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Suturing is Fun!

Suturing is Fun!. Dr. Linda Frasca Edward Via Virginia College of Osteopathic Medicine Clinical Skills – Block 8. Eversion, eversion, eversion !!

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Suturing is Fun!

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  1. Suturing is Fun! Dr. Linda Frasca Edward Via Virginia College of Osteopathic Medicine Clinical Skills – Block 8

  2. Eversion, eversion, eversion !! This is the most important principal of suturing. I will always remember the lecture I attended by a plastic surgeon after working all night in the emergency room, he stressed eversion as the most important aspect. You should “BUILD PYRAMIDS, NOT DITCHES.”

  3. The goals of laceration and incision repair are as follows: • Achieve hemostasis • Prevent infection • Preserve function • Restore appearance • Minimize patient discomfort

  4. Indications • Lacerations that are open and less than 12 hours old • (If on the face, or if the patient is worried about cosmetic appearance less than 24 hours may be okay, however consider revision/removal of edges before suturing OR a plastic surgeon referral. ) • Some bite wounds in cosmetically important areas. Bite wounds of the face and scalp from dogs and cats may be sutured ( close follow-up advised). • Repair of sites where a lesion has been surgically removed.

  5. Contraindications • Wounds more than 12 hours old (more than 24 hours old on the face). If not closed, wound may heal by secondary intention, or delayed primary closure in 3-5 days. • Animal and human bite wounds to the hand. (Cat and primate bites on the face and scalp maybe sutured, but sutures should be avoided in other locations.). • Puncture wounds.

  6. Equipment • Surgical prep (betadine, surcleanse) • Irrigation device for contaminated wounds • Anesthetic • 10 ml syringe • 27 and 18 gauge needles (18 gauge to draw up anesthesia and small gauge needles to administer it) • Sterile drapes, fenestrated drape • 4 x 4 – inch gauze sponges • Sterile instruments: needle holder, scissors, forceps • Suture

  7. Patient Preparation • Inform patient of the nature of the laceration. • If in a cosmetically important area consider a plastic surgeon. • Discuss risks: including pain, bleeding, infection, scarring. • For skin lesion excision it is advisable to use a consent form.

  8. Local Anesthesia To minimize the pain of injecting local anesthetic: • Use a small gauge needle (27 gauge or smaller). • Inject slowly. • Inject directly into the dermis through the open wound (not through intact skin). • Warm anesthetic to body temperature. • Buffer the anesthetic with sodium bicarbonate ( 10 ml to 1 ml) optional.

  9. Approaches For Allergic Patients • Cooling agent (ice cube, ethyl chloride, etc.). • Single-dose vials instead of multidose vials (do not contain preservatives, which may cause an allergic reaction). • Bacteriostatic saline. • Substitute an amide for an ester. • Lidocaine and Marcaine (Amide) • Novocaine and Tetracaine (Ester) • Diphenhydramine (benadryl). 1% solution

  10. Best Reported Allergies • “Allergic to all painkillers except Demerol.” • “Allergic to all painkillers except one, called ‘percasomething’ but I really don’t remember the exact name.” • “Allergic to Demeral, codeine, morphine, and 2mg Dilaudid. But I can take 4 mg Dilaudid.” (This slide is for comic relief, Ha!)

  11. Wound Preparation Wound Cleansing: • Use normal saline with angiocatheter or splash shield . • Chemical compounds i.e. betadine, hibiclens, phisohex should not be used inside wounds but may be applied to external intact skin. Debridement and Undermining with care: • Undermining reduces the blood supply to the wound, damaging wound defenses and increasing risk of infection. • Reserve undermining for more elective surgery.

  12. Technique • Control all bleeding before closure. • Eliminate “dead space”. • Accurately approximate tissue layers to each other. • Minimal skin tension. • NO blind clamping in a wound, can damage a nerve, artery or tendon!!!! • Needle should enter the skin surface at a 90-degree angle.

  13. Simple Interrupted Suture: Eversion, Eversion, Eversion • Most commonly used technique. • First suture placed in the CENTER of the wound. • Strength of interrupted sutures are superior to continuous. • The stitch should be as wide as deep. • The knots should be lined on one side. • The finer the suture, the closer the stitches. • Number of TIES correspond with the suture size.

  14. Required technique for student to pass laboratory

  15. A Simple Running Stitch • Advantages: • Results are excellent if little skin tension • Most appropriate for long linear wounds • If gaping of the wound use interrupted sutures. • Disadvantages: the entire stitch must be removed at once. Takes a great deal of practice

  16. Required technique for student to pass

  17. Intradermal (Buried) Sutures Indications: deeper wounds and wounds under tension, to close dead spaces. Advantages: aid in closing a wound, remove tension from superficial skin sutures, and decrease scarring. Contraindication: not to be used in contaminated wounds, because they increase the risk of infection.

  18. Vertical Mattress Suturing Advantages: promotes eversion • Closure of gaping wounds and deep lacerations that need more than simple sutures to close potential dead space. • Combines advantages of deep and superficial sutures. • Useful when natural tendency of loose skin is to create inversion of the wound margins , which is to be avoided. • Frequent Uses: Thin or lax skin : High tension areas (extremities)

  19. Required technique for student to pass

  20. Horizontal Mattress Suture • Indication: wounds under a moderate amount of tension. • Promotes wound edge eversion. • Bleeding scalp wounds, palms or soles • Patients who are poor candidates for deep sutures because of susceptibility to wound infections. • More rapid than simple interrupted sutures.

  21. Required technique for student to pass

  22. Subcuticular Running Stitch Indications: to close linear wounds that are not under much tension. • Excellent cosmetic result. • Ends of the suture do not need to be tied. • Taping under slight tension preserves approximation. • If desired, the two ends can be tied over the wound, or a knot at each end. Avoid: pressure on the wound, since this stitch separates easily.

  23. Three-point or Half-Buried Mattress • Permit closure of the acute corner tip of a laceration, without impairing blood flow to the tip. • Intradermal stitch. • Do not tie the knot over the point of the flap.

  24. The following complications may occur within the first 2 weeks: Infection Hematoma Pain Bruising and swelling Bleeding Suture spitting Dehiscence Prolonged or permanent complications may include: Scarring Hypertrophic scaring Keloid Hyperpigmentation Nerve damage Hypopigmentation Imperfect cosmetic alignment (ie. Vermilion border) Complications

  25. Postprocedure patient Education • Most wounds protected with some sort of dressing during the first 24-48 hours after closure. • For hemostasis, a pressure dressing if needed. • Patients may shower after 24 hours. • Facial and scalp lacs dressed with topical ointment. • Return if signs of wound infection. • Wounds at risk for infection or poor healing require a wound check within 48 hours. Tetanus Immunization: remember to update.

  26. Suture Selection • SUTURE SIZE: the more “0s” the smaller the suture : 5-0 smaller than 3-0. • ABSORBABLE: mucous membranes and buried closures. • Natural: dissolve<1 week; plain catgut, chromic. • Synthetic braided: strength decreases over a month, : vicryl. • Synthetic monofilament: strength 70% at 1 month: maxon, PDS. • NONABSORBABLE: greatest strength, used for skin • Monofilament: NYLON (ethilon), polypropylene(prolene). • Multifilament: cotton, silk (local inflammation).

  27. Punch Biopsy • To obtain a full thickness cylindrical specimen • Punch biopsy tool, pickups, scissors, suture if needed • Sterile technique if sutures: ie. 5mm biopsy • The technique: • Anesthesia • Choose punch unit ( 2 to 5 mm) • STRETCH the skin perpendicular to the lines of skin tension • Push the unit vertically and rotate • Withdraw the punch and use scissors to cut the plug • Suture if a 5 mm biopsy done

  28. Three Good Reasonsto become a Doctor • Free latex gloves • Stylish scrubs • The world doesn’t need any more lawyers.

  29. REFERENCES • Procedures for Primary Care by Pfenninger and Fowler: 2003 (figures shown in this presentation) • Emergency Medicine by Rosen: 2002 • The 5 Minute Emergency Medicine Consult by Rosen etc.1999 • Emergency Medicine by Tintinalli, fourth edition • Lacerations and Acute Wounds by Adam Singer and Judd Hollander: 2003 • Wound Management and Suturing Manual: Ethicon

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