Operational Medicine 2001
Field Medical Service School
Student Handbook

SUTURE MATERIALS AND TECHNIQUES

FMST 0421

17 Dec 99

TERMINAL LEARNING OBJECTIVE:

1. Given a casualty with a laceration in a combat environment (day and night) and standard Field Medical Service Technician supplies and equipment, perform suture procedures, per the references. (FMST.04.22)

ENABLING LEARNING OBJECTIVES:

1. Without the aid of references and given a list of suture materials, identify the various types and sizes, per the student handout. (FMST.04.22a)

2. Without the aid of references and given a list of surgical instruments, identify the proper instruments for suturing, per the student handout. (FMST.04.22b)

3. Without the aid of references and when given a list of injectable anesthetic agents, identify the different agents and correct dosages, per the student handout. (FMST.04.22c)

4. Without the aid of references and given a list of wounds, determine whether they need suturing, per the student handout. (FMST.04.22d)

5. Without the aid of references and given a list of steps for preparation for suturing, identify the proper sequence, per the student handout. (FMST.04.22e)

6. Without the aid of references, and given a FMST MOLLE Medic bag and simulated casualty with wound, suture the wound and then remove the sutures, per the student handout. (FMST.04.22f)

OUTLINE:

Before repair of wounds or lacerations is initiated, a thorough evaluation of the patient must be completed. Wound characteristics, anatomic site, and underlying conditions affect the management of every wound. It is important to keep in mind that all wounds can be potentially life-threatening, therefore initial attention should be directed at maintaining the patients ABC's and the stabilizing their vital signs.

A. REQUIRED EQUIPMENT

1. SUTURE MATERIALS: There are several criteria that must be met before a particular suture material can used. A good suture material must have tensile strength to resist breakage, good knot security, and workability in handling, low tissue reactivity, and the ability to resist bacterial infection. The two main classes of suture materials are: 1) absorbable and 2) non-absorbable.

a. ABSORBABLE: Those that are absorbed or digested by the body cells and tissue fluids in which they are embedded during and after the healing processes.

1. SURGICAL GUT: The most commonly used absorbable suture material. Derived from the small intestine of healthy sheep. It is uniformly fine-grained and possesses great tensile strength and elasticity.

2. DEXON (POLYGLYCOLIC ACID): Widespread absorbable suture material of a synthetic, braided polymer. Dexon has low rate of reactivity and infection rate, and has excellent knot security and tensile strength. A drawback of Dexon is its high friction that binds and snags when wet.

3. CHROMIC SUTURE MATERIAL: Chromic suture materials have undergone various intensities of tanning with the salt of chromic acid to delay the tissue absorption time. Typical examples of chromic suture and absorption times are:

1. Type A: Plain, 10 days

2. Type B: Mild chromic, 20 days

3. Type C: Medium chromic, 30 days

4. Type D: Extra chromic, 40 days

b. NON-ABSORBABLE: Those suture materials that can not be absorbed by the body cells or fluids.

1. NYLON (ETHILON): Of all the non-absorbable suture materials, monofilament nylon is the most commonly used in surface closures. It has minimal tissue reactivity and resists inflections greater when compared to braided suture materials. It has a high tensile strength that ensures wound security. The disadvantage of nylon is the difficulty in achieving good knot security. Because of this at least 4-5 "throws" (knots) are required to achieve a secure knot.

2. PROLENE: Polymer polypropylene (Prolene) appears to be stronger then nylon and has better overall wound security. However, it has a greater memory (returns to its packaging shape) and is more difficult to work with.

3. BRAIDED: These include cotton, silk, braided nylon and multifilament Dacron. Until the advent of synthetic fibers, silk was the mainstay of wound closure. It is the most workable and has excellent knot security. Disadvantages: high reactivity and infection due to the absorption of body fluids by the braided fibers.

b. SUTURE SIZES: The size of suture material is measured by its width or diameter and is vital to proper wound closure. As a guide the following are specific areas of their usage:

1. 1-0 and 2-0: Used for high stress areas requiring strong retention, i.e. - deep

2. fascia repair

3. 3-0: Used in areas requiring good retention, i.e. - scalp, torso, and hands

4. 4-0: Used in areas requiring minimal retention, i.e. – extremities. Is the most common size utilized for superficial wound closure.

5. 5-0: Used for areas involving the face, nose, ears, eyebrows, and eyelids.

6. 6-0: Used on areas requiring little or no retention. Primarily used for cosmetic effects.

c. SURGICAL NEEDLES: There are a variety of needles for wound closure. Curved needles have two basic configurations; tapered and cutting. For wound and laceration care, the reverse cutting needle is used almost exclusively. It is made in such a way that the outer edge is sharp so as to allow for smooth and atraumatic penetration of tough skin and fascia. Tapered needles are used on soft tissue, such as bowel and subcutaneous tissue, or when the smallest diameter hole is desired.

d. SURGICAL INSTRUMENTS: It is not necessary to have large numbers of instruments for emergency wound care. Wounds and lacerations can be managed with the following instruments:

1. NEEDLE HOLDERS: Needle holders come in various sizes and shapes, but for most lacerations a standard size 4" will complete the task. For larger, deeper wound closures a larger needle and needle holder may be required.

2. FORCEPS: Grasping and controlling tissue with forceps is essential to proper suture placement. However, whenever force is applied to skin or other tissues, inadvertent damage to cells can occur if an improper instrument or technique is used. Be gentle when grasping tissue, and never fully close the jaws on the skin.

3. SCISSORS: There are three types of scissors that are useful in minor wound care.

   1. IRIS SCISSORS: Iris scissors are predominantly used to assist in wound debridement and revision. These scissors are very sharp and are appropriate in situations that require very fine control. They are very delicate and are not recommended for cutting sutures. However, when very small sutures require removal they can be use.

   2. DISSECTION SCISSORS: Used for heavier tissue revision as necessary for wound undermining.

   3. SUTURE REMOVAL SCISSORS: Standard 6-inch, single blunt-tip, suture scissors are most useful for cutting sutures, adhesive tape, and other dressing materials. Because of their size and bulk, these scissors are very durable and practical.

5. HEMOSTATS: Hemostats have three functions in minor wound care: clamping small blood vessels for hemorrhage control, grasping and securing facia during debridment, and are an excellent tool for exposing, exploring and visualizing deeper areas of the wound.

6. KNIFE HANDLES AND BLADES: The knife handle holds the blade and is used in the debridment and excisions during wound revision. Common blades are the #10 blade (used for large excisions), #15 blade (small, versatile and well suited for precise debridement and wound revision), and the #11 blade (ideal for incision and drainage of superficial abscesses and the removal of very small sutures).

e. ANESTHETIC AGENTS: Prior to suturing of wounds a thorough understanding of the properties of anesthetic solutions and injection techniques is required. The choice of anesthetics and techniques are individualized for every patient in relationship to severity of wounds, location of wounds, and allergic reactions; which could lead to anaphylactic shock.

f. ANESTHETIC SOLUTIONS

1. LIDOCAINE (XYLOCAINE): Lidocaine is the most commonly used anesthetic solution. It has a rapid on-set in local infiltration. Duration of action is approximately 75 minutes; though some patients appear to metabolize Lidocaine very rapidly and require repeated injections.

1. STRENGTH: 0.5%, 1.0%, & 2.0%

2. DOSE: Maximum individual dose should not exceed 5mg/kg, not exceeding 300mg

2. LIDOCAINE (XYLOCAINE WITH EPINEPHRINE): The same as Lidocaine, but contains epinephrine, which provides vasoconstriction, decreased bleeding, and prolongs the duration of the anesthetic effect.

1. STRENGTH: 0.5% & 1.0%

2. DOSE: Maximum individual dose 7mg/kg not exceeding 500mg.

3. CAUTIONS: Due to its vasoconstriction properties never use Lidocaine with epinephrine on: EYES, EARS, NOSE, FINGERS, TOES, PENIS, or SCROTUM

3. MEPIVACAINE (CARBOCAINE): Widely used as an emergency wound anesthetic. It has a slower on-set then Lidocaine but the duration is 30 to 60 minutes longer than Lidocaine.

1. STRENGTH: 1%

2. DOSE: Maximum individual dose 5mg/kg

4. BUPIVACAINE (MARCAINE): Although it is a very effective anesthetic its chief drawback is that is has a slow onset of action (10 - 15 minutes). The main advantage of bupivacaine is its duration of action, which is considerably longer then Lidocaine and mepivacaine.

1. STRENGTH: 0.25%

2. DOSE: Maximum individual dose 3mg/kg

g. INJECTION TECHIQUES: There are a large variety of needles and syringes available to deliver local anesthetics. For local, direct, and parallel wound infiltration, a 25, 27, or 30-gauge needle can used. Depending upon the amount of anesthetic required a 6 or 10 cc syringe will suffice. A key principle in the use of local anesthetics is to always aspirate the syringe before injection to check for blood return. Other guidelines include:

1. Check for allergies

2. Insert the needle at the inner wound edge

3. Aspirate to ensure infusion does not take place in an artery or vein

4. Inject agent into tissue and slowly withdraw (forming a small wheel at wound edge)

5. Avoid high pressure injections as they damage and distort tissue

6. Test the site in approximately 10 minutes, by touching the area around the wound (ask patient if the sensation is "sharp or dull")

7. After anesthesia has taken effect, suturing may begin

h. SUTURING PROTOCOL: The attending Medical Officer (MO) is ultimately responsible for the evaluation, cleaning, suturing, dressing, and overall management of wounds and lacerations. Hospital corpsmen will suture only upon his/her direction and only when subject corpsmen has current suture certification training.

i. MEDICAL OFFICER: Prior to suturing, the MO will:

1. Inspect and evaluate wounds and lacerations

2. Dictate the nature of treatment to be rendered, to include

3. Type of suture material used, if any

4. Type of stitch

5. Type and amount of anesthesia used

6. Type of dressing applied

7. Determine the need for radiographic studies

8. Order tetanus prophylaxis

9. Provide orders and instruction regarding dressing changes, suture removal and further follow up care.

j. HOSPITAL CORPSMEN: Once inspected and evaluated the attending MO will issue orders and instructions to the corpsman regarding the nature of treatment, cleansing materials, type of stitch, anesthesia, and dressing. The following wounds will not be sutured by Hospital Corpsmen

1. Wounds or lacerations with nerve, tendon or major vessel involvement.

2. Wounds or lacerations of the eye, eyelids, bites, and other severely contaminated wounds.

3. Wounds entering the thoracic or abdominal cavities.

k. WOUND EVALUATION: In most circumstances wounds penetrating the epidermis and dermis, with involvement of subcutaneous fat will require suturing. Before suturing take in to account the following factors:

1. Time of incident - most wounds will not be closed if 12 hours have past from time of injury.

2. Size of wound.

3. Depth of wound.

4. Tendon/nerve involvement.

5. Bleeding at site.

l. CONTRAINDICATIONS

1. If there is reddening and edema of the wound margins

2. Infection manifested by discharge or pus

3. Persistent fever or toxemia

4. Puncture wounds or animal bite

5. Tendon, verve, or vessel involvement

6. Any wound more than 12 hours old. With the exception of the face and hands

m. CLOSURE TYPES: There are three types of closure when determining wound repair: primary closure, secondary closure, and tertiary closure (delayed).

1. PRIMARY CLOSURE (PRIMARY INTENTION): Primary closure can only be done on lacerations that are relatively clean and minimally contaminated, with minimal tissue loss. Repair is usually necessary within 8-12 hours from the time of injury.

2. SECONDARY CLOSURE (SECONDARY INTENTION): Skin ulceration, abscess cavities, punctures, animal bites, and large tissue losses are often best left to heal by secondary intention. They are not primarily closed with sutures but are allowed to gradually heal by granulation of the epithelial tissues and then sutured as required.

3. TERTIARY CLOSURE (DELAYED PRIMARY CLOSURE): These are wounds that are too contaminated to close primarily. Wounds that fall into this category are often older, excessively contaminated with soil, feces (caused by human or animal bites), or the result of high-velocity missiles wounds. Once casuistry effects or infection have passed (4 to 5 days), normal closure can take place.

n. WOUND PREPARATION: Wound preparation is the most important step for reducing the risk of wound infection. It is essential that all contaminants and devitalized tissue be removed prior to wound closure. If not, the risk of infection and of a cosmetically poor scar are greatly increased.

o. PERSONNEL PRECAUTIONS: Because the process of preparing, cleaning, and suturing a wound brings personnel into contact with blood and other secretions, it is recommended that appropriate protective gloves and eyewear be worn at all times. The main infective agents that are of concern in these settings are hepatitis B and the human immunodeficiency virus (HIV). Refer to reference 4 (HM3 & 2) Chapter 5, for aseptic technique.

p. WOUND CLEANSING SOLUTION: Clean the wound area by using normal saline solution or other solutions such as Chlorhexidine or Hexachlorophene. Avoid betadine or alcohol.

q. WOUND SCRUBBING: Scrubbing the wound will assist in loosening debris and contaminates from the site.It is essential to be gentle and to start at the wound itself. The motion should be circular, with gradually larger circles away from the wound.

r. IRRIGATION: Wound irrigation is probably the most effective way to remove debris and contaminants. Method of irrigation is through an 18-gauge plastic catheter attached to a 30 to 50 cc syringe. Irrigate 1-2 inches from the wound refilling as necessary to achieve maximum reduction of wound contaminants.

s. DEBRIDEMENT: In spite efforts to cleanse and irrigate the wound, gross contaminants can still remain adhered to the injured tissues. If this occurs, sharp debridement should be carried out prior to closure. Removal of imbedded or adherent debris or dead tissue can be accomplished with tissue scissors or by scalpel excision.

t. BASIC LACERATION REPAIR - PRINCIPLES AND TECHNIQUES: Each wound and laceration has different technical requirements that have to be met in order to properly effect closure. During closure, every attempt is made to match each layer evenly and produce a wound edge that is evenly matched.

1. DEFINITION OF TERMS: Several techniques and maneuvers used in wound care are referred to by terms that can be confusing. These term are defined below:

2. BITE: The amount of tissue taken when placing the suture needle in the skin or fascia. The farther away from the wound edge that the needle is introduced into the epidermis, for example, the bigger the bite will be.

3. THROW: Each suture knot consists of a series of throws. In general you will need 3 or 4 throws per suture to ensure knot security. Some suture materials require more, such as nylon.

4. PERCUTANEOUS (DEEP) CLOSURE: Sutures, usually of a nonabsorbable material, that are placed in the skin with the knot on the surface.

5. DERMAL CLOSURE: Sutures, usually of an absorbable material, that are placed in the superficial (subcutaneous) fascia and dermis with the knot buried in the wound.

6. INTERRUPTED CLOSURE: Single sutures, tied separately, whether deep or percutaneous. For lab procedures and training, you will be using this type of closure.

7. CONTINUOUS CLOSURE (RUNNING SUTURES): A wound closure effected by taking several bites that are the full length of the wound, without tying individual knots. Knots are tied only at the beginning and end of the closure to secure the material.

8. SUTURE TECHNIQUES:

• Wound layers should be placed in close approximation.

• Minimal amount of tension across the suture line.

• Wound edges should be slightly everted.

• Equal bites, horizontally and vertically are important for wound position and healing.

• Debride devitalized tissue.

3. SUTURE PROCEDURES

1. Apply the needle to the needle driver approximately one quarter the distance from the blunt end of the needle.

2. The needle should enter the skin with a 1/4-inch bite from the wound edge at a 90-degree angle.

3. Release the needle from the needle driver and reach into the wound and grasp the needle with the needle driver and pull it free so that you have enough suture material to enter the opposite side of the wound.

4. Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites.

5. Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2-inch suture strand protruding form the bites site.

6. Release the needle from the needle driver and wrap the suture around the needle driver two times.

7. Grasp the end of the suture material with the needle driver and pull the two lines across the wound site in opposite direction (this is one throw).

8. Do not position the knot directly over the wound edge.

9. Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap.

10. Cut the ends of the suture 1/4-inch from the knot.

11. The remaining sutures are inserted in the same manner.

4. FOLLOW-UP CARE

1. Following the placement of the sutures cleanse the suture site with normal saline.

2. Apply a small amount of Bacitracin and cover with an appropriate size sterile non-adherent dressing.

3. Depending on nature and extent of the wound, antibiotic therapy or Tetanus Toxoid way be indicated.

4. Attending MO will provide orders and instructions regarding dressing changes, suture removal, and further follow-up care.

5. Inform the patient theta the suture site needs to be checked in approximately 24 hours for signs of infection or complications.

5. SUTURE REMOVAL

1. TIME FRAME FOR REMOVING SUTURES: Times will vary according to the location and depth of the wound. However, the average time frame is 7-10 days after application. The following general rules can be sued in deciding when to remove sutures:

2. FACE: 4-5 days.

3. BODY & SCALP: 7 days.

4. SOLES, PALMS, BACK OR OVER JOINTS: 10 days

5. Any suture with pus or signs of infections should be removed immediately.

6. Once MO determines that the sutures should be removed, a suture removal kit, consisting of scissors and a pair of tweezers is utilized to remove the sutures.

7. Using the tweezers, grasp the knot and snip the suture below the knot with the scissors as close as possible to the skin.

8. Pull the suture line through the tissue and place on a 4x4.

9. Once all sutures have been removed count the sutures.

10. The number of sutures needs to match the number indicated in the patient's health record.

REFERENCE (S):

1. Emergency War Surgery

2. Advanced Trauma Life Support

3. Advanced Special Operations Medical Training Course

4. Hospital Corpsman 3&2 (NAVEDTRA 10669)

Field Medical Service School
Camp Pendleton, California

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Operational Medicine 2001
Health Care in Military Settings

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