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Suturing Basics

Suturing Basics. Terren Trott. Objectives. Understand Basic Suturing Anatomy Indications for Suturing Materials and Preparation Suturing Techniques. Options to Sutures. Dermabond Superficial lacerations Facial lacerations Staples Commonly used on the scalp or huge lacerations

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Suturing Basics

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  1. Suturing Basics Terren Trott

  2. Objectives • Understand Basic Suturing Anatomy • Indications for Suturing • Materials and Preparation • Suturing Techniques

  3. Options to Sutures • Dermabond • Superficial lacerations • Facial lacerations • Staples • Commonly used on the scalp or huge lacerations • Faster, lower infection, reduced inflammation • Greater tensile strength • CI: face, joints, hands • Steristrips • Healing by Secondary Intention • If wound has been open for more than 6 hours

  4. Suture Anatomy • Absorbable • Plain gut, FAST gut, vicryl, monocryl • Non-absorbable • Ethilon (Nylon) • Silk • Polypropylene (Prolene) • Monofilament VsPolyfilament

  5. Suturing Preparation • Hemostasis • Anesthetic • Irrigation • Exploration • Draping • Suture selection

  6. Hemostasis • Direct pressure and elevation • Blood Pressure Cuff • Lidocaine with Epinephrine • Figure-8 stitch

  7. Anesthetic Anesthetic Pearls Epinephrine vasoconstricts Amides: have two ‘I’s in the name, esters have one ‘I’ Infiltrate with anesthetic slowly to reduce the burn Consider digital blocks Bicarb can be used to buffer lidocaine and reduce burning Withdraw on the syringe to make sure you’re not in a vessel

  8. What does lidocaine toxicity look like? • Early symtoms • Headache, nausea/vomiting, AMS • Late Symptoms • Seizures • Cardiac Arrythmias: PEA, vtach, torsades • Tx: Sodium Bicarb, IV Lipids

  9. Irrigation IRRIGATION IRRIGATION IRRIGATION IRRIGATION IRRIGATION IRRIGATION IRRIGATION

  10. Exploration • Radiograph/Ultrasound for foreign bodies • Digital exploration of scalp lacerations for skull fractures • Tendon injuries must be examined through entire course of anatomical range • Missed foreign objects are a common source of Emergency Department litigation

  11. Suture Technique Pearls • “Approximate, Don’t Strangulate” • For proper wound eversion, the needle should enter the dermis at 90 degrees • Exit the wound equidistant from the entry site • Reduce tension with deep sutures • No matter how small the laceration, use universal blood precautions • Antibiotics are no substitute for thorough irrigation and cleaning • Shaving hair is a relative contraindication • Use only the minimum number of sutures, excess sutures provide a nidus for infection • Grasp needle ¾ of distance from tip • Use the forceps to grasp under the dermis to prevent crush injury

  12. Knot Tying Pearls • Knot throwing: throw as many knows as size suture material • 6-0 throw 6 knots • Knots are tied in opposite directions • Hand tie vs. instrument tie

  13. Simple Interrupted • Most commonly used technique to close skin • Attempt to keep all knots on one side • For uncomplicated wound closure

  14. Vertical Mattress • Large bite 1 – 1.5 cm from wound edge, cross equidistant to other wound edge. • Reverse the needle • Enter the dermalepi-dermal junction, 2 – 3mm from wound edge • Advantages: acts as both deep and superficial closure, reducing wound tension

  15. Horizontal Mattress • All entry and exit points are equidistant • Advantages: distribution of tension across greater area, improved wound eversion

  16. Corner Stitch • Advantages: approximation of corners and stellate lacerations without capillary compromise of the corner

  17. Running • Advantages: Faster • Disadvantages: one compromised stitch compromises entire suture

  18. Deep Sutures • To decrease tension and approximate tissues • Enter the tissue low and exit high so that the knot ties to the bottom

  19. References • http://www.jpatrick.net/WND/woundcare.html

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