Suturing Basics
Terren Trott
Objectives
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Understand Basic Suturing Anatomy
Indications for Suturing
Materials and Preparation
Suturing Techniques
Options to Sutures
• Dermabond
– Superficial lacerations
– Facial lacerations
• Staples
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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
Suture Anatomy
• Absorbable
– Plain gut, FAST gut,
vicryl, monocryl
• Non-absorbable
– Ethilon (Nylon)
– Silk
– Polypropylene
(Prolene)
• Monofilament Vs
Polyfilament
Suturing Preparation
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Hemostasis
Anesthetic
Irrigation
Exploration
Draping
Suture selection
Hemostasis
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Direct pressure and elevation
Blood Pressure Cuff
Lidocaine with Epinephrine
Figure-8 stitch
Anesthetic
Name
Onset
Duration
Max Dosing
Lidocaine
1 – 5 minutes
1.5 – 2 hours
4mg/kg
Lidocaine with Epi
1 – 5 minutes
2 – 3 hours
7mg/kg
Mepivacaine
1 – 5 minutes
3 hours
5mg/kg
Mepivacaine with Epi 1 – 5 minutes
4 – 5 hours
7mg/kg
Bupivacaine
10 – 15 minutes
~4 hours
2.5mg/kg
Bupivacaine with Epi
10 – 15 minutes
~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
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
Irrigation
IRRIGATION
IRRIGATION
IRRIGATION
IRRIGATION
IRRIGATION
IRRIGATION
IRRIGATION
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
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
N/A
4–5 days
Eyebrow
6-0, 5-0 Monofilament
5-0 Absorbable
4–5 days
Nose
6-0 Monofilament
5-0 Absorbable
4–5 days
Lip
6-0 Monofilament
5-0 Absorbable
4–5 days
Face/forehead
6-0 Monofilament
5-0 Absorbable
4–5 days
Chest/abdomen
5-0, 4-0 Monofilament
3-0 Absorbable
8–10 days
Back
5-0, 4-0 Monofilament
3-0 Absorbable
12–14 days
Arm/leg
5-0, 4-0 Monofilament
4-0 Absorbable
8–10 days
Hand
5-0 Monofilament
5-0 Absorbable
8–10 daysb
Extensor tendon
4-0 Monofilament
N/A
N/A
Foot/sole
4-0, 3-0 Monofilament
4-0 Absorbable
12–14 days
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
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
Simple Interrupted
• Most commonly used technique to close skin
• Attempt to keep all knots on one side
• For uncomplicated wound closure
Vertical Mattress
• Large bite 1 – 1.5 cm
from wound edge, cross
equidistant to other
wound edge.
• Reverse the needle
• Enter the dermalepidermal junction, 2 –
3mm from wound edge
• Advantages: acts as
both deep and
superficial closure,
reducing wound tension
Horizontal Mattress
• All entry and exit
points are
equidistant
• Advantages:
distribution of
tension across
greater area,
improved wound
eversion
Corner Stitch
• Advantages:
approximation of
corners and stellate
lacerations without
capillary
compromise of the
corner
Running
• Advantages: Faster
• Disadvantages: one compromised stitch
compromises entire suture
Deep Sutures
• To decrease tension
and approximate
tissues
• Enter the tissue low
and exit high so that
the knot ties to the
bottom
References
• http://www.jpatrick.net/WND/woundcare.ht
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