Suturing

WIPERNA

Hello, I'm________
I'm a_________
How are you?

Explain
Okay, I understand you had an accident. It seems that you'll need a few stitches for your wound, just to help it heal properly, and reduce scar formation, hopefully. This involves using a small needle and special thread, and we'll use LA to help ensure that you're not in pain. Does that sound okay? You're happy for us to go ahead? Are you alright with needles?


I'll just get my equipment.

... Wash hands...
Equipment
Sterile gloves

Lignocaine 1% LA (max 3mg/kg)
Syringe
Green needle

Orange needle

Sterile water/Saline
Gauze
Syringe
Suture pack
-tray
-needle holder
-scissors
-curved scissors
-toothed forceps (skin only)
-non-toothed forceps (needle only)
Suture Needle

Sharps box

Prepare Equipment
Wash hands

Open suture pack with sterile technique

Drop pair of gloves, syringes, sutures and needles into field

Put antiseptic solution into bowl

Sterile gloves on

WH/SF/SW/Gl

Prepare Patient
Questions - tetanus, allergy, LA ?
Inspect wound for debris/dirt - clean and debride if present
X-ray - potential of foreign body
Cleanse/irrigate wound and surrounding skin

0.9% saline soaked gauze/in syringe or with chlorhexidine/betadine (high risk contamination)

Swab held with forceps/hand

Centre outwards

Postion pt so they're comfortable

Cover wound with drape with hole in it - sterile field

Q/Insp/Clean/SF

Anaesthetic
Select syringe and attach the 21G green needle
Draw up 10ml of 1% lignocaine
Dispose of green needle
Attach orange needle

Inject LA into skin encompassing wound approx 0.5-1cm from its edge
Aspirate needle on inserting to ensure a vessel has not been entered
Fan shape around wound

Wait 5-10mins for anaesthetic to work - test area
Ask pts after signs of LA toxicity eg tingling in mouth, metallic taste, dizziness or light headaches, ringing in ears or difficulty in focusing eyes

Max lignocaine = 3mg/kg
Lasts approx 30 mins

Lg/Fan/Wt

Suturing
Mount needle
Grasp curved needle with needle holder (short. blunt forceps with straight jaw)
Hold needle 2/3 along shaft from tip
Perpendicular to needle holder
Hold needle holder with thumb and ring finger, with index to stabilise

Pass through skin about 0.5cm wound edge at middle of wound
Use forceps to pick up skin (toothed) - above hand
Pass N perpendicularly
Full thickness through skin to the base of the wound - xbacteria
Pull suture threat through hole, leaving 2-3cm tail behind
Pass N through opposite skin edge using forceps to hold the skin
Not too tight or loose
Make sure exit hole opposute insertion hole, and 0.5cm from edge
Put needle in sterile tray

Tie knot
- double throw
- needle holder parallel to wound
- wind two loops of long end of suture in a clockwise motion around the needle holder
- needle holder to 12 o'clock
- pull short end of stitch through the loops using the mouth of the needle holder
down to 6 o'clock
- pull knot gently down to the skin, opposing the two sides of wound at the same time

- tighten so skin edges are apposed but without tension

2nd throw - single

3rd throw - single
- single throws in opposite direction
Suture material can then be cut to complete the stitch
- 1cm
- ensure the knots created are everted and spaced 5-10mm apart
- knots on same size
- good opposition - no pie crust or puckering

Halves
- offer to place the next suture (rule of halves) half-way between the present suture and the distal, medial end of the wound. Repeat until the wound closed

Mount/SgKn/Hvs

Tidy Up
Dressing
- dry dressing
- Tetanus immunity if wound contaminated / pt has not had booster in last 10years

Document
- detail of sutures
- polypropelene

Dispose of waste
inform pt that sutures can be removed in 10days

Tell the patient to attend GP
- if any worries (red, oozing wound, stitches come out etc)
- and to in about 7-10 days time for stitches removal./or come back to A&E

Dr/Tt/Doc/Disp/GP

Thank you
Any questions?

Sutures
- scalp
3/0, non absorbable
7 days

- trunk
3/0, non absorbable
10 days

- limbs
4/0, non absorbable
10 days

- hands
5/0, non absorbable
10days

- face
6/0 non absobable
3-5days

Deep wounds
Absorbable eg monocryl, vicryl, dexon
Superficial wounds
Monofilament non-absprbable
eg Nylon (Ethilon) or Prolene