Transcript Document

Suture Workshop
FM / Rural
Clerkship
Competency

Given a pt presenting with a laceration in an
office or urgent / emergent care setting and
standard supplies and equipment, treat the
wound appropriately.
Objectives
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Identify the various types and sizes of suture
material.
Choose the proper instruments for suturing.
Given a list of injectable anesthetic agents,
identify the different agents and correct dosages.
Determine whether a wound requires suturing.
Under supervision, anesthetize, clean, and close a
wound with sutures.
Recommend appropriate laceration care and
follow-up.
Suture Materials
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Criteria
– Tensile strength
– Good knot security
– Workability in handling
– Low tissue reactivity
– Ability to resist bacterial infection
Suture Materials
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ABSORBABLE:
lose their tensile strength
within 60 days.
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NONABSORBABLE:
Absorbable Sutures
PLAIN GUT:
Derived from the small
intestine of healthy
sheep.
Loses 50% of tensile
strength by 5-7 days.
Used on mucosal
surfaces.
CHROMIC GUT:
Treated with chromic
acid to delay tissue
absorption time.
50% tensile strength by
10-14 days.
Used in episiotomy
repairs.
•Polyglycolic acid (Dexon®)
Braided
Low-memory
50% tensile strength = 25 days
Sites = subcutaneous closure skin
Polydioxanone (PDS®)
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Monofilament
 50% tensile strength = 30+ days
 Sites = need for prolonged strength,
Polyglycan 910 (Vicryl®)
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Braided, synthetic polymer
 50% tensile strength for 30 days
 Used: subcutaneous
Non-absorbable Sutures
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Nylon (Ethilon®): of all the nonabsorbable suture materials, monofilament
nylon is the most commonly used in surface
closures.
Non-absorbable Sutures
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Polypropylene (Prolene®): appears to be
stronger then nylon and has better overall wound
security.
 BRAIDED: includes cotton, silk, braided nylon
and multifilament dacron. Before the advent of
synthetic fibers, silk was the mainstay of wound
closure. It is the most workable and has excellent
knot security. Disadvantages: high reactivity and
infection due to the absorption of body fluids by
the braided fibers.
Suture Sizes
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5-0 is small, and 2-0 is big
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The usual sizes = 3-0 or 4-0
 Examples:
– might use 5-0 on the face
– 2-0 on the plantar surface of a foot
Surgical Needles
Wide variety with different company’s
naming systems
 2 basic configurations for curved needles
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– Cutting: cutting edge can cut through tough
tissue, such as skin
– Tapered: no cutting edge. For softer tissue
inside the body
Surgical Needles
Surgical Instruments
Needle Holders
Forceps
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Tissue forceps
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Dressing forceps
Iris Scissors
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Iris scissors are predominantly used to assist
in wound debridement and revision.
Dissection Scissors
Used for heavier tissue revision as necessary
for wound undermining.
Suture Removal Scissors
Hemostats
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Clamping small blood vessels
 Hemorrhage control
 Grasping
 Exposing
 Exploring
 Visualizing
A Cheap Skin Hook
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Put a hypodermic needle on a small syringe
or use a hemostat to hold the needle
 Bend the tip of the needle back (sterile
technique)
 General principle: Minimize trauma in
handling tissue
Scalpels
Scalpel Blades
#15 blade
Dermabond®
A sterile, liquid topical skin
adhesive
 Reacts with moisture on
skin surface to form a
strong, flexible bond
 Only for easily
approximated skin edges of
wounds
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– punctures from minimally
invasive surgery
– simple, thoroughly cleansed,
lacerations
Anesthetic Solutions
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Lidocaine (Xylocaine®)
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Most commonly used
Rapid onset
Strength: 0.5%, 1.0%, & 2.0%
Maximum dose:
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5 mg / kg
300 mg
– 1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc
– 300 mg = 0.03 liter = 30 ml
Anesthetic Solutions
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Lidocaine (Xylocaine®) with epinephrine
– Vasoconstriction
– Decreased bleeding
– Prolongs duration
– Strength: 0.5% & 1.0%
– Maximum individual dose:
 7mg/kg, OR
 500mg
Anesthetic Solutions
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CAUTIONS: due to its vasoconstriction
properties never use Lidocaine with epinephrine
on:
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Eyes
Ears
Nose
Fingers
Toes
Penis
Scrotum
Anesthetic Solutions
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Mepivacaine (CARBOCAINE):
– Slower onset than Lidocaine
– Longer duration
– Strength: 1%
– DOSE: maximum individual dose 5mg/kg
Anesthetic Solutions
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BUPIVACAINE (MARCAINE):
– Slow onset
– Long duration
– Strength: 0.25%
– DOSE: maximum individual dose 3mg/kg
Injection Techniques
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25, 27, or 30-gauge
needle
 6 or 10 cc syringe
 Check for allergies
 Insert the needle at the
inner wound edge
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Aspirate
 Inject agent into tissue
SLOWLY
 Wait…
 After anesthesia has
taken effect, suturing
may begin
Complicated Wounds
Wounds or lacerations with
Nerve
Tendon
Major vessel
Wounds or lacerations of the
Eye
Eyelids
Bites
Severely contaminated
wounds.
Wounds entering the
Thoracic
or abdominal cavities.
Wound Evaluation
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Time of incident
 Size of wound
 Depth of wound
 Tendon / nerve involvement
 Bleeding at site
Contraindications
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Redness
 Edema of the wound margins
 Infection
 Fever
Contraindications
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Puncture wounds
 Animal bites
 Tendon, verve, or vessel involvement
 Wound more than 12 hours old
Closure Types
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Primary closure (primary intention)
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Secondary closure (secondary intention)
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Tertiary closure (delayed primary closure)
Wound Preparation
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Most important step for reducing the risk of
wound infection.
 Remove all contaminants and devitalized tissue
before wound closure.
– IRRIGATE
– CUT OUT DEAD, FRAGMENTED TISSUE
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If not, the risk of infection and of a cosmetically
poor scar are greatly increased
Wound Preparation
Personnel Precautions
Wound Preparation
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Wound cleansing solution
 Wound scrubbing
 Irrigation
– Take only the soft, flexible part from an 18
gauge IV needle (angiocath)
– Put angiocath tip on 20 cc or 50 cc syringe
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Debridement
Basic Laceration Repair
Principles And Techniques
Principles And Techniques
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Minimize trauma in skin handling
 Gentle apposition with slight eversion of
wound edges
– Visualize an Erlenmeyer flask
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Make yourself comfortable
– Adjust the chair and the light
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Change the laceration
– Debride crushed tissue
Definition of Terms
– Bite
– Throw
– Percutaneous (deep) closure
– Dermal closure
– Interrupted closure
– Continuous closure (running sutures)
Principles And Techniques
Suture Techniques
Suture Procedures
Suturing
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Apply the needle to the needle driver
– Clasp needle 1/2 to 2/3 back from tip
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Rule of halves:
– Matches wound edges better; avoids dog ears
– Vary from rule when too much tension across
wound
Suturing
Rule of halves
Suturing
Rule of halves
Suturing
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The needle enters the skin with a 1/4-inch
bite from the wound edge at 90 degrees
– Visualize Erlenmeyer flask
– Evert wound edges
 Because scars contract over time
Suturing
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Release the needle from the needle driver, reach
into the wound and grasp the needle with the
needle driver. Pull it free to give enough suture
material to enter the opposite side of the wound.
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Use the forceps and lightly grasp the skin edge
and arc the needle through the opposite edge
inside the wound edge taking equal bites.
Follow the needle’s arc
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Rotate your wrist to follow the arc of the
needle.
 Principle: minimize trauma to the skin, and
don’t bend the needle. Follow the path of
least resistance.
Suturing
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Release the needle and grasp the portion of the
needle protruding from the skin with the needle
driver. Pull the needle through the skin until you
have approximately 1 to 1/2-inch suture strand
protruding form the bites site.
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Release the needle from the needle driver and
wrap the suture around the needle driver two
times.
Suturing
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Grasp the end of the suture material with the
needle driver and pull the two lines across the
wound site in opposite direction (this is one
throw).
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Do not position the knot directly over the wound
edge.
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Repeat 3-4 throws to ensuring knot security. On
each throw reverse the order of wrap.
Suturing
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Cut the ends of the suture 1/4-inch from the
knot.
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The remaining sutures are inserted in the
same manner
The trick to an instrument tie
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Always place the suture holder parallel to
the wound’s direction.
 Hold the longer side of the suture (with the
needle) and wrap OVER the suture holder.
 With each tie, move your suture-holding
hand to the OTHER side.
 By always wrapping OVER and moving the
hand to the OTHER side = square knots!!
Simple, Interrupted
Vertical Mattress
Good for everting wound edges
(neck, forehead creases, concave surfaces)
Horizontal Mattress
Good for closing wound edges under high tension,
And for hemostasis.
Suturing - finishing
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After sutures placed, clean the site with
normal saline.
 Apply a small amount of Bacitracin and
cover with a sterile non-adherent dressing.
Suturing - before you go…
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Need for tetanus globulin and/or vaccine?
– Dirty (playground nail) vs clean (kitchen knife)
– Immunization history
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Tell pt to return in one day for recheck, for
signs of infection or complications.
Suture Removal
Time frame for removing sutures:
Average time frame is 7-10 days
FACE: 4-5 days
BODY & SCALP: 7 days
SOLES, PALMS, BACK OR OVER JOINTS:
10 days
Any suture with pus or signs of infections should
be removed immediately.
Suture Removal
1.
2.
3.
Clean with hydrogen peroxide to remove
any crusting or dried blood
Using the tweezers, grasp the knot and
snip the suture below the knot, close to the
skin
Pull the suture line through the tissue- in
the direction that keeps the wound closed and place on a 4x4
Suture Removal
Once all sutures have been removed, count
the sutures
The number of sutures needs to match the
number indicated in the patient's health
record