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Basic Suturing for Family Nurse Practitioners

Wayne McLeod FNPKellie Keel FNPSaguaro Surgical PC.TMC Wound Center andHyperbaric MedicineJuly 30,2017

Wound  Evaluation and Preparation

Local Anesthesia

Suture Selection

Suturing Techniques

Staples

Dermabond

Documentation

Overview

The student will be able to:

1. Discuss the principles and management of wound repair

2. Explain local anesthesia concepts, pharmacology, and possible complications

3. Perform simple interrupted suturing technique

4. Discuss suture material choices and wound healing processes

5. Document 

Objectives

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Hemostasis

• Blood clots to stop bleeding

Inflammation

• Dilation of capillaries and slight increased erythema around wound but not more than 1‐2 cms may last up to 30 days

Granulation

• Fills in wound when healing by secondary intention

Remodeling

• May take up 9 months

Phases of Wound Healing

• Medical History

• Allergies to tape, Abx, latex

• Tetanus status

• On anti‐coagulation Meds, chemotherapy, RA Medications

• PMHX: DM, HIV, HepC, PAD

• Hx of poor wound healing

Patient Information

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“Assess the whole person not just the hole in the person”(Dr. Gary Sebold)

Types of Lacerations

Simple

Stellate

Avulsed

Complex

Wound Status Wound Status

Foreign Bodies

Wood

Pebbles

Glass

Thorns

Etc.

Associated with Fracture

Onset:  

Time from injury

Extremities – 12 hours

Face – 24 hours

Mechanism of Injury:

Clean knife/glass

Trauma

Dog bite

Clean vs Contaminated

Puncture

Basic Principles

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General rule of “6” for acute wounds› Most wounds over 6 hours should not be

closed primarily Exceptions Face and Neck Children have longer safe period If wound is clean with excellent perfusion or can

be aggressively debrided

Basic Principles

The goals of laceration repair are to achieve hemostasis, avoid infection, restore function to the involved tissue, and achieve optimal cosmetic results with minimal scarring. 

For any traumatic lesion – Don’t Forget Tetanus

Traumatic› Skin Tears› Abrasions› Lacerations› Punctures

Other wound types› Pressure Ulcers› Arterial Ulcers› Venous Ulcers

Types of wounds

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Viability of tissue Location of laceration

Tissue loss

Necrotic tissue

Depth of injury

Associated injuries

Fractures?

Gross contamination

Foreign Bodies

Wound Evaluation

Foreign Bodies

Anesthesia

Lidocaine with or without Epinephrine

No epi to nose, toes, fingers, hose, or earlobes

Lidocaine 1%  (10mg per ml)

Lidocaine 2% (20mg per ml)

Max dose 3 – 5 mg/kg without epinephrine and up to 7mg/kg with epinephrine

May also use Marcaine or Bupivicaine 0.25% on small wounds.  1‐2mg/kg without epinephrine and up to 3mg/kg with epinephrine

Wound Preparation

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1% Lidocaine 

• Blocks pain stimulation but leaves pressure and touch sensation intact

2% Lidocaine

• Blocks all awareness of stimuli including pressure and touch

Lidocaine

• Use a small needle for infiltration usually a 25 gauge or even 30 gauge

• May add Bi Carb 1ml of 8.4% solution to 10ml of Lidocaine

• May help to drip a small amount of lidocaine into the wound for 10 – 15 minutes prior to injecting the rest

Reducing pain from local anesthetic

Avoid allowing patient to view injection of local

Aspirate prior to injecting

Drip solution in wound a few minutes before injecting local

Inject within the wound

General Guidelines

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Follows basic principles for all wounds 

regardless of location

Wound Preparation

1. Universal Body Fluid Precautions

2. Deep wounds require multiple layer closure with absorbable suture

3. Aseptic Technique

1. Including sterile fields and gloves

› Flush wound out with Normal Saline or tap water› 30 -60 ml syringe with 18

gauge needle or angiocathprovides 5-8 lb per Sq inch of pressure.

› Avoid using full strength betadine or H2O2 directly on wound bed

› Clip any hair around the edges of wound

Wound Preparation

1st and foremost know when to turfLacerations over jointsPossible ligament, tendon, or nerve damageAssociated with fractureGrossly contaminatedRequires precise cosmetic closure

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Needle Holder

Skin Forceps

Scissors 

Hemostats

Appropriate Suture

Instruments

Non‐Absorbable

Ethilon

Prolene

Silk

Nylon

Absorbable

Chromic

Vicryl – complete absorption by 42 days – 0% tensile strength at 14 days

Monocryl – approx 60 – 90 days – 20% tensile strength at 21 days

Dexon

They are digested by body enzymes or Hydrolyzed by body fluids

Suture Classifications

Suture

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Suture Needles

Used to close spaces below the skin

Special areas that are hard to get to

ie. Tongue

Situations where future removal is difficult

Eliminates trauma of suture removal

Low skin tension

Absorbable Sutures

Hairy or Keloid prone areas

Requires removal

Silk no longer used for skin closure due to their poor tensile strength and high tissue reactivity

Non‐Absorbable Sutures

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Optimal cosmetic results:

• 5.0 0r 6.0 should be used on face

• 4.0 or 5.0 on the extremities depending on skin thickness and location 

• 3.0 or 4.0 on back and trunk

• Consider using blue prolene for scalp wounds to differentiate from hair.  Staples commonly used now

General Suture Guidelines

Holding the needle

Suturing

http://search.tb.ask.com/search/video.jhtml?searchfor=simple+suturing&p2=%5EBVB%5Exdm301%5EYYA%5Eus&n=781B3B0B&ss=sub&st=hp&ptb=5D148315‐FE3A‐4FA2‐B997‐70F1FBBCA1DD&si=314029_mysocialviewer&tpr=sbt

Needle should enter skin at 90 degrees

Suturing

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Horizontal Mattress

Stitch

Best for gaping or high tension wounds

Wound edges must be everted for proper healing

Suturing

Running Sub‐cutaneous stitch

Suturing

• Close Wound in segments

• Sutures equidistant from skin edges on either side of wound

• Evert skin edges

• Wound margins loosely approximated 

• Repeatedly bisect the wound

Suture Placement 

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“Wounds should be approximated, not strangulated”

Too tight = tissue necrosisToo loose = edges not aligned

Key Steps

• Initiate tie with surgeon’s knot

• Tighten knot so it lies flat

• Second throw in opposite direction

• Two additional throws to secure knot

Knot security

Face and Neck – 3‐5 days

Scalp – 7‐10 days

Joints – 10‐14 days

Back and Feet 10 – 14 days

Suture Removal

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• Stainless steel 

• Used to close thick skin on extremities, trunk, and scalp

• NEVER on face, neck, hands or feet

Staplers

• Comparable with sutures in cosmetic results, dehiscence rates, and infection

• Can be applied more quickly

• Require no anesthesia

• Eliminate need for follow up

Tissue Adhesives

• Low tensile strength 

• Contraindicated in patients at high risk for poor healing

• Should not be used on contaminated, complex, or jagged lacerations

• Avoid in high moisture areas, mucosal surface, groin, axillae

Tissue Adhesives

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• Follow up is similar regardless of technique

• An antibiotic ointment or white petrolatum ointment can be applied daily (do not use if closed with Dermabond)

• Written instructions should be given to all patients

Post Closure Care and follow up care

Post Closure Care and follow up care

Antibiotics?› Never give Rx for Abx

and tell pt to start if looks infected

Follow up?› 1-2 days if concerned

about infection

Billing for laceration repair depends on:

1. Size and location of the laceration

2. Complexity of repair

1. Simple laceration repair includes superficial single layer closures with local anesthesia;

2. Intermediate repairs includes multiple layer closure or extensive cleaning;

3. Complex  includes multiple layer closure, debridement, and wound preparation ie: undermining of skin for better closure

Documentation/Billing

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• Suture removal is generally included in laceration repair fee

• However, if sutures placed in ED or elsewhere then can be billed

Documentation/Billing

http://www.youtube.com/watch?feature=player_detailpage&v=PoORW7pQs2M

https://m.youtube.com/watch?v=TFwFMav_cpE

Any Questions