The LSUHSC New Orleans Emergency Medicine Interest Group Presents The Student Procedure Manual

Basic Suturing

by Charlie Clasen with
Patrick Hymel

Indications

• Control of hemorrhage
  
• Restoration of the functional integrity of the skin,
  minimization of scarring

Contraindications

• No absolute contraindications, but delayed closure may be the best option in dealing with highly contaminated wounds or when there has been a long interval since the time of injury (>24 hours for the face, >8-12 hours for the rest of the body)

Prerequisites

• A radiograph of the involved area of injury is indicated
  if the potential for fracture or foreign body exists

Equipment

• Sterile saline
  
• Suture materials
  
• Betadine solution
  
• Fine-tooth forceps
  
• Local anesthetic
  
• Needle holder
  
• Sodium bicarbonate (44mEq/50ml)
  
• Suture scissors
  
• Iris scissors / scalpel with No. II blade (for heavy debridement)
  
• 25 G needle
  
• 19 G needle
  
• 3-5 ml syringe
  
• 4x4-inch gauze pads
  
• 50 ml syringe
  
• Sterile basin
  
• Sterile drapes
  
• Wound dressings
  
• Topical antibiotic ointment

Procedure

1. Wear a mask, gloves, and an eye shield (universal precautions).
   
2. Explain procedure and expected results - scar.
   
3. Check: drug allergies
   • tetanus immunization status
     
   • motor and sensory function of injured area prior to anesthesia
     
   • pulses distal to injury
4. Consider an X-ray of area-fracture, foreign body.
   
5. Prep surrounding area with Betadine solution, apply sterile drapes. Remember: Betadine and hydrogen peroxide are cytotoxic. And should not be poured directly into the wound.
   
6. Anesthetize wound (see ED Anesthesia and Nerve
   Blocks): regional block or local infiltration into wound, aspirate slightly before injection to avoid intravascular injection of local anesthetic (symptoms: twitching, restlessness, drowsiness, light-headedness, seizures). Do not use local anesthetic with epinephrine on fingers, toes, nose, ears or penis. Do not exceed the maximum dose of anesthetic. (1% solution= 10mg/ml).
   *To make the injection of local anesthetic less painful:
7. Needle size 25 G or smaller
   
8. Inject slowly
   
9. Inject through wound, not through intact skin (only if wound is not heavily contaminated or has been irrigated well beforehand)
   
10. Wait several minutes before proceeding to allow anesthesia to take effect
    *Warm anesthesia to body temperature (carry vial around in shirt pocket)
    *Btiffer anesthetic.- 9cc 1% lidocaine + 1cc sodium bicarbonate (44mEq/5Oml)
    
11. Debride dead tissue using iris scissors or scalpel.
    
12. Irrigate wound using 250-500 ml normal saline directed into wound via an 18 G needle on a 50 ml syringe. Pour the saline into a sterile basin for ease of drawing into the syringe.
    
13. Under adequate lighting, carefully inspect the wound, looking for foreign bodies or damage to adjacent structures (tendons, nerves, joints). It may be necessary to have the patient move the tendon or joint as you observe the wound. If any deep structures are visibly damaged or if the wound is in an awkward location or complex configuration, seek consultation.
14. If necessary, close the subcutaneous fascial layers with interrupted absorbable sutures. Approximate the edges very carefully.
    
15. Skin Closure:
    • Choose the appropriate size suture. A 3/8 circle cutting needle is the most common skin closure needle. Use absorbable sutures (Dexon or Vicryl) for
      subcutaneous tissue and nonabsorbable sutures (nylon or polypropylene) for skin.
      
    • Grasp the needle with the needle holder in you dominant hand.
      
    • Hold the toothed forceps in your nondominant hand.
      
    • Close short wounds by starting at one end and working to the other. Close long wounds by starting in the middle and bisecting the wound with each successive suture.
      
    • Hold the skin edge with the toothed forceps.
      
    • With the tip of the needle perpendicular to the skin,
      positioned near the edge of the wound, close to the skin edge, twist your wrist (supinate) to advance the needle through the skin on one side of the wound and out the skin of the other side. As the needle passes through the wound, reposition the toothed forceps over the second skin edge to steady it as the needle passes up and through the skin. In some cases where the wound is wide relative to the size of the needle, it may be necessary to pass the needle through the skin, down and into the wound, grasp the tip of the needle in the wound with the forceps. Release the needle holder and pull the needle out of the wound with the forceps. Reclamp the needle with the needle holder and pass the needle through the inner surface of the other edge of the wound and up through the skin. Make sure that the distance between the passage of the needle through the skin and the skin edge is equal on both sides, and make sure the depth of the suture is equal on both sides.
      Make sure that the distance between the passage of the needle through the skin and the skin edge is equal on both sides, and make sure the depth of the suture is equal on both sides.
    • Hold the skin edge with the toothed forceps.
    • With the tip of the needle perpendicular to the skin, positioned near the edge of the wound, close to the skin edge, twist your wrist (supinate) to advance the needle through the skin on one side of the wound and out the skin of the other side. As the needle passes through the wound, reposition the toothed forceps over the second skin edge to steady it as the needle passes up and through the skin. In some cases where the wound is wide relative to the size of the needle, it may be necessary to pass the needle through the skin, down and into the wound, grasp the tip of the needle in the wound with the forceps. Release the needle holder and pull the needle out of the wound with the forceps. Reclamp the needle with the needle holder and pass the needle through the inner surface of the other edge of the wound and up through the skin. Make sure that the distance between the passage of the needle through the skin and the skin edge is equal on both sides, and make sure the depth of the suture is equal on both sides. Make sure that the distance between the passage of the needle through the skin and the skin edge is equal on both sides, and make sure the depth of the is equal on both sides.
      
    • DO NOT RESET YOUR NEEDLE BY HAND! This is a terrible habit to get into and is a very common way to get stuck! Do yourself and your loved ones a favor and learn to do this the correct way.
      
    • Tie the suture using a surgeon's knot with an instrument tie,) carefully applying tension. Put at least 4 knots on each suture to prevent slippage. Cut the ends of the material with the suture scissors and repeat the steps above until the wound is closed. The width of each suture should equal the distance between sutures; sutures closer to the skin edge and closer to one another ensure better healing
      
    • Keep in mind that these suturing directions apply only to simple, uncomplicated lacerations that are relatively uncontaminated. Deep puncture wounds that are contaminated or that may involve other structures require consultation.
16. Use gauze moistened with saline to cleanse the sutured wound and gently blot it dry with plain gauze
17. Apply topical antibiotic ointment to the wound.
    
18. Dress the wound with a nonadherent pad and gauze with or without tape. You may leave scalp and facial wounds uncovered.
19. Tell the patient how to care for the wound, describe the signs of infection, arrange for suture removal, and consider tetanus immunization and a prescription analgesic.

Complications

• Infection
  
• Hematoma
  
• Wound dehiscence
  
• Retained foreign body
  
• Possible missed injury to deeper structures.

Follow-up

• Analgesic, assure patient education on signs infection and wound care instructions.

Suture removal

• Gently remove dried blood with saline-moistened gauze.
  
• Make sure the wound is sufficiently healed to allow suture removal.
  
• Using forceps, elevate the knot off the skin.
  
• Cut the suture as close to the skin as possible,pull the long end with forceps, towards the scar.
  
• Never pull a knot through the skin.

Related procedures / tests

• X-ray for foreign bodies or fractures
  
• Tetanus immunization/prophylaxis
  
• Suture removal
  
• Instrument tie diagrams
  
• Suture material selection chart
  Anesthetic chart