Key Points to understand when closing a wound
- Patient History
- Blood Loss
- Contamination & Mechanism (puncture through tennis shoe? Or Animal bite?)
- Co-morbidities (DM,HIV, CA…)
|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)|
- Td or Abx?
- Films or no Films (underlying fracture, FB…)
- Complete Physical Exam (pulses, ROM, Strength, Sensation, Visualize base of wound) May need good pain control for this!
- Principles of Closure
- Decrease contamination
- Remove FBs and devitalized tissue
- Gathering Material
Bring the following items to the bedside:
Lidocaine, 10cc syringe,
18 gauge and 25 gauge needle chucks basin
Flush kit with splashguard
Protective eye wear
- Pain Control
- Proper Irrigation of a wound
- Deciding What type of Suture to use
- 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.
|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|
|Cotton||Twisted fibers||Cotton fiber||50% in 6 months 30% in 2 years|
|Silk||Braided||Silkworm spun fiber||Gone in one year|
|Nylon (Ethilon, Dermalon)||Mono||Synthetic polymer||Loses 20% a year|
|Polypropylene (Prolene )||Mono||Synthetic polymer|
- Determine Size of Suture
- Size 0-7 0 largest 7 smallest
- Refer to Chart for usual recommendation
|Size of Suture to Use|
|Face (eyes, ears, nose, lip)||6-0|
|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”.
- What type of suture to place
- Simple interrupted (most common)
- Mattress (for large tension wounds)
- Subcuticular or Running stitch
- 3 point suture for triangular laceration
- When to have your patient return for Suture Removal
- 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
- 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.
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).