Basic Suturing and Wound Management

A Self-Directed Learning Module

Technical Skills Program
Queens University
Department of Emergency Medicine
Introduction
The purpose of this tutorial, which includes this online module and a suturing seminar, is to
introduce students to the basics of wound management and allow them to practice simple
suturing on a prosthetic model. asic suturing is an essential psychomotor s!ill in the everyday
practice of medicine. "lthough suturing techni#ue is important, the physician must also have a
thorough understanding of wound management in general to effectively care for a patient with a
laceration. Students should complete this module and complete the embedded multiple-choice
questions prior to their scheduled suturing seminar. There will be a brief multile-choice e!am
based on this material at the beginning of the seminar"
#b$ecti%es
$n completion of this module, students will%
&. Understand the principles of wound management as they apply to a simple laceration.
'. e able to demonstrate the preparation of a simple laceration for closure.
(. e able to demonstrate sterile techni#ue while preparing and suturing a simple laceration
on a model.
). e able to demonstrate basic suturing techni#ues on a model.
Wound considerations
Each wound that is encountered and considered for repair must be addressed independently.
*actors such as location, si+e, mechanism of in,ury, time elapsed since in,ury, li!elihood of
contamination and patient dependent factors must be addressed prior to formal treatment. "s
well, the physician or student should consider whether or not they have the s!ill or
e-perience to ade#uately manage a particular wound.
.ound location is important. /acerations on the face, hands and perineum, for e-ample, are
more complicated for cosmetic structural reasons. These areas should be reserved for more
e-perienced physicians. /acerations of the scalp, trun! and pro-imal e-tremities tend to be
less comple- so more appropriate for beginners. "s with all forms of medical care, it is
important to be aware of one0s own abilities and limitations and to re#uest assistance, if
necessary.
" functional assessment of nerves, blood vessels, muscles and tendons is essential early in
the evaluation of the wound. 1t must be done prior to in,ection of local anaesthesia, as this
will obviously interfere with the assessment.
2nowledge of the mechanism of in,ury can provide valuable insight into the potential
for in,ury to ad,acent structures, the li!elihood of contamination and the preferred method of
repair. Deep puncture wounds can in,ure blood vessels and nerves, and contaminate several
tissue planes. They are probably best left open after thorough cleansing, as there is a high ris!
of subse#uent infection if sutured primarily. 3onversely, a superficial laceration from clean
glass may be cleaned and either sutured or taped to appro-imate the edges.
/acerations resulting from significant blunt force often re#uire debridement and revision of
wound edges to optimi+e healing. "s well, the edema and inflammatory response resulting
from blunt in,ury can adversely affect the already tenuous blood supply to the area.
"ll traumatic wounds must be assumed to have some degree of contamination by virtue of
the presence of dirt, microorganisms and devitali+ed tissue. "n infected wound will not heal
properly due to adverse effects on tissue regeneration.
The time elapsed from in,ury to repair has a direct bearing on the subse#uent ris! of wound
infection. "ny wound that has been e-posed for greater than 4 hours is at significant ris! for
infection, regardless of the mechanism of in,ury.
.ounds that are more than 4 hours old and grossly contaminated wounds, such as animal
bites and farming in,uries, are at such high ris! for subse#uent infection that consideration
should be given to leaving them open. 1nitial management should focus on thorough cleaning
and close monitoring for infection. 5uturing a grossly contaminated wound, which greatly
increases the ris! of infection, should always be balanced against the benefits of faster
healing and better cosmetics.
6atient dependent factors !nown to negatively influence the process of wound healing
include advanced age, poor nutritional status and co7e-isting illness such as diabetes. These
factors can lead to delayed healing, dehiscence, abnormal scarring and infection and must be
considered when instructing the patient regarding follow7up.
&ategories of wound closure
Closure by primary intent:
This refers to wound closure immediately following the in,ury and prior to the formation of
granulation tissue. 1n general, closure by primary intent will lead to faster healing and the best
cosmetic result. Most patients presenting within 4 hours of in,ury can have the wound closed by
primary intent. 5imple and clean facial wounds, by virtue of the rich vascular supply to the face
and the need for a good cosmetic result, can be closed by primary intent as late as ') hours after
the in,ury.
Closure by secondary intent:
This refers to the strategy of allowing wounds to heal on their own without surgical closure. $f
course the wound should be cleaned and dressed as with any wound. 3ertain wounds such as
small partial thic!ness avulsions and fingertip amputations are best left to close by secondary
intent.
Closure by tertiary intent:
This refers to the approach of having the patient return in (7) days, after initial wound cleansing
and dressing, for wound closure. This is also referred to as delayed primary closure. 3losure by
tertiary intent is used for patients with wounds who present late 89') hours: for care,
contaminated crush wounds and mammalian bites when leaving the wound open would result in
an unacceptable cosmetic result.
Wound antisesis and sterile techni'ue
Un#uestionably, efforts ta!en to properly prepare the wound and the surrounding s!in surfaces
will influence the li!elihood of infection and will directly impact on the process of wound repair.
Under normal circumstances, the s!in surface surrounding a wound about to be sutured should
be washed and disinfected with a solution that is rapidly acting, with a broad spectrum of
antimicrobial activity.
6rior to cleansing, the area around a wound may have to be anaestheti+ed to reduce the
discomfort to the patient.
Most Emergency Departments will stoc! a range of antiseptic solutions, including &; 6rofidone
1odine 86roviodine:, <ydrogen 6ero-ide and 3hlorhe-idine7based solutions 85avlodil, 5avlon:.
"lthough e-cellent s!in cleansers, these solutions are potentially to-ic to the local wound
defenses and may increase the rate of subse#uent wound infection if they are spilled into a
wound in large #uantities. These solutions should be irrigated from the wound with a sterile
normal saline solution as the final step in wound cleansing.
1t is rarely necessary to remove significant #uantities of body hair prior to repair of a simple
laceration. 1n fact, ra+or removal of hair has been shown to damage surface s!in follicles and
lead to increased rates of wound infection. $ccasionally, for repair of scalp lacerations, for
e-ample, scissor trimming will allow for easier identification of wound margins and will
facilitate later wound care. Due to inconsistent regrowth of eyebrow hair, it should never be
shaved when repairing lacerations in that area.
"ctual preparation of the wound involves cleansing and debridement. The ideal wound cleanser
should have broad antimicrobial activity, but should not delay healing or reduce tissue resistance
to infection. There is controversy about the potentially adverse effects of the readily available
s!in cleansing antiseptic solutions when introduced directly into the wound. .hat is certain,
however, is that =.>; normal saline is a very effective and non7to-ic irrigating solution.
Therefore, =.>; normal saline should be used as the final solution when cleaning a wound and
one should minimi+e spillage of other solutions into the wound during preparation.
.ound irrigation is a form of mechanical wound cleansing that is !nown to effectively remove
bacteria and other debris. " &= c.c. or '= c.c. syringe can be fitted with a commercially available
splash cover, and the wound can then be irrigated with either normal saline or ?inger0s lactate.
These solutions are used because they do not irritate body tissues. *ollowing irrigation,
remaining debris and devitali+ed tissue can be removed with fine forceps or with a scalpel.
Ensuring sterile techni#ue while repairing a wound is, perhaps, the most difficult concept for the
ine-perienced person to grasp. " brea! in sterile techni#ue, with contamination of the field, is a
common procedural error. 1t leads to an increased incidence of wound infection and brea!down.
5terile techni#ue re#uires that the physician%
is able to open and don gloves without contamination to the sterile surface of the gloves
is able to clean and drape the wound and surrounding area
is able to control the instruments and suture, such that they are not contaminated by non7
sterile surfaces
Local Anaesthetics
*or any patient about to be sutured, attention must be given to obtaining ade#uate analgesia
and ensuring overall comfort. "fter documenting the neurovascular status of ad,acent
structures, which must be done in every case, a local anaesthetic can be in,ected into the
tissue in and around the wound. " &; solution 8&= mg@cc: of lidocaine can be used for most
wounds.
/idocaine &; is very safe when used in the small #uantities usually re#uired for simple
lacerations. The physician should not use in e-cess of (mg@!g of lidocaine. 1ts onset of action
when infiltrated locally is within seconds and its duration of action is generally (= to A=
minutes. /idocaine is also available in =.B; 8B mg@cc: and '.=; 8'= mg@cc:. The =.B; is
useful in pediatric patients, whereas the '.=; solution is rarely necessary.
Epinephrine is added to some of the commercially available lidocaine solutions. 1t is a potent
vasoconstrictor and functions to prolong anaesthesia by slowing vascular upta!e of the
lidocaine, and to reduce the bleeding into the wound, which can impair visuali+ation of
structures. 5olutions containing epinephrine are best avoided by ine-perienced physicians as
there are ris!s associated with their use.
/idocaine causes an intense burning sensation when in,ected locally. The burning is
dependent on the rate of in,ection and the acidity of the solution. The burning can be
minimi+ed by slow in,ection using a small gauge needle 8C'B, C'D, or C(=:. "n e-perienced
physician can in,ect local anaesthetic with virtually no discomfort if time and care are ta!en.
?ecently, it has been shown that the addition of bicarbonate to buffer the lidocaine solution
can reduce some of the burning sensation at the in,ection site. <owever, this buffered
solution is not available commercially and must be made up in the Emergency Department as
it has a short shelf life.
Suture Materials
There are a number of suture materials available, but it is beyond the scope of this module to
cover them in any detail. 1n selecting a particular suture, the physician needs to consider the
physical and biological characteristics of the material in relation to the healing process.
5uture materials can be broadly categori+ed as absorbable and non7absorbable. "bsorbable
sutures do not re#uire removal as they are digested by tissue en+ymes. Eon7absorbable or
permanent sutures need to be removed at a later date.
"bsorbable sutures can be further divided into rapidly absorbing 8days: and slowly absorbing
8months:. The choice will depend on the rate at which the particular tissue regains its
strength. *ortunately, the choice is often not an issue in the Emergency Department because
most wounds encountered there re#uire support for a matter of days to wee!s. 5utures
available in the Emergency Department will meet this re#uirement.
oth absorbable and non7absorbable sutures are graded for si+e or diameter of the strand. The
grading system uses the letter $ and the number of stated $0s indicates the si+e. The more
$0s, the smaller the si+e. *or e-ample, a A7$ is smaller than a )7$. "ccordingly, tensile
strength of a particular suture type increases as the number of $0s decreases.
The needles supplied with sutures also have important features. 1n general, for Emergency
Department use, needles are either large or small and either cutting or non7cutting. /arge
needles have the advantage of closing a deeper layer of tissue with each FbiteF. The concern
with small needles is that there will be inade#uate closure of deep subcutaneous tissues,
leaving potential space for hematoma formation. <owever, small needles create smaller
puncture wounds and may have the advantage of reducing scarring
3utting needles have at least two opposing cutting edges to facilitate passage through tough
tissue. These needles are used for s!in closure. Eon7cutting or tapered needles are used to
close subcutaneous tissue, muscle and fascia. They have sharp points, but do not have cutting
edges.
Tetanus roh(la!is
Tetanus is a serious disease characteri+ed by muscle spasm and rigidity. The mortality rate is
appro-imately '=; and is due to spasm of the muscles of respiration. Tetanus is an illness
preventable through primary immuni+ation and regular booster shots.
The Emergency Department patient encounter provides an ideal opportunity to screen for
ade#uate tetanus immuni+ation and to provide it, when necessary. 1n Eorth "merica, the vast
ma,ority of people seen in the Emergency Department will have received primary immuni+ation.
Groups that may have missed primary immuni+ation include elderly patients and immigrants.
6rimary immuni+ation involves a series of four to-oid in,ections for preschool children or three
to-oid in,ections if started at age D or older. *ollowing primary immuni+ation, children receive a
booster shot at age B and additional boosters every &= years subse#uent to that.
6atients seen in the Emergency Department with clean, minor wounds are considered ade#uately
immuni+ed if they have received primary immuni+ation and have had a booster within the past
&= years. 1f a wound is FdirtyF 8which includes wounds contaminated with saliva, feces or dirt,
and burn in,uries: then a booster within the past B years is necessary to ensure immuni+ation.
1f the patient has not received primary immuni+ation, 8or if the patient is unsure: then passive
immunity with tetanus immune globulin 8T.1.G.: is provided. "t the same time, but with a
different in,ection site, tetanus and diphtheria to-oid should be given. This initiates primary
immuni+ation but ade#uate follow7up should be arranged to ensure completion of the series.
Eote that the diphtheria to-oid is added to ensure ade#uate immunity to diphtheria in the
population.
6atients will occasionally present stating they have an allergy to the to-oid. "dverse reactions
such as local pain, erythemia, fever, malaise or rash are common but should not preclude further
immuni+ation. " true anaphylactic or serious neurologic reaction to the to-oid are the only
contraindications to further immuni+ation with the tetanus and diphtheria to-oid.
1f a patient has had a true serious reaction in the past, they should receive a T.1.G. in the
Emergency Department and then follow7up with an allergist to assess immuni+ation status. The
table below summari+es the 3D3 guidelines for tetanus prophyla-is.
Tetanus 1mmuni+ation%
)or clean* minor wounds+

Give patient Tetanus
Diphtheria To-oidH
Give patient Tetanus 1mmune
GlobulinH
Un!nown or less than ( doses of absorbed
Tetanus To-oid
Ies Eo
Greater than ( doses of of absorbed Tetanus
To-oid
Eo 8unless 9&= years since last
booster:
Eo

)or all other wounds+

Give patient Tetanus
Diphtheria To-oidH
Give patient Tetanus
1mmune GlobulinH
Un!nown or less than ( doses of
absorbed Tetanus To-oid
Ies Ies
Greater than ( doses of of absorbed
Tetanus To-oid
Eo 8unless 9B years since
last booster:
Eo
Wound dressing
Dressings are applied after suturing for several reasons. They shield the wound from gross
contamination, which is more or less important depending on the patient0s occupation. "s well, a
dressing can absorb blood and serous material oo+ing from the wound, which serves to protect
clothing and bed linen. *inally, a dressing can improve patient comfort by immobili+ing in,ured
tissue and avoiding further in,ury.
"lthough dressings can prevent gross contamination, it has been shown that wounds which
remain covered for periods of greater than )4 hours without an inspection or change are more
li!ely to become infected than wounds left open. "fter suturing a simple laceration, the patient
should be instructed to change the dressing at )4 hours.
Dressing material should be clean, but does not necessarily have to be sterile. Most wounds are
covered with a simple, light dressing prior to discharging the patient. 1f a layered dressing is
re#uired for the purpose of greater absorption or application of pressure or splinting, then the
first layer should be a non7adherent material such as Jaseline gau+e.
5ubse#uent layers can include absorptive gau+e and a pressure pad, if desired.
The final layer should be a 2lingK wrap or elastic bandage to secure the dressing and apply
pressure as needed.
ul!y pressure dressings serve to reduce wound drainage and deter hematoma formation, which
can increase the potential for infection. "s well, they can improve patient comfort by splinting
the wound and by supporting the surrounding tissues and may reduce the ris! of dehiscence.
.et dressings should be changed immediately and dirty dressings should be changed as often as
&'7') hours.
Many patients will as! when they can get the sutured wound wet. " clean minor wound can be
immersed for brief periods after )4 hours. This allows them to bathe, shower and even swim. The
patient should be cautioned against prolonged immersion, as this tends to brea! down the wound.
Instructing the atient
6atients leaving the Emergency Department after wound management and suturing need a
specific set of instructions for ongoing wound care and routine follow7up. "s well, they need to
be cautioned about possible complications.
.ound care will vary, but in general patients should be told to !eep the area clean and dry. The
wound may be gently cleaned with plain water or diluted hydrogen pero-ide to remove crusting
and debris. Dressings that have become wet or dirty should be changed.
1f there is significant swelling associated with the wound, elevation of the affected area will
improve patient comfort. 1n areas under stress, such as over ,oints, splinting for a few days can
improve comfort and aid in healing.
1nstructions for suture removal need to be given in each case. The length of time sutures are left
in depends on the amount of tension in the tissues in the area of the wound, balanced against the
fact that sutures will cause additional scarring when left in too long.
The following guidelines for suture removal are generally accepted:
*ace )7B days. ?eplace with 5teri7strips
TM
5calp and trun! D7&= days
"rms and legs &=7&) days
Loints &) days
The most common and important complication for patients to be aware of is infection. 5igns and
symptoms of infection include increased pain, swelling, redness, fever or red strea!s spreading
pro-imally. 6atients should be cautioned about the potential for infection and encouraged to
return to the Emergency Department if any signs of infection are noted.
The suture tra(
The basic emergency department suture tray has the e#uipment necessary to manage a simple
laceration.

Surgical Draes
The surgical drapes should be used to completely surround
the wound and a portion of the surrounding sterile field.
,- ! ,- .au/e
The gau+e is used to clean the wound area.
Suture Materials - ,"0 and 1"0
*or facial wounds, a smaller gauge suture such as A.= is used.
*or wounds under greater stress and of less cosmetic
importance such as a thigh laceration, a ).= suture would be
appropriate.
Antisetic Solution and Saline
The antiseptic solution is for cleansing the s!in around the
wound and saline is used to cleanse and irrigate the wound
itself.
S(ringe with slash co%er
.ound irrigation has been shown to be the most effective
means of removing debris and contaminants. The splash
cover helps to avoid e-posure to the patient0s blood and body
fluids.
Scalel
The operator may re#uest a scalpel to allow a wound to be
e-tended or wound edges to be debrided.
Straight 2emostat
The straight hemostat can be used for blunt dissection. 1t
should not be used to clamp blood vessels or tissues since it
will in,ure these structures.
&ur%ed 2emostat
The curved hemostat can be used for blunt dissection. 1t
should not be used to clamp blood vessels or tissues since it
will in,ure these structures.
Toothed )orces
The toothed forceps are used to grasp the s!in edges while
suturing. They tend to be less traumatic than non7toothed
forceps but can damage tissues if applied forcefully.
3on-toothed )orces
This is considered to be a more traumatic instrument than its
toothed counterpart for grasping tissue.
3eedle Dri%er
The needle driver is reinforced instrument designed to grasp
the suture needle.
Scissors
The scissors are intended only to cut sutures. They have no
rule in the dissection or removal of tissue.
Ste 4+ 2istor( and h(sical e!amination
Each wound that is encountered must be addressed independently. *actors such as location, si+e,
mechanism of in,ury, time elapsed since in,ury, li!elihood of contamination and patient
dependent factors must be addressed prior to formal treatment.
Mechanism of injury% provides insight into potential in,ury to ad,acent structures, li!elihood of
contamination and preferred method of repair. /aceration resulting from blunt force often re#uire
debridement and revision of wound edges to optimi+e healing.
Time elapsed from injury to repair% any wound that has been e-posed for greater than 4 hours is
at significant ris! for infection, regardless of the mechanism of in,ury. Grossly contaminated
wounds such as animal bites and farm in,uries are at such great ris! for infection that they are
best left open.
atient dependent factors% includes advanced age, poor nutritional status and coe-isting illnesses
such as diabetes which can lead to delayed healing, abnormal scarring and infection and must be
considered when instructing the patient regarding follow7up.
" functional assessment of nerves, blood vessels, muscles and tendons is essential and must be
done prior to in,ection of local anesthesia as this will obviously interfere with the assessment.
"s with all medical care, it is imprtant to be aware of one0s own abilities and limitations and to
re#uest assistance if necessary.
Ste 5+ 6se of non-sterile glo%es
E-ploration of any open wound should be done with universal precautions in mind. "s such, it is
necessary for the student or physician to use non7sterile gloves during the initial physical
e-amination and when in,ecting local anesthesia.
Ste 7+ Drawing local anesthetic
Ste ,+ In$ecting local anesthetic
Ste 8+ Donning sterile glo%es
Ste 1+ &lean and irrigate wound
Ste 9+ Draing
Ste :+ Simle interruted suture
Ste ;+ <ertical mattress suture
Ste 40+ Disosing of shars
1n the interest of safety, the student or physician must personally ensure that all sharps have been
disposed of in the yellow sharps container immediately upon completion. This includes needles,
scalpels and scalpel blades.
Ste 44+ Instrucing the atient
.ound care will vary, but in general, patients should be told to !eep the area clean and dry. The
wound may be gently cleaned with plain water and dressings that have become wet or dirty
should be changed. 1f there is significant swelling, elevation of the affected area will improve
patient comfort.
1nstructions for suture removal need to be given in each case. The following guidelines for suture
removal are generally accepted%
*ace% )7B days
5calp and trun!% D7&= days
"rms and legs% &=7&) days
Loints% &) days
The most common and important complication for patients to be aware of is infection. 5igns and
symptoms of infection include increased pain, swelling, redness, fever or red strea!s spreading
pro-imally. 6atients should be cautioned about the potential for infection and encouraged to
return if any signs of infection are noted.
Ste 45+ Suture remo%al
=not t(ing
"n important part of correct suturing techni#ue is correct method in !not tying. The !nots
demonstrated here are those most fre#uently used by physicians. *or clarity, one half of the
strand is yellow and the other is white. The yellow strand is initially held in the left hand. oth
!nots demonstrated here are s#uare !nots which resist slipping of completed properly. 1ncorrect
techni#ue can result in a granny !not that easily slips when tension is applied. .hen the two
ends of a suture are pulled in opposite directions with uniform rate and tension, the !not may be
tied more securely.
$ne hand techni#ue% Two hand techni#ue%
Self-assessment 'uestions
Question &
.hich of the following is true regarding animal bites and farming in,uriesH

They should be treated the same as any other in,ury.
They always re#uire e-tensive debridement.
They are at high ris! for infection, so re#uire careful cleaning and irrigation and may be best
managed by not suturing.
They are best sutured and treated with antibiotics.
Question '%
.hich of the following is true regarding toothed forcepsH

They are considered more traumatic to the tissues than non7toothed forceps.
They are considered less traumatic to the tissues than non7toothed forceps.
They can substitute as a needle driver if necessary.
They should not be used in management of simple lacerations.
Question (
Groups at ris! for inade#uate primary immuni+ation against tetanus include which of the
followingH

5chool7aged children
Elderly patients and immigrants
"lcoholics
6regnant females
Question )
.hich of the following is true regarding suturesH

a A7$ is stronger than a )7$
a A7$ is larger than a )7$
a )7$ is stronger than a A7$
a )7$ is smaller than a A7$
&redits
3ongratulationsM
Iou have now completed the asic 5uturing and .ound Management module.
3redits
This web7based module was developed by "dam 5+ulews!i based on content written by
Dr. ob McGraw, Laelyn 3audle, Lordan 3hen!in, and 2ari 5ampsel for the Queen0s
University Department of Emergency Medicine 5ummer 5eminar 5eries and Technical
5!ills 6rogram.
The module was created using e-e % e/earning N<TM/ editor with support from "my
"llcoc! and the Queen0s University 5chool of Medicine MedTech Unit.
/icense
This module is licensed under the 3reative 3ommons "ttribution Eon73ommercial Eo
Derivatives license. The module may be redistributed and used provided that credit is given to
the author and it is used for non7commercial purposes only. The contents of this presentation
cannot be changed or used individually. *or more information on the 3reative 3ommons license
model and the specific terms of this license, please visit creativecommons.ca.
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