Suturing 101

4/13/2016
Suturing 101
Susan Bray, DNP, FNP-C
Ryan Mallo, PhD(c), DNP, FNP-C
Disclosure Statement
I have no current affiliation or financial
arrangement with any grantor or commercial
interests that would have direct interest in
the subject matter of this CE Program
Objectives
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Review of Key Factors in Wound Care.
Review of Patient Evaluation in Wound Care.
Review of Anatomy of Wound Repair.
Review of Injury Pathophysiology & Healing.
Review of Wound Cleansing & Decisions Prior
to Closure.
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Objectives
• Review of Anesthesia & Suturing
Instrumentation.
• Review of Special Wounds & Aftercare.
• Instruction of Simple Interrupted Suturing.
• Instruction of Running Suture Closure.
Key Factors in Wound Care
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Cleaning the Wound
Hair removal
Irrigation
Debridement
Prophylactic antibiotics
Patient Evaluation of Wounds
• Initial Evaluation: patient assessment
determines proper management and
preparation of a wound or laceration
• Apply direct pressure over the site to help
control external bleeding.
• Remove all rings or jewelry that may constrict
the injured body part when edema progresses
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So you want to sew
• Lacerations can be repaired with:
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Pertinent Medical History
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Allergies and current medications
Intentional vs unintentional injury
Occupational injury
Assault or self-inflicted
Type of force
Human or animal bites or punctures
Symptoms
Pertinent Medical History
• Foreign body potential: foreign body sensation
• Contamination: how much time has elapsed
since the time of the until injury until initial
cleansing of the wound?
• Time from the initial injury until presentation
• Wound care performed prior to arrival
• What object caused the injury?
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Considerations for Suturing
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Wound location and etiology of injury
Time from injury until presentation
Degree of contamination
Importance of cosmetic appearance
Wound examination should be done with
minimal residual bleeding
Patient Preparation
• Obtain verbal and written informed consent
after explaining the extent of the laceration and
proposed treatment
• Advise the patient about risks of bleeding, pain,
infection, scarring, and dehiscence.
• Offer the option of a plastic surgeon to an area
that is cosmetically important
Equipment
• Adequate lighting
• Anesthetic: 1% or 2% Lidocaine with or
without epinephrine (or other agent)
• Sterile drapes or surgical sterile towels
• A ruler in centimeters and a marking pen
• 18 & 27 gauge 1 ¼ inch needle to administer
anesthetic:
• Irrigation device 30ml syringe and sterile saline
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Equipment
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Sutures
4x4 gauze pads
Sterile gloves
PPE: protective mask with shield for eyes and
gown
• Sterile suture kit with: 4 ½ in needle holder;
curved or straight iris scissors; Adson forceps
Equipment
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Iris Scissors
Suture Scissors
Scalpel (no. 11 or 15)
Cleansing agents
Splash shields
Instrumentation
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Phases of Wound Healing
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Vascular phase:
vasoconstriction,
vasodilation
• Inflammatory: immediate
greater than 3-5 days
erythema, edema, warmth,
and pain
• Proliferative or healing: up to
the 14th day
• Maturation: remodeling:
collagen fibers are replaced
from day 14 on
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Anatomy of Wound Repair
• Cosmetic results are better with minimal tension
placed on wound edges at the time of repair. The
sutures should be placed parallel to the natural skin
tension lines (Langer’s Lines)
Tension Lines
Anatomy of Wound Repair
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Wound Healing by Stage
• Primary
• Secondary
• Tertiary
Complications in Healing
• Technical Factors
– Inadequate wound
preparation
– Excessive suture tension
– Reactive suture materials
– Local anesthetic
• Anatomic Factors
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Static skin tension
Dynamic skin tension
Pigmented skin
Oily skin
Body Region
• Associated Conditions
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Advanced age
Alcoholism
Uremia
Diabetes
PVD
Malnutrition
• Drugs
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Steroids
NSAID
Anticoagulants
Antineoplastic agents
Injury Pathophysiology
• Shearing
• Tension
• Compression
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Scarring
Cleansing
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Betadine
Hibiclens
Shur-Clens
PharmClens
Soap
Sterile Water
Isotonic Saline
Tap Water
Hydrogen Peroxide?
Preparing for Wound Closure
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Hand Washing
Universal Precautions
Hair Removal
Anesthesia
• NEVER SHAVE EYEBROWS
• Removal of Foreign Material
• Wound Soaking
• Periphery Cleansing
• Irrigation
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Tricks of the Trade
Exploration & Debridement
Timing to Closure
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Animal Bites
Bite Wound ABX Reccomendations
CDC Guide to Td / Tdap
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Referral?
Non-Absorbable Suture
Absorbable Suture
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Suture Selection
• 0: Fascia closure in surgery
• 2-0: as in 3
• 3-0: Skin of foot, Chest, Abdomen,
Back, extremities
• 4-0: Scalp, chest, abdomen, foot,
extremities
• 5-0: Scalp, brow, oral, abdomen, hand,
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Mucosal Lacs
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Scalp, Torso, Extremities
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Face, Eyebrow, Nose, Lip
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• 6-0: Ear, eyelid, nose, lip, face, penis
• 7-0: Eyelid, lip, face
Non-absorbable: 4-0 or 5-0
Non-absorbable: 6-0
Ear, Eyelid
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penis, brow, nose, lip, face, hand
Absorbable Suture: 3-0 or 4-0
Non-absorbable: 6-0
Hand
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Non-absorbable: 5-0
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Foot or Sole
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Penis
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Non-absorbable: 3-0 or 4-0
Non-absorbable: 5-0 or 6-0
Needle Selection
Ready for Anesthesia
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Anesthesia
Alternatives
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No anesthetic.
Ice
Check your allergy
Diphenhydramine
Topical Anesthesia
Nitrous Oxide
Sedation
Direct Wound Infiltration
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Digital Block
Digital Block
Picture the Anatomy
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Aftercare
Simple Interrupted Suture
Basic Technique
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Simple Interrupted Suturing
Running Suture Closure
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Running Suture
Questions
Bibliography
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