1.

Indications
a. Lacerations <12 hours on the body or <24 hours on the face
b. Bite wounds in cosmetically important areas
c. Repair of sites where a lesion has been removed
2. Contraindications
a. Lacerations >12 hours on the body or >24 hours on the face
b. Human bite wounds
c. Some puncture wounds
3. Complications
a. Within the first 2 weeks – may develop infection, pain, bleeding, dehiscence
b. Permanent complications – may have scarring, keloid, nerve damage
4. Equipment
a. Betadine prep
b. Irrigation device – 30mL syringe, sterile saline, splash guard
c. Anesthetic (Lidocaine)
d. 10ml syringe
e. 27 & 18 guage needles
f. Sterile drapes – fenestrated & non fenestrated
g. 4x4 gauze
h. Sterile instruments – my needle holder, pickups, & forceps, scissors
i. Suture material
5. Preprocedural Patient Prep
a. General
i. Normal stuff – indications, CI’s, complications
ii. Talk about cosmesis
iii. Warn to wear sunscreen for 6 months
b. Initial Assesment
i. Assess neurovasculature status prior to anesthetic
c. Antibiotic Prophylaxis
i. In general, not needed
ii. Consider if…
1. DM, Old, Immunocomp., PVD, Malnutrition, Steroids, Radiation, Obesity, Prior Infection
2. Axilla, mouth, anogenital area, end-arterial areas, over joint spaces
3. Contaminated wounds – human/cat bites, dirty farms, meat packing, deep punctures
4. Crush injury with devitalized skin or penetrating injury
iii. Good cleansing & sterile technique are the best way to prevent infection
iv. Cats & Dogs = Pasteurella multicocida
v. Humans = Eikenella corrodens & S. aureus
vi. Cover with Amoxicillin Clavulanate
d. Local Anesthetic
i. 1% or 2% Lido with or without Epi
ii. To decrease pain
1. Use a small guage needle (27G)
2. Inject slowly
3. Inject through the open wound (not intact skin)
4. Warm the anesthetic
5. Buffer with NaHCO3 (10mL to 1mL
e. Inspect Thoroughly
i. X-ray or US as needed
 f. Cleanse
i. 15psi via an 18G & 30mL with a splash guard & at least 200mL
ii. Low risk wounds may be cleansed under running tap water for 2 minutes
iii. Don’t apply chemical cleaning compunds in the wound, only around the wound
iv. Greasy contaminants can be removed with petroleum based compounds (bacitracin)
g. Debridement
i. Afterwards, hold wound edges together to make sure there is no abnormal tension
ii. If so, use two layer sutures
h. Undermining
i. Significantly reduces skin tension where there’s a gap to be closed but increases risk of
infection
6. Technique
a. Four Principle Techniques
i. Control all bleeding before closure
ii. Eliminate dead space (where tissue fluid & blood can accumulate)
iii. Accurately approximate edges & tissue layers
iv. Approximate with minimal tension
b. Simple Interrupted
i. Skin margins should be slightly everted
ii. Needle enters the skin at 90°
iii. Stitch should be as wide as it is deep & equal margins on both sides of the laceration
iv. No closer than 2mm, generally speaking distance between should be ½ width of the sutures
v. Avoid tying knots too tight
vi. Line up knots to the same side of the wound
c. Simple Running
i. Advantages – in sterile wounds with little to no tension, provides quick care with even tension
ii. Good cosmetic results
iii. But increased risk of contamination, not for use in traumatic lacerations
iv. Not good for large gaping wounds (better served by simple interrupted)
v. Relative disadvantage is that the entire suture must be removed if needed
d. Deep with a Buried Knot
i. Helps with decreasing surface tension – use absorbable
e. Vertical (through the wound) Mattress
i. Promotes eversion of the skin edges
ii. Useful when natural tendency of the skin is to create inversion – loose flabby skin of old people
iii. Also appropriate for thin skin when interrupted sutures may pull through
f. Horizontal (to the wound) Mattress
i. Helpful in wounds that are under a moderate amount of tension & also promotes eversion
ii. Especially usefull on the palms or soles or in patients with who are poor candidates for deep
sutures due to susceptibility to wound infections
g. Subcuticular
i. Good cosmesis in wounds that are linear & under minimal tension
ii. Ends don’t have to be tied, just put a knot in the suture to prevent slipping & use steri-strips
h. Three Point or Half-Buried Mattress or Corner Stitch
i. Designed to permit closure of the acute corner tip of a laceration without impairing blood flow
i. Wound Closure with Tapes & Strips
i. Small superficial, especially in children
ii. Also more resistant to infection
iii. May use to help reinforce sutures or staples or after suture removal for resistance to dehisce
 j. Delayed Primary Closure (Tertiary Intention)
i. Primary = sutures/tapes/adhesives
ii. Secondary = no attempt to close the wound, granulates on its own
iii. Tertiary = delayed primary closure after ealing
1. Used for wounds greater than 12 or 24 hours old & need to watch for infection
2. Still anesthetize & irrigate, put on petroleum gauze for & 5 day course of cephalexin
3. Return in 3 days for definitive repair
4. Reanesthetize, reirrigate, and close with nonabsorpbable
7. Complications
a. Listed above
8. Post-procedural Patient Education
a. General
i. Protect with dressing for 24-48 hours, pressure dressing if hemostasis is needed (folded gauze
with tape will work or tradename stuff)
ii. LEs  elevate for 24 hours
iii. Ice as needed
iv. May begin to shower & redress after 24 hours
b. Suture Size & Time Until Removal
i. Face  5-0/6-0, remove in 4-5 days
ii. Hand  4-0/5-0, remove in 7-10 days
iii. Upper body  4-0, remove in 7-10 days
iv. Lower body  4-0, remove in 10-14 days
v. Scalp  4-0 or staples, remove in 10-14 days
vi. Over Joint  4-0, remove in 14-21 days
9. Concurrent Treatment
a. Tetanus Prophylaxis
i. Unknown Tetanus or Not UTD  yes for all & give TiG for dirty wounds
ii. UTD but >10 years ago  yes for all but no TiG needed
iii. UTD but >5 years  no for clean minor wounds, yes for dirty wounds

Suture Repairing
1. General Principles
a. Grasping suture with an instrument weakens it (except for grabbing the tag/tail end)
b. First throw should just approximate tissue, subsequent knots should be tied firmly
2. Knot Mechanics
a. Monofilament Material
i. Gut, Nylon, Polyproylene, Polydioxanone
ii. Coefficient of friction will be low leading to a tendency of knots to slip
iii. Also have memory so tend to maintain shape they were manufactured (easier to untie)
iv. Pliability (ability to form a tight loop) is higher in Nylon than the others
b. Braided Multifilament
i. Silk, Polyester, Polyglactin (Vicryl), Polyglycolic (Dexon)
ii. Higher coefficient of friction & less memory – easier to tie & less slippage
c. Square Knot
i. Easy, strong, doesn’t loosen easily
ii. Surgeons knot is a variation with two wraps on the first knot to avoid slippage
3. Choosing Tying Technique
a. Instrument tying is slower but more economical
 b. Hand tying is faster, preferred to be done with two hands
i. One handed may be fastere but is difficult to do well, more prone to tie half-hitches due to too
much tension on one strand
ii. Also increased possibility of needlestick injuries
4. How Tight
a. Approximate but don’t strangulate (ischemia/poor blood flow) leading to railroad track scar)
b. Give allowance for the swelling
i. First throw creates the tension & second throw locks it in place
c. Excess tension is noted by…
i. Puckering effect (mounding of the skin)
ii. Pale color underneath the suture
d. Best to remove & replace rather than leave it & hope for the best
5. How Many Throws
a. A

Module Stuff
1. Suture Selection
a. Absorbable
i. Mucous membranes & buried closures
ii. Naturals dissolve in <1 week – catgut, chromic
iii. Synthetic braided – strength decreases over a month (vicryl)
iv. Synthetic mono – strength 70% at 1 month – maxon, PDS
b. Non-absorbable
i. Greatest strength, used for skin
ii. Monofilament – nylon (ethilon), polypropylene (prolene)
iii. Multifilament – cotton, silk (local inflammation)
2. Local Anesthetics
a. Lidocaine 1% Plain
i. Can cause vasodilation
ii. Lasts 30-60 minutes
iii. Use in contaminated wounds
iv. Use in fingers, nose, toes, penis, & earlobes
v. Use if vascular disease is present or if immunocompromised
vi. Use if there are cerebrovascular or cardiovascular risks
vii. Use for nerve blocks
b. Lido 1% w/ Epi
i. Causes vasoconstriction
ii. Has a longer duration
iii. Use in highly vascular areas
iv. Use in clean wounds
v. In general, do not use on fingers, nose, toes, & earlobes
c. Bupivicaine
i. AKA Marcaine
ii. For longer duration
iii. For nerve blocks
d. Amino Esters
i. Procaine
ii. Tetracaine
iii. Chlorprocaine
e. Amino Amides
i. Lidocaine – 0.5% to 2%, FAST  maximum dose of 500mg w/ Epi, 300mg without Epi
a. In 1mL of 1% Lidocaine you have 10mg
2. Lido without Epi = 4.5mg/kg not to exceed 30mL (or 300mg)
a. If weigh 20kg = 20*4.5 = 90mg = 9mL of 1%
3. Lido with Epi = 7mg/kg not to exceed 500mg
a. If weigh 20kg = 20*7 = 140mg = 14mL of 1% with Epi
ii. Etidocaine
iii. Mepivicaine
iv. Bupivicaine – 0.25%, SLOW
1. 3mg/kg (not greater than 175mg with Epi or 225mg without Epi)
2. If weigh 20kg = 20*3 = 60mg = 24mL
3. 1ml of .25% = 2.5mg
v. Options For Allergies
1. Use cooling spray
2. Nothing
3. Single dose vials without the paraben preservatives
4. Bacteriostatic saline alone
5. Amide for Ester
6. Benadryl 10-50mg IM (50mg/mL with 4mL of saline)
f. Eliminate dead space
g. Control bleeding
h. Approximate accurately
i. Approximate with minimal skin tension
j. Needle at 90°
k.