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Suturing in the Pediatric ED

Suturing in the Pediatric ED. Sujit Iyer, M.D. Goals . Review the fundamental history, preparation and techniques in suture repair in the ED Brief repair/pearls on how to make suturing more successful and less traumatic for pediatric patients Review discharge and follow up instructions.

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Suturing in the Pediatric ED

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  1. Suturing in the Pediatric ED Sujit Iyer, M.D.

  2. Goals • Review the fundamental history, preparation and techniques in suture repair in the ED • Brief repair/pearls on how to make suturing more successful and less traumatic for pediatric patients • Review discharge and follow up instructions

  3. Checklist • Type of Wound – Which do you close? • Wound care – Foreign body? How deep is it? • Choice of anesthetic – LET !?! • Suture type

  4. Should you close it? • Close only clean wounds! • Dirty wounds: MOST animal bites, contaminated wounds you can not clean adequately • Cosmetic wounds – the face! • Wounds requiring hemostasis • New wounds: less than 12 hours old (up to 24 hours on face) • Wounds overlying joints (knee) – make sure not continuous with joint cavity – may need ortho consult to inject joint

  5. Wound Care • Irrigate it! Volume and pressure clear bacteria! • Use only saline or nontoxic surfactants • Foreign bodies are rarely discovered unless you anticipate one! Consider using XR, CT, ultrasound when necessary • If grossly contaminated, irrigate and then XR • Consider antibiotics for : • Contaminated wounds • Bite wounds • Crush wounds • Missile Wounds • Delayed wound closure

  6. Irrigation technique

  7. Wound Care Basics • Always consider deeper damage and suture material needs: • Tendon, joint • Galea • Muscle/Fascia l

  8. Anesthesia • Infiltrative anesthesia (Lidocaine) • Can be painful, ? If other painless equally effective options (see LET) • Max dose: Without epi (4-5 mg/kg), with epi (5-7 mg/kg) • Consider nerve blocks to prevent toxicity for large wounds

  9. Infiltrative Anesthesia – PLEASE CONSIDER TOPICAL ANESTHESIA (LET) WHENEVER POSSIBLE

  10. TOPICAL ANESTHESIA • Alternative to local infiltrative anesthesia • LET gel – apply directly to wound with adhesive (i.e., Tegaderm) or with cotton ball and direct pressure • Advantages: • NOT PAINFUL • May be only anesthetic needed for face or scalp • May decrease need for infiltrative anesthesia or at least decrease pain for trunk and extremity wounds • Blanching of surrounding tissue indicates onset of anesthesia • NO adverse side effects reported from systemic absorption

  11. Anesthesia considerations in Pediatric laceration repair • Anxiety equally (if not greater) component than pain. Tips to ease anxiety: • Child life consult – distraction techniques, explaining procedure, etc.. • Comfort positioning (see SLC module!) • Intranasal medicine (Versed, Fentanyl, or both) • Use non painful anesthetics when possible (LET vs infiltrative lidocaine) • Anxiety/pain of suture removal of non-absorbale sutures when absorbable suture equal cosmetic/functional option.

  12. Sutures – The Basics to Consider • Absorbable vs Non-absorbable • Absorbable: Fast absorbing gut, Chromic gut, Vicryl, PDS • Non-absorbable: Prolene, Ethilon, Silk • Smaller the number (“O”) the bigger the thread • Packaging will show actual needle size • Curved needle for all ED needs

  13. Which Suture, Where? ABSORBABLE • Fast Absorbing Gut • Face • Chromic Gut • Mucous membs, fingertip amputation • Vicryl • Deep layers only • PDS • Deep layers only NON-ABSORBABLE • Prolene • Any skin surface • Ethilon • Any skin surface • Silk • Rarely: suturing tubes/lines in place

  14. Which size; and for non-absorbable when do they come out?

  15. Let’s get started…

  16. How to suture…

  17. Discharge Instructions • Watch for signs of infection • Topical or oral antibiotics when indicated • Suture removal timing if using non-absorbable • Tetanus? (look up if indicated) • How Do I minimize scar formation? • Keep area clean, proper suture removal if indicated • Sublock and Vitamin E (Scars form over the next 6 months to 1 year)

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