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2014
Oregon Nurse Practitioners Conference
Suture Workshop
Mary Fey FNP
Avoid infection
Goals of Wound Management
Hemostasis
Esthetically Pleasing Scar
Epidermis
Dermis
-indistinguishable from each other visibly
Subcutaneous Layer
-Adipose, nerve fibers, blood vessels, hair follicles
Deep Fascia
-Muscle
Tissue Layers
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Coagulation begins immediately
-vasospasm, platelet aggregation, fibrous clot formation
Epitheliazation occurs in epidermis
-complete bridging of wound occurs in 48 hours
New blood vessel growth peaks 4 days after injury
Collagen formation begins 48 hours, peaks first week, continues
12 months
Wound contraction occurs 3-4 days after injury
-full wound thickness moves toward center of wound
Mechanism of Wound Healing
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•Mechanism of Injury
•Age of Injury
•Possible contamination or foreign body
•Extent of the wound
•Neurovascular Compromise or tendon injury
•Need for Tetanus prophylaxis
•Risk factors that might affect healing, i.e.
Diabetes, immunocompromised
Wound Assessment
Animal Bites
Deep puncture Wounds
Actively bleeding (arterial)
Stained wounds (Grease)
Contraindications of Closure
Preferably within 6 hours
Up to 18 hours if no concerns of infection (High Risk)
Diabetic
Contaminated Wound
May need to debride edges if greater than 6 hours
Timing of Closure
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Clean and/or Irrigate
Normal Saline
Surfactant Cleaners (ShurClens)
Debridement
Wound Preparation
Anesthesia
Lidocaine 1%
Use when need large amount
Lidocaine2%
Most common
Lidocaine 2% plus Epinephrine
Use UNLESS fingers, toes, penis, or nose (and earlobes)
Marcaine 0.5% (Lasts longer)
Sensorcaine 0.5%
Sodium Bicarbonate
Lessens ‘sting’ of Lidocaine
Do not use with Marcaine or Sensorcaine (precipitates)
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Equipment
• Needle Holder
• Tissue Forcep
• Iris Scissors
• Face Shield
• 3 cc Syringe with 25-30 g. needle
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Dermal Suture Material:•Needles (3/8 circle most common)
•Ethilon6-0 Face
5-0 Everywhere else
•Prolene6-0 Face
Common Suture Materials
Most Common and Recommended
Evert edges of wound
Penetrate skin surface at 90 degree angle
Loop same distance at skin and base of wound
Start in center
Equal amount of sutures on both sides
Interrupted Suture
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Correct vs. Incorrect
Useful for closing punch biopsy
Useful for very small laceration
Figure of 8 Suture
A C
D B
A C
D B
Figure of 8 Suture
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Suture Removal
• Face/neck 3-5 days
• Scalp 7-10 days
• Trunk 7-10 days
• Joints 10-14 days
• Back/Foot 10-14 days
Great for Scalp Wounds
Good for Tension Wounds (Knee laceration)
Start at one end and advance to other end
May be able to apply with just local anesthetic
if only 1-2 staples – Good for someone who is
having high anxiety
Staples
Staple Technique
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Dermabond
• Useful for small clean wounds
Works Cited
Patrick, J. (2003, Sep 14). Mt. auburn hospital emergency department: wound care. Retrieved Sep 8, 2012, from jpatric.net:
http://www.jpatrick.net/MAHFiles/orient/woundcare_manual.html
Corner Stitch
“Boat in the Dock”
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•Start suture in epidermis across from flap
•Insert needle into dermis only and come out in dermis
•Assure you have a ‘good bite’
• Exit through dermis very near insertion point
• Apply sufficient tension to pull flap into corner
•Tie knot across from corner of flap
CORNER STITCH HALF-BURIED HORIZONTAL
MATTRESS
Bibliography
Boriskin, Mitchell: “Primary Care Management
of Wounds”, Nurse Practitioner 1994, pp. 38-58.
Christoph, R.A. et al.: “Pain Reduction in Local
Anesthesia Administration Through pH
Buffering”, Annals of Emergency Medicine,
1988, 17:2, pp. 117/27-120/30.
Bibliography (continued)
• Patrick, J. (2003, Sep 14). Mt. auburn hospital
emergency department: wound care.
Retrieved Sep 8, 2012, from
jpatric.net:http://www.jpatrick.net/MAHFiles/
orient/woundcare_manual.html
• Trott, A: Wounds and Lacerations: Emergency
Care and Closure, St. Louis, Mosby Year Book,
Inc., 1991
