emig suture handout

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UW EMERGENCY MEDICINE INTEREST GROUPA GUIDE TO THE BASIC SUTURE WORKSHOPIntroduction Materials Anesthesia Wound Cleaning and Irrigation Basic Suturing Techniques Patient Instructions and Follow-Up

IntroductionHistory How long ago? (>12 hr on body or >24 hr on face should not be closed as a general rule. This may vary by institution) Amount of blood loss? Last tetanus shot? (>10 yrs needs booster, or >5 years if contaminated wound) Contamination / foreign body? Mechanism of injury (consider fracture)? Complicating medical conditions? (elderly, vascular disease, diabetes, etc)

Physical exam - Signs of serious blood loss (provide initial hemostasis, pressure, elevation) - Assess motor and sensory function (before and after closure) - Assess 2 point discrimination distal to the injury site (if hand, assess both ulnar and radial side) - Assess circulation distal to injury (before and after closure) - Note size and depth of the lesion - Visualize wound base to assure depth and lack of foreign bodies (after anesthesia) Principles of wound care - Minimize bacterial contamination - Remove foreign bodies and devitalized tissue - Achieve hemostasis - Handle tissue gently - Approximate, dont strangulate Steps - Assess - Gather materials - Anesthetize - Irrigate / cleanse - Prep - Suture Fig. 1: 2 point discrimination can be tested with a - Bandage splayed paperclip 10 years old (assuming the patient has received the 3 shot primary series in the past). If the wound is contaminated with debris, a tetanus booster should be considered if the previous tetanus shot is >5 years old. In the event a patient has sustained a tetanus prone wound and has not received the primary 3 shot series, they will require tetanus immune globulin and must be initiated on the primary immunization series. Wound care After the first 24-48 hours, patients should gently wash the wound with soap and water, dry it carefully, apply topical antibiotic ointment, and replace the dressing/bandages. Facial wounds generally only need topical antibiotic ointment without bandaging. Sunscreen spf 30 should be applied to the wound to prevent subsequent hyperpigmentation. Suture removal Removing sutures is generally a quick and painless procedure. Removal time considers both the potential for scarring and the required tensile strength of the wound to withstand stressors.

Area Face Neck Scalp Upper extremity Trunk Extensor surface of hands Lower extremity

Removal Time 3-5 days 4-6 days 7-12 days 8-14 days 6-14 days 10 days 14-28 days

When to RTC / ER Patients should be instructed to return to the clinic/ED if they note signs of infection (redness, heat, pain, puss, etc), inadequate analgesia, or suture complication. The latter may include suture strangulation or knot failure with possible wound dehiscence. It should be emphasized to patients that they return at the appropriate time for suture removal or complications may arise leading to further scarring or subsequent surgical removal of buried sutures.

Summary

References and Suggested Reading Trott, Alexander MD. Wounds and Lacerations Emergency Care and Closure. Philadelphia: Mosby, (2005). Thomsen, Todd MD. (2006) Basic Laceration Repair The New England Journal of Medicine. Oct. 355:17.

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