Suture Workshop Bryan Combs, MSN, CRNP, FNP-BC, CNL, ATC University of Alabama at Birmingham
Overview For emergency provider average laceration is 1 cm. - 3 cm. (0.4 in. – 1.2 in.) Infection most common complication 3.5% - 6.3% of lacerations 13% of lacerations were considered significantly contaminated Most important step to prevent infection wound irrigation 95% of glass in wounds is radio-opaque and radiographs recommended
Overview Locations 51% - Face/Scalp 34% - upper extremity Etiology Blunt Object – 42% Sharp (non-glass) – 34% Glass – 13% Bites Dog – 3% Human – 1% Other – 2% Locations 51% - Face/Scalp 34% - upper extremity 13% - lower extremity
Anatomy PERCUTANEOUS DEEP FASCIA
Wound Healing
Wound Healing
Infiltration and Anesthesia
Infiltration and Anesthesia
Infiltration and Anesthesia
Infiltration and Anesthesia
Infiltration and Anesthesia
Irrigation & Cleansing The most important step Providone-iodine solution (not scrub prep) most effective skin cleanser Water or Saline best option for wound irrigation and debridement Hydrogen peroxide not recommended due to more negative then positive effects Never shave the eyebrow Make sure to numb them first
Irrigation & Cleansing
Irrigation & Cleansing
Closure Basics Some text say this is wrong And this is correct
I say what is most comfortable Closure Basics I say what is most comfortable Some text say this is wrong And this is correct
Closure Basics Remember Back 1/3 and perpendicular
Closure Basics
Closure Basics The index finger is important with scissors and provides steadiness and precision
Closure Basics
Closure Basics
Closure Basics
Closure Basics Tapered Needle Reverse Cutting Needle Cutting Edge on Outside A Cutting Needle has Cutting Edge on Inside of needle
Excisions
Excisions
Excisions
Basic Repair Layer Matching Stay level as needle advances from one side of wound to other
Basic Repair Wound Edge Eversion Point of needle needs to be 90-degree angle when piercing skin
Wound Tension The farther sutures are apart the more tension on wound and skin The closer sutures are together there is less tension on wound and skin
The Simple Suture Knot The knot is the crucial step in suturing The way I remember: 3/1/1 and always opposite 1st – wrap suture clockwise around needle holder 3 times 2nd – grab the end of the “pig tail” and pull to the pig across the street 3rd – wrap suture counter clockwise around the needle holder 1 time 4th – grab the end of the “pig tail” and pull to the pig across the street 5th - wrap suture clockwise around the needle holder 1 time 6th - grab the end of the “pig tail” and pull to the pig across the street
Simple Suture
Simple Suture 1st – wrap suture clockwise around needle holder 3 times
Simple Suture 2nd – grab the end of the “pig tail” and pull to the pig across the street
Simple Suture
Simple Suture 3rd – wrap suture counter clockwise around the needle holder 1 time
Simple Suture 4th – grab the end of the “pig tail” and pull to the pig across the street
Simple Suture
Simple Suture 5th – wrap suture clockwise around the needle holder 1 time
Simple Suture 6th – grab the end of the “pig tail” and pull to the pig across the street
Simple Suture
Simple Suture This examples only shows two knots but you will see three done most of the time. The second knot is the most important in terms of locking it down
Instrument Knot Tie https://www.youtube.com/watch?v=wbpQhiNDxvo
Simple Suture https://www.youtube.com/watch?v=SYNHSDI69kk
Vertical Mattress
Vertical Mattress https://www.youtube.com/watch?v=UV-j1zxckXA
Horizontal Mattress
Horizontal Mattress https://www.youtube.com/watch?v=8QYEXw76CPE
Deep Suture
Running Suture
Running Mattress https://www.youtube.com/watch?v=ODZtJL_gb4E
Subcuticular Running Suture
Subcuticular Running Mattress https://www.youtube.com/watch?v=iYts9c6Jrx8
Pull Out Dermal Suture
Beveled Edge or Wound You have to get a bigger bite on beveled side
Dealing with Corners
Dealing with Corners
Parallel Lacerations
PRACTICE MAKES PERFECT PRACTICE, PRACTICE, PRACTICE
Find a way to Practice All kinds of ways to practice Eggplant Meat with skin Purchase mold device Make your own Be creative
References Trott, A. (2012), Wounds and Lacerations Campo, T. and Lafferty, K. (2011), Essential Procedures for Practitioners in Emergency, Urgent, and Primary Care Settings