1. Suturing Basics
Terren Trott

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

3. Options to Sutures Dermabond Staples Steristrips
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 Non-absorbable Monofilament Vs Polyfilament
Plain gut, FAST gut, vicryl, monocryl
Non-absorbable
Ethilon (Nylon)
Silk
Polypropylene (Prolene)
Monofilament Vs Polyfilament

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
Name
Onset
Duration
Max Dosing
Lidocaine
1 – 5 minutes
1.5 – 2 hours
4mg/kg
Lidocaine with Epi
2 – 3 hours
7mg/kg
Mepivacaine
3 hours
5mg/kg
Mepivacaine with Epi
4 – 5 hours
Bupivacaine
10 – 15 minutes
~4 hours
2.5mg/kg
Bupivacaine with Epi
~8 hours
3mg/kg
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

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. Anatomic Site Skin Deep Duration Scalp 5-0, 4-0 Monofilament
4-0 Absorbable
6–8 days
Ear
6-0 Monofilament
N/A
4–5 days
Eyelid
7-0, 6-0 Monofilament
Eyebrow
6-0, 5-0 Monofilament
5-0 Absorbable
Nose
Lip
Face/forehead
Chest/abdomen
3-0 Absorbable
8–10 days
Back
12–14 days
Arm/leg
Hand
5-0 Monofilament
8–10 daysb  
Extensor tendon
4-0 Monofilament
Foot/sole
4-0, 3-0 Monofilament

12. 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

13. 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

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

15. 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

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

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

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

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

20. References