Preparing to Suture. 6 th Annual Pediatric Advanced Practice Conference Tuesday, February 9, :30 pm. Workshop B: Suturing for Beginners

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1 Preparing to Suture Kristen Devick, MPAS, PA-C University of Colorado Department of Emergency Medicine NONE! Skin Anatomy Trott, 2012, p.11 Preparing to suture Initial evaluation Hemostasis Anesthesia Irrigation Wound exploration Closure of laceration History Mechanism of injury/other complaints Age of wound FB sensation? Allergies Tetanus status PMH Medications Page 1 of 10

2 As a general rule: Any injury <24 hours from time from injury, that can be converted with cleansing and débridement to a freshappearing, slightly bleeding, non-devitalized wound, with no visible contamination or debris after aggressive cleansing, irrigation, & débridement, can be considered for primary closure (Trott, 2012) Timing of Closure The chance of developing a wound infection increases each hour after the laceration occurred Trott, 2012 Physical Exam Location Size, shape, depth, contaminated/fb ROM (tendon injury or fx) Distal perfusion and sensation (Vascular and Nerve injury) Consent/Expectations Prior to anesthesia, informed consent of procedure (suture, staples, dermabond) Scar: all lacerations to skin will leave a scar. Benefit of closure is smaller scar. Possible infection Onset of Action Anesthetic Solutions Lidocaine 1 or 2% most commonly used Lidocaine with Epinephrine: Duration of action increased Vasoconstriction Myth vs Truth Epi contraindicated in areas with terminal circulation. Examples: fingers, nose, toes, ears. Trott, 2012, p.43 Page 2 of 10

3 Plane of Anesthesia for Local Skin Infiltration Digital Block Traditional Digital Block Vs Subcutaneous block Trott, 2012, p. 42 LET Lidocaine-Epinephrine-Tetracaine minute preparation Helpful in superficial laceration, abrasions, prior to cleaning, prior to local injection of anesthesia Summary of Wound Cleansing Agents Ready to Close? Wound should appear Visually clean & without contaminants Tissue pink & viable There is no active bleeding No FB Trott, 2012 Page 3 of 10

4 Suture Preparation NEJM video Questions? Resources Hollander J, Singer A. Emergency Wound Management. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli s Emergency Medicine. 6th ed. New York: McGraw-Hill; 2004; Trott, A. (2012). Wounds and Lacerations Emergency Care and Closure (fourth edition). Philadelphia, PA: Elsevier. Page 4 of 10

5 None! Principles and Techniques Kristen Devick, MPAS, PA-C Department of Emergency Medicine All lacerations will leave a scar. You can influence how good the outcome looks! Bite: amount of tissue taken when placing the suture needle into the skin The farther from the wound edge that the needle is introduced, the bigger the bite Throw: each suture knot consists of a series of throws. Square knot=2 throws, additional throws to secure the knot Percutaneous Closure (skin closure):sutures placed in skin with knot tied at surface Dermal Closure (deep closure): sutures placed in superficial (subcutaneous) facia & dermis with knot buried in the wound Usually absorbable sutures Page 5 of 10

6 Layer Matching: important to match each layer of a wound edge to its counterpart superficial fascia has to meet superficial fascia dermis to dermis Why? Proper wound healing & less scarring Needle driver Pickups (I prefer the toothed pickup) Scissors Non-Absorbable suture versus Absorbable Suture Needle size, curvature & cut. Most commonly used in the emergency setting. Enter and exit skin at 90 degrees. Evert edges Start by closing middle or most cosmetically sensitive Sutures should be placed just far enough from each other so that no gap appears between the wound edges. A. Suture needle is introduced at a 90-degree angle to the epidermis. B. The suture should be square. C. Incorrect technique and inversion, pitting As a general guideline, the distance between sutures is equal to the bite distance from the wound edge Page 6 of 10

7 RUNNING SUTURE INTERRUPTED SUTURES A Review of Several Techniques & Indication Sequence for tie of standard percutaneous closure Sequence for tie of standard percutaneous closure of deep & superficial closures Surgeons knot: two throws, then single throw. Usually 4-5 throws total. Similar to simple interrupted but no individual knots tied. Faster and efficient. Care must be taken with tying knot on opposite end Another useful method for wound edge eversion The horizontal mattress suture is often used in closing hand (palm & dorsum) lacerations The vertical mattress suture is helpful in areas of lax skin (e.g., elbow, dorsum of hand), where the wound edges tend to fall or fold into the wound. It can act as a deep & a superficial closure all in one suture. Page 7 of 10

8 Same start as simple interrupted A second bite is taken approximately 0.5 cm adjacent to the first exit & is brought back to the original starting edge, also 0.5 cm from the initial entry point. The knot is tied, leaving an everted edge. First take a large bite of tissue approximately 1 to 1.5 cm away from the wound edge & crossing through the tissue to an equal distance on the opposite side of the wound. Needle is then reversed & returned for a small bite (1 or 2 mm) at the epidermal/dermal edge to approximate closely the epidermal layer When wound edges are sutured together, inevitable tension & pressure is created in the tissue within the suture loop. It is important to minimize tension! Approximate don t strangulate. A. Drive the needle from deep in the wound to superficial. B. The needle is driven superficial to deep on the opposite side of the wound. C. The leading & trailing sutures come out on the same side of the cross suture. D. This same-side technique allows for the knot to be tied deep and away from the wound surface. E. If the same-side technique is not followed, the knot is forced to the wound surface by the cross suture and may protrude out of the wound. Trott, 2012 A. A few sutures, placed far apart & far from the wound edges, will increase wound tension. B. More sutures, placed closer together and closer to the wound edges, will reduce tension. Mastering this clinical skill Sutures can act as foreign bodies & can potentiate infection. Page 8 of 10

9 Best for lacerations with: low tension easy to approximate no oozing or bleeding clean & even edges that can be closed with no gaps Benefits: Less pain and time, slough off in 7-10 days, act as its own dressing, no antibiotic ointment needed p. 289 Linear lacerations of the scalp, trunk, & extremities. 1. Forceps are used to evert the wound edges before placement of each staple 2. Stapler is placed gently on the skin over the wound without indenting the skin 3. Trigger is squeezed gently & evenly to advance the staple into the tissue 4. When the staple is placed, a space should be visible between it & skin. A common mistake in placing staples is to apply excessive downward pressure, causing the staples to seat deep in the wound. Staples are kept in place for the same length of time as are sutures in similar anatomic sites. Lip Lacerations: Vermillion boarder Lower Lip: avoid ectropion Lacrimal Duct/ Lid Margin: plastics or ophthalmologist Eyebrow 6 cm right upper arm laceration repair Anesthetized with 1% lido with epi, irrigated with 300 ml of NS, betadine prep and sterile drape. Explored: no vascular involvement, no apparent foreign body, no muscle or tendon involvement. Distal sensation intact. Closed with 4.0 monosoft interrupted sutures, 6 sutures. Good wound edge approximation. Topical antibiotics and dressing. Tolerated procedure well. Lacerationrepair.com Videos, photos, blog on laceration repair by EM physician Page 9 of 10

10 Trott, A. (2012). Wounds and Lacerations Emergency Care and Closure (fourth edition). Philadelphia, PA: Elsevier. Hollander J, Singer A. Emergency Wound Management. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma, OJ, Cline DM, editors. Tintinalli s Emergency Medicine. 6th ed. New York: McGraw-Hill; 2004; Page 10 of 10

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