Simple Suturing: Assessment and Procedure Preparation

00:01 Hello, my name is Glenna Lashley and I'm an Advanced practice registered nurse.

00:06 Here at Lecturio, we realize that many students don't always get the chance to see or talk through advanced skills during their clinical rotations.

00:16 The need for simple sutures is a skill that comes up in almost every area of practice, but many students don't get an opportunity to practice.

00:25 So let's get going. When we talk about suturing a wound, you will hear the word primary closure.

00:32 This is mechanically pulling the layers of tissue together compared to healing by secondary intention. Why don't we take a quick review of skin and muscle anatomy to show you what I mean? Here we're going to see the layers of the skin.

00:49 We're starting with the epidermis layers, then the dermis layer, then the subcutaneous layer, and then the muscle layer.

00:57 Typically the sutures that you're going to see for simple suturing are going to either go through the epidermis, the dermis and the subcutaneous.

01:05 Not many should get to the actual muscle layer.

01:07 And you definitely in the office would not be suturing if it was to the bone.

01:12 A suture pulls those layers of skin all together, so that all the different layers are meshing up together with making sure that the epidermis, the dermis and the muscle are all coming together.

01:25 This approach remains the gold standard of wound treatment over adhesive strips to provide greater cosmetic outcomes.

01:34 So when you perform your thorough assessment, you definitely want to evaluate the depths of the wound.

01:41 As you can see, we've got many different depths here, as well as widths and shapes and sizes.

01:48 So you want to evaluate that when I'm looking at these types of wounds, these wounds here where you see the Y shape or you see the angle shape, These would be a little bit more complicated and often be referred out.

02:02 You want to make sure that how old the wound is as well.

02:06 If it's greater than six hours, this is going to be a higher risk for developing infection with a primary closure.

02:13 In general, facial lacerations can be closed up to 24 hours, and that's due to the rich blood supply.

02:20 Depending on where the laceration is, there are different approaches .

02:25 And if the laceration is especially mangled or if on the face, you might want to refer to a plastic surgeon.

02:34 As with any procedures, there are supplies and steps you need to know. I will talk you through the steps and then show you the procedure itself.

02:42 As always, I will give you some insights along the way.

02:47 You first are going to typically get a suture kit.

02:50 This is not a sterile procedure at the moment because I'm showing you the supplies that you would need. You need to think about the type of suture material that you're going to be using. Typically, you're going to use 4.0 to 6.0 nylon or polypropylene for facial lacerations. And again the same either nylon or polypropylene 3 to 4.

03:15 What that sizing tells you is the higher the number, it's the smaller diameter as well as the tensile which is the strength of the suture.

03:29 You can want to make sure that these are non- absorbent sutures that you'll be using as well.

03:36 You also are going to need lidocaine 1%.

03:40 You would want to use lidocaine with epi except in these contraindicated areas.

03:46 You would not do that on a digit.

03:48 You would not do it on the tip of the nose, on the ear, the eye or the lips. So you want to make sure which lidocaine you have and make sure you grab the correct one. You're going to need to clean the wound.

04:00 So you're going to use chlorhexidine or iodine solution.

04:05 So here I have a chlorhexidine and here I have some iodine.

04:11 Typically, in an office situation you're probably going to have these in a liquid form. So that would already be laid out on your sterile field before starting.

04:19 You also want sterile gloves as well as a mask and eye protection.

04:26 Because I'm wearing glasses I will not be using goggles today.

04:30 You also will need normal saline for irrigation, and you will need a non-adhesive dressing to go over the wound.

04:41 One of the things that's very important is you need to get patient consent with this procedure. So you want to make sure that you're discussing the risk and benefits.

04:50 So we want to let them know that the risk of leaving it open is going to be risks for bacteria and growth to happen, and possible infection.

05:00 You also want them to know additional bleeding could take place as well.

05:05 Um, the benefit is that we can close the wound, it's going to heal faster and hopefully prevent it from becoming infected.

05:12 You do want to discuss scarring with them? Um, that's why a lot of times, if it's a facial laceration, you want to send them to a plastic surgeon.

05:22 Due to that reasoning, um, depending on how intense the wound is, it might have more issues with scarring as well.

05:30 Some facilities will require photography before and after the closure.

05:36 Um, just so that you have pictures to see.

05:39 In some practices, they may give the patient oral anxiety or pain medication.

05:45 Typically you're not going to see this happen in outpatient, but it could. So you want to make sure you contain that consent prior to administering any of those medications.

05:59 Then you're going to make sure you've gathered all your supplies, because nothing's worse than not having everything that you need on the table, and you're already sterile and you're in the middle of the procedure.

06:09 So you want to make sure you have all of your supplies.

06:11 You want to make sure that you perform proper hand washing before you become sterile as well. The first thing that you're going to do is you're going to want to clean the wound.

06:22 You want to make sure you clean the entire wound, and that you use your iodine or your chlorhexidine wipe as well.

06:32 And then you are going to irrigate with normal saline.

06:37 You want to use a PSI of at least eight.

06:40 And you can do that with using a syringe.

06:44 So you would clean that area out with the normal saline.

06:47 Then you're going to anesthetize the area.

06:51 And typically you want to start at the edge of the wound.

06:54 But most of the time with a wound this size or the sizes that are listed on here, you're going to need to do a block.

07:00 So that whole area is numbed up.

07:06 As you irrigate, you want to make sure that you're looking for any debris, you're looking for any pieces that are not supposed to be there.

07:14 You're also wanting to make sure that the tissue is viable.

07:18 So if you have an area that is not viable, then you may have to clean up the area a little bit with some sterile scissors in order to get clean borders and make sure that the wound approximates correctly when you're suturing.

07:33 And this also, making sure that the wound is very clean is going to make sure that the risk of infection is less as well.

07:42 You want to insert your actual needle that's going to be on your suture material at a perpendicular angle, about 2 to 3mm from the wound's edge.

07:54 You're going to drive it through all the way completely to the other side, making sure you're approximating about the same measures that 2 to 3mm.

08:05 You're then going to tie a square knot at the appropriate tension.

08:11 And you want to make sure that when you're throwing that you actually do three throws because you want to make sure that that is secure and it's not going to open up.

08:21 Nothing's worse than sewing up a wound.

08:23 And then the patient gets out and does a little bit of work, and then all of a sudden the wound is open.

08:28 That's going to be a longer heal time as well as risk of infection.

08:34 You want to place the sutures at appropriate intervals, and you want to make sure that you're keeping the spacing about the same, about 3 to 5mm. Um, research shows that water spacing increases the chance of the wound dehiscing, which means the wound is actually going to come open.

08:53 You want to keep the wound clean and dry for at least 24 to 48 hours.

08:57 Typically, I tell my patients for 24 hours, do not take this bandage off, right? Keep the original bandage on.

09:04 You want to make sure you're using a non-adherent dressing, because you don't want to pull the skin or irritate the skin, or pull the sutures as well.

09:14 You want to use some antibiotic ointment.

09:16 Sometimes it may require an oral antibiotic as well, depending on where the laceration came from.

09:23 You also want to keep in mind about your tetanus vaccinations depending on how the laceration occurred. You also want to schedule a follow up for suture removal.

09:34 And this on the face is going to be about 3 to 5 days.

09:37 But on most extremities you would do this in 7 to 10 days.