Basic Suturing Cynthia Durham, MSN, ANPC, RNFA

1. Basic Suturing • Cynthia Durham, MSN, ANPC, RNFA • “Your greatest tool is your ability to critically think: it is not your hands” • Charles Sherman MD

2. Financial Disclosure • I have not received financial compensation from any pharmaceutical or suture company in preparation of this suturing course

3. 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

4. Assessment Of Injury • Most important phase • Take your time • Elicit much info quickly • But in the meantime….

5. 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

6. Hemostasis • May be life saving • Allows for proper visualization of wound • Enables accurate repair • Promotes wound healing • Decreases scar tissue

7. 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

8. 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

9. Age of Wound • "Golden period” = ideal time to close • < 12 hours for most wounds • 12 - 16 hours for facial wound

10. Extent of Injury • Tendon ID & fx assessment • Nerve testing • Blood supply assessment • Bone assessment

11. Wound Classification • Laceration • Penetration • Amputation

12. 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

13. 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

14. 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.

15. 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

16. 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

17. Factors Affecting Wound Healing • Age • Anatomic location • Technical • Associated conditions • Drugs

18. 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

19. 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

20. Herbs That Reduce Hemostasis • Chinchona Danshen • Devil’s claw Garlic • Gingko Papaya • Feverfew Ginger • Echinacea Vitamin E

21. 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

22. 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

23. Local Anesthetics Sensory Modalities • “The art of life is the avoidance of pain” • Thomas Jefferson • 2 point discrimination • Pain • Light touch • Paresthesia • Pressure • Proprioception

24. 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)

25. 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

26. 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

27. Addition Of Epinephrine To Local Anesthetic • Advantages • Vasoconstriction • Decreases bleeding • Decreases toxicity • Disadvantages • Increases BP • Increased allergic reaction +/- • Tissue ischemia

28. 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

29. 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

30. 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

31. 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

32. Normal Saline As Local Anesthetic • Advantage – great for people with “caine” allergies • Disadvantage - very short acting

33. Ice As Local Anesthetic • Advantage - noninvasive • Disadvantage - short acting • Doesn’t need to be sterile

34. 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

35. 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

36. Choice Of Sutures • Nonabsorbable: • Polypropylene, nylon or silk Known as Ethilon, Silk, Dermalon, Prolene Must be removed Used for skin closure

37. Choice Of Needle • Size – long enough to pass thru tissue unimpeded • Suture boxes usually have WYSIWYG pictures • Size is not standardized

38. 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

39. Wound Closure Instruments • 4” needleholder • Adson forceps • Suture scissors • Skin hook,scalpel, iris scissors

40. “Antiseptics” • Halogens - chlorine, iodines • Alcohol • Biguanides • Oxidizing agents • Surfactants

41. Wound Field Prep • Hair trimming – AVOID • Packing the wound • Irrigation • Prep intact skin

42. Suture Patterns • Simple interrupted • Vertical mattress • Subcuticular

43. Simple Interrupted • Easiest to put in & take out • Can be used almost anywhere • Can be alternated with VM • Doesn’t always every skin edges

44. Vertical Mattress • Best skin edge eversion • Can be used anywhere • Takes longer to put in • Can be more difficult to take out

45. 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

46. 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!!

47. 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

48. 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

49. After Care • Dressings - dry vs moisture permeable • Topical agents - bacitracin vs neosporin • Wound check - timing • Suture removal - when and how

50. 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