for this!
  4. Principles of Closure
    1. Decrease contamination
    2. Remove FBs and devitalized tissue
    3. Cosmesus
  5. Gathering Material

        Bring the following items to the bedside:
        Lidocaine, 10cc syringe,
        18 gauge and 25 gauge needle chucks basin
        Flush kit with splashguard
        500cc NS
        4x4s
        Light
        Mayo stand
        Suture Kit
        Suture material
        Protective eye wear
Sterile gloves
Bandage material,
Tape
Antibiotic ointment

  1. Pain Control
  2. Proper Irrigation of a wound
  3. Deciding What type of Suture to use
    1. Do Not Get lost here in general use the following

                                         i.    External superficial use Nylon (non Absorbable)

                                        ii.    Subcuticular or Deep use Vicryl or Dexon

                                      iii.    Face Gut or fine Nylon (we like nylon bc pt returns for wound check)

As time goes on and you get more experience suturing we sometimes consider other factors like suture strength, rate of decay, and type of material for certain wounds BUT IN GENERAL USE ABOVE GUIDE. This is just food for thought.

Absorbable
Gut Plain Mammalian collagen 7 to 10 days  
Gut Chromic Mammalian collagen 21 to 28 days  
Polyglycolic acid (Dexon * ) Mono Synthetic polymer 20% in 15 days 5% in 28days  
Polydioxanone (PDS) Mono Polyester polymer 70% in 14 days 50% in 28 days  
Polyglactic acid (Vicryl) Braided Coated polymer 60% in 14 days 30% in 21 days  
Polyglyconate (Maxon) Mono PoIyester 81% in 14 days 59% In 28 days  
Nonabsorbable
Cotton Twisted fibers Cotton fiber 50% in 6 months 30% in 2 years  
Silk Braided Silkworm spun fiber Gone in one year  
Steel Mono Alloy Fe-Ni-Cr Indefinite  
Nylon (Ethilon, Dermalon) Mono Synthetic polymer Loses 20% a year  
Polyester (Mersilene) Braided Polyester Indefinite  
Polypropylene (Prolene ) Mono Synthetic polymer    

 

  1. Determine Size of Suture
    1.  Size 0-7     0 largest         7 smallest
    2. Refer to Chart for usual recommendation

 

                      Size of Suture to Use
Face  (eyes, ears, nose, lip) 6-0
Extremities 4-0
Scalp 4-0
Trunk or Foot 3-0 or 4-0
Oral mucosa, Brow, Penis, 5-0
G tubes or Chest Tubes 2-0 or larger

Note this is a general guide one must use judgment, for example a child with a fine eyelid lac may need a 6 or 7-0 vs 5-0 on the face! You get the idea.

Now the Fun Part Lets Practice some Sutures!!

Remember approximate don’t strangulate and “pucker your wounds”.

  1. What type of suture to place
    1. Simple interrupted (most common)
    2. Mattress (for large tension wounds)
    3. Subcuticular or Running stitch
    4. 3 point suture for triangular laceration

 

  1. When to have your patient return for Suture Removal
    1. Give good Wound care instructions (signs symptoms to look for, topical abx etc..)

•Face and head – 5-7 days

•Trunk – 7 days

•Arms – 8 days

•Hands – 8-10 days

•Legs – 9 days

•Feet – 10 days

  1.  
    1. Children – about 1 day less at each site

Note this is in accordance with Annals of Emergency Medicine, again use your judgment based of type of wound and pt reliability.

Other Topics like undermining and removing “dog tails”, nerve blocks etc. will be discussed in other lectures.

 

Disclaimer: The above hand out and lecture is to serve as a recommended suggestion for suture repair. For a full understanding and current guideline recommendations for laceration repair please refer to Roberts  and Hedges Clinical procedures in Emergency Medicine.

Resources Used:

1. Hollander JE – Ann Emerg Med – 01-SEP-1999; 34(3): 356-67 Laceration management. Annals of Emergency Medicine – Volume 34, Issue 3 (September 1999).