Suturing

  • Wash hands
  • Gloves
  • History – allergies, medications, tetanus
  • Ensure proper equipment – needle driver, Addison’s, sutures/staples/glue/steristrips, freezing
  • Suture selection
    • Non absorbably monofilament (Prolene 4-0, 3-0), with a cutting needle (less trauma to skin) – remove in 5-7 days
    • Non-absorbable (silk, Prolene)
    • Absorbable (plain and chromic gut, vicryl and monocryl)
    • Monofilament (Monocryl, Prolene)
    • Multifilament (Silk, Vicryl)
  • Freezing
    • xylocaine 5mg/kg without epinephrine, 7mg/kg with epinephrine
    • marcaine 2mg/kg without epinephrine
    • 1% = 10mg/cc, 1g/100cc
    • SE: decrease CVS, anaphylaxis, bradycardia, hypotension; with epi may have seizures, convulsions, somnolence, vision disturbances
    • If allergic: benadryl 50 mg IM, epinephrine 0.5ml of 1:1000 SC
  • Irrigate wound with 30cc syringe, 18gauge needle and saline
  • Debride devitalized tissue
  • Suture
  • Tetanus schedule
    • 0.5 cc absorbed toxoid if clean, incomplete shots, shorts >5 years
    • Tetanus prone: >6hr, tissue loss, >1cm in size and depth, missle/crush/burn/frostbite, devitalized, denervated, contamination
      • Td 0.5 cc IM
      • Tetanus IMG 250-500 units IM
      • Must be in separate sites
    • If unknown status or <3 doses give Td and TIG if prone, and just Td if not prone.  If 3 doses or more give Td if > 5 years and prone, or >10 years and not prone
    • Wound healing stages
      • Coagulation
      • Inflammation (days 0-4) – PMNs, macrophage
      • Proliferation (3 days to 3 weeks) – fibroblasts, collagen laid
      • Maturation (3 weeks to 2 years) – crosslinks
  • Clean (atraumatic, no break in aseptic technique, no GI/GU/resp/biliary) vs clean-contaminated (atraumatic, minor break in aseptic technique, minor spillage of GI/GU/resp/biliary) vs contaminated (traumatic, major break in aseptic technique, gross spillage GI/GU/resp/biliary) vs infected
  • Universal precautions:
    • Gown
    • Gloves
    • Mask
    • Eye protection
    • Don’t handle sharps
    • Dispose of sharps
    • Don’t recap sharps
    • In OR pass sharps carefully
    • Get your own immunizations (Hep B)
    • Get patient’s history/status
    • Report needle sticks and splashes to occupational health

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