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Basic Suturing Cynthia Durham, MSN, ANPC, RNFA “ Your greatest tool is your ability to critically think: it is not your hands ” Charles Sherman MD. Financial Disclosure. I have not received financial compensation from any pharmaceutical or suture company in preparation of this suturing course.
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Basic Suturing • Cynthia Durham, MSN, ANPC, RNFA • “Your greatest tool is your ability to critically think: it is not your hands” • Charles Sherman MD
Financial Disclosure • I have not received financial compensation from any pharmaceutical or suture company in preparation of this suturing course
Objectives • At the end of this session the participant will be able to demonstrate: • Injection of a local anesthetic • Simple interrupted suture closure • Vertical Mattress suture closure • and if mastered, then • Running Subcuticular closure
Assessment Of Injury • Most important phase • Take your time • Elicit much info quickly • But in the meantime….
Initial Hemostasis • Direct pressure in absence of foreign bodies 5-10 minutes • "Eye" cautery for smaller blood vessels • Suture ligature for larger vessels • Topical or injected agents
Hemostasis • May be life saving • Allows for proper visualization of wound • Enables accurate repair • Promotes wound healing • Decreases scar tissue
Topical/Injected Hemostatic Agents • 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
Mechanism of Injury • Sharp - i.e. A knife wound • Usually the cleanest and most easily repair • Blunt - i.e. Baseball bat lac • Usually with underlying hematoma • Frequently filled with devitalized tissue
Age of Wound • "Golden period” = ideal time to close • < 12 hours for most wounds • 12 - 16 hours for facial wound
Extent of Injury • Tendon ID & fx assessment • Nerve testing • Blood supply assessment • Bone assessment
Wound Classification • Laceration • Penetration • Amputation
Condition of Wound - 8 Terms 1. Tidy – no devitalized tissue or debris 2. Untidy - + dead tissue/debris in wound • Convert to tidy via irrigation and/or debridement 3. Clean - little bacterial contamination of wound 4. Contaminated - lots of bacteria in wound
Condition of Wound 5. Non- complex: Flat surface Right angle to skin surface Linear with a regular configuration away from critical anatomy Parallel to skin tension lines
Condition of Wound 6. Complex wound Convexity or concavity Flexion crease At angle to normal skin crease Non-linear with skin flaps Edge irregularities Oblique to skin surface Must convert to non-complex configuration.
Condition of Wound 7. Simple Wound only dermis and fat lacerated 8. Compound Wound can involve nerves, ducts, tendons, major blood vessels, glands, fascia, muscle
NORMAL WOUND HEALING 5 Phases 1. Hemostasis - 3 components • Vascular spasm • Platelet aggregation • Coagulation 2. Inflammatory response 3. Collagen formation 4. Wound contracture 5. Re- epithelization
Factors Affecting Wound Healing • Age • Anatomic location • Technical • Associated conditions • Drugs
Diseases That Affect Wound Healing • Diabetes- vascular compromise • Anemia – dec O2 transport • Renal failure – toxic metabolites • Malnutrition –dec protein synthesis • Systemic infection - decinflam response • Malignancy - nutritional deficiencies
Effects of Drugs on Wound Healing • Steroids - suppress inflammation, protein synthesis, wound contraction and re-epithelialization • ASA - suppresses inflammation • Colchicine - arrests cell replication and suppresses collagen transport • Chemo - arrests cell replication, suppresses inflammation and protein synthesis
Herbs That Reduce Hemostasis • Chinchona Danshen • Devil’s claw Garlic • Gingko Papaya • Feverfew Ginger • Echinacea Vitamin E
Wound Closure Terminology • 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
Guidelines For Antibiotics • Traumatic injuries with heavy contamination • Untidy wounds with inadequate debridement • Wounds entering joints • +/- Wounds > 6 hours old • Animal or human bites • Compromised host
Local Anesthetics Sensory Modalities • “The art of life is the avoidance of pain” • Thomas Jefferson • 2 point discrimination • Pain • Light touch • Paresthesia • Pressure • Proprioception
Local Anesthesia Types • Esters – not usually used in laceration repair – short acting, more allergies • Procaine (novocaine), tetracaine (pontocaine), cocaine • Amides - most widely used • Lidocaine (xylocaine), bupivicaine (marcaine)
Lidocaine • Blocks initiation and conduction of impulses • How supplied 1%, 2% Plain or w/epi • Onset 0.5-1 min • Duration 30 - 120 min w/o epi • 90-180 min w/epi Maximum dose plain 300 mg Maximum dose w/epi 500 mg Peds over 5 yo 75-100mg
Bupivicaine • Blocks conduction and generation by increasing threshold of excitation • How supplied 0.25%, 0.5% • Duration 3-6 hrs w/o epi 4-8 hrs w/epi • Onset 10-20 min • Max dose 175mg w/o epi 250mg w/epi Peds dose NONE
Addition Of Epinephrine To Local Anesthetic • Advantages • Vasoconstriction • Decreases bleeding • Decreases toxicity • Disadvantages • Increases BP • Increased allergic reaction +/- • Tissue ischemia
Use Of Bicarbonate In Local Anesthetic • Ph of tissue ~ 7.0 • Ph of lido 6.49 • Mix 1:10 stable 24 hours • Ph of lido and bicarb = ~ 7.38
Administration Of Local Anesthetic- 2 Methods • Packing – can be used w/epi or w/o • Advantage - no needles, doesn’t drag bacteria into wound, provides some hemostasis, works well in atrophic skin • Disadvantages - not as precise infiltration, may need a touch up • Technique - gauze soaked with lido and packed snugly into wound
Administration of Local Anesthesia – 2 Methods • 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
Tips For Comfort • Technique- insert needle thru lac edge – not intact skin • Warm the solution • Inject s-l-o-w-l-y • Buffer the solution • Use a small needle – preferably 27-29 ga
Normal Saline As Local Anesthetic • Advantage – great for people with “caine” allergies • Disadvantage - very short acting
Ice As Local Anesthetic • Advantage - noninvasive • Disadvantage - short acting • Doesn’t need to be sterile
Suture Sizes • Size based on circumference NOT strength • Range - #3, #2, #1, 0,1-0, 2-0, 3-0, 4-0, 5-0 etc to 12-0 • 7-0 = human hair circumference • Choose finest suture capable of doing the job • See appendix for suture size by region
Choice Of Sutures • Absorbable • Gut, polyglycolic acid, polylactic acid, polydioxanone. • Known as – Chromic, Plain, Dexon, Vicryl, PDS • Break down either by hydrolysis or proteolytic enzymes • Used for layered closure, mucous membranes or genitalia
Choice Of Sutures • Nonabsorbable: • Polypropylene, nylon or silk Known as Ethilon, Silk, Dermalon, Prolene Must be removed Used for skin closure
Choice Of Needle • Size – long enough to pass thru tissue unimpeded • Suture boxes usually have WYSIWYG pictures • Size is not standardized
Choice of Needle 3 Tip Shapes • 1. Taper- used for layers, internal organs • Will Not pass thru skin 2. Cutting – standard used for skin closure 3. Reverse Cutting – preferred by plastic surgeons
Wound Closure Instruments • 4” needleholder • Adson forceps • Suture scissors • Skin hook,scalpel, iris scissors
“Antiseptics” • Halogens - chlorine, iodines • Alcohol • Biguanides • Oxidizing agents • Surfactants
Wound Field Prep • Hair trimming – AVOID • Packing the wound • Irrigation • Prep intact skin
Suture Patterns • Simple interrupted • Vertical mattress • Subcuticular
Simple Interrupted • Easiest to put in & take out • Can be used almost anywhere • Can be alternated with VM • Doesn’t always every skin edges
Vertical Mattress • Best skin edge eversion • Can be used anywhere • Takes longer to put in • Can be more difficult to take out
Subcuticular • Used with non- and absorbable suture • No “hash marks” • No visible suture • Easy & less painful to take out • More difficult to do • Gaps along suture line • Patients like it • Don’t use on face or hands
Depth Of Tissue To Take • No deeper than laceration!! • Must have a respect for tissue below the depth of the laceration as well as laterally!!
Width of Tissue to Take • From laceration edge • Eyelid .5-1mm Nose 1.5-2mm • Face 1-2mm Trunk 3-5mm • Extremities 2.5-4mm Scalp 7-7.5mm • Dorsal Hand 1-2mm • Volar hand 1.5-2.5mm • Forehead 2-3mm
Suture Removal in Days Site Adult Child Face 4-5 3-4 Scalp 6-7 5-6 Trunk 7-10 6-8 Arm 7-10 5-9 Leg 8-10 6-8 Ext surface 8-14 7-12 Flex surface 8-10 6-8 Hand 7-12 5-10 Foot sole 7-12 7-10
After Care • Dressings - dry vs moisture permeable • Topical agents - bacitracin vs neosporin • Wound check - timing • Suture removal - when and how
Technique Tips • Gentle tissue handling • Meticulous hemostasis • Needle enters/exits at right angles to skin • Skin edges everted NOT inverted • Ask for help and refer out PRN • Seek out better technique