UC IRVINE EMERGENCY MEDICINE INTEREST GROUP

SUTURE WORKSHOP :: page 1

LACERATION
HISTORY TAKING
With any laceration, you must consider several things that will help guide treatment. Always ask
exactly how long ago it happened, approximate amount of blood loss, and how long ago the patients
last tetanus shot was, Try to get an idea of how contaminated the wound is and how likely a foreign
body is. You will be deciding: dT shot? (yes if unknown last shot or if last shot was >10years ago)
Hypertet treatment? (if no known immunization) Antibiotics? Imaging studies? Closure? And if you
decide to close it, what method will be best?

The injury: The mechanism of injury is important in assessing the degree of risk of
complications of a given wound. For example, the farmer who pierces his foot with a manureladen pitchfork is at high risk for gas gangrene and sepsis. Management would include extensive
local wound care and possible admission to hospital for intravenous antibiotics. Mammalian
bites present another risk situation for infection. Is there likely to be a foreign body present in
the wound? Does the force of injury suggest there is likely to be extensive trauma to deeper
tissues and/or fracture?
The patient: Consider complicating medical conditions such as diabetes, other
immunosuppressed states or other major organ dysfunction (such as renal or hepatic failure)
and peripheral vascular disease. These all may affect both resistance to infection and wound
healing itself.
Time of injury: The age of the wound is important in deciding the timing of closure, if at all.

Laceration

Age / Condition

Extremity

< 12 hours and clean

Extremity

>12 hours older or dirty

Face

< 24 hours

Treatment
suture primarily
Older or obviously contaminated or infected
lacerations are best left alone for healing by
secondary intention or tertiary intention (closure
a few days later). Saline soaks and antibiotics
usually will be required. If cosmetic or other
functional considerations apply, then referral to a
plastic surgeon is necessary.
suture primarily unless obviously infected (rare)

PHYSICAL EXAM
Dont be too distracted by the wound, do a thorough physical, then come to the laceration last. Look
for signs of excessive blood loss (tachycardia, conjuctival pallor). Assess motor and sensory function
distal to the wound, as well as circulation (pulses, capillary refill) and range of motion. Make careful
note of the size and depth of the lesion, amount of necrotic tissue, contaminants, and involved tissues.
Especially important to note is exposure of bone or transection of large artery or nerve. Visualize the
wound base to be sure of depth and lack of foreign bodies. Better visualization will be achieved as you
are flushing the wound.

P Binkley, D Acevedo, A Bernaba, W Wiechmann

UC IRVINE EMERGENCY MEDICINE INTEREST GROUP

SUTURE WORKSHOP :: page 2

CLOSURE
PRINCIPLES OF WOUND CLOSURE

Minimize bacterial contamination

Remove foreign bodies & devitalized tissue
Achieve hemostasis
Handle tissue gently.
Approximate; dont strangulate

STEPS
1) Assess
Once you have decided that the laceration should be sutured, determine what types of stitch
(eg. simple interrupted, running subcuticular, vertical/horizontal mattress), and how many
stitches you will use. Determine the appropriate type, size, and quantity of suture material
based on the location, size, and complexity of the laceration.
2) Gather materials
Bring the following items to the bedside:
Lidocaine, 10cc syringe, 18 gauge and 25 gauge needle
chucks
basin
flush kit, 500cc NS (OR a bottle of NS, a 30 or 60cc syringe, an 18 gauge IV catheter, and a
medication cup)
betadine, 4x4s
procedure light
mayo stand
laceration tray
suture material
goggles
sterile gloves
4x4s or appropriate bandage material, tape
antibiotic ointment
Once you have everything together, make sure your field is well lit (use a procedure light if
available) and free from any potential contaminators/obstructers (eg. patient clothing). Raise
the bed so that you dont hunch over during the procedure. Make sure the mayo stand is
within easy reach.
3) Anesthetize
Clean the area you will be anesthetizing with sterile water or ChloroPrep. Warn the patient
that this will sting/burn, but assure them it is the most painful part of the procedure. Choose
1% lidocaine with epinephrine for most procedures. Consider adding Bicarbonate to the
lidocaine to potentially decrease the burn while infusing. Use lidocaine without epinephrine
when anesthetizing digits and appendages that are in danger of ischemia. Use bupivicain for
longer procedures (it has a longer duration of action but also takes longer for onset). Draw up
the anesthetic with a 10cc syringe and a large needle, then use a small needle to inject,
making sure the air is out of the syringe before you insert the needle. Insert the needle
through the wound into the subcutaneous tissue, attempt to aspirate before infusing (to make
sure the needle is not in a vein), then make a weal under the skin around the wound margins.
Dont be shy, use plenty of anesthetic.
4) Flush
Wear your eye protection! Make absolutely sure that all foreign bodies have been removed
from the wound by thoroughly inspecting down to the base of the wound. With chucks under
the patient, and a basin to catch runoff, flush wound with copious (more than you want to)
amount of saline. Aim a high power stream directly into the wound. Some hospitals have a kit
for flushing, which you can attach to an IV bag. Otherwise use a large syringe (however it must
be small enough to fit into a saline bottle to draw up the saline) and IV catheter as propulsion

P Binkley, D Acevedo, A Bernaba, W Wiechmann

UC IRVINE EMERGENCY MEDICINE INTEREST GROUP

SUTURE WORKSHOP :: page 3

device. You can poke a hole in the bottom of a medicine cup and put the catheter through it
so it acts as a splash guard. When you are done flushing remove the basin and wet chucks so
the patient isnt sitting in a pool. Dry the skin, being very careful not to contaminate the
wound.
5) Prep
Using ChloroPrep or Sterile water clean the skin around the wound. Use of Betadine has fallen
out of favor for cleaning and prepping wounds. Use sweeping circular motions starting at the
wound margin and spiraling outward. Make the area of sanitized skin at least as wide as the
whole in your drape, so there will be no contaminated skin in your field. Do three spiral swipes
with three clean applicators to be thorough. Let it dry, and dab off any excess with sterile
gauze. Open the kit, then open the suture material onto the tray. Put on sterile gloves, then
place your drapes.
6) Sew
Using forceps and a needle driver, close the wound appropriately. Make sure ALL sharps are
disposed of in sharps container before leaving the bedside.
7) Bandage
Cover the nicely approximated laceration with ointment and sterile gauze. Instruct patient on
how to care for the wound, and tell them where and when to go for suture removal.

SUTURE TYPES RECOMMENDED FOR SKIN CLOSURE

A.

B.

Deep (dermal or buried) Absorbable Sutures

1.
Polyglecaprone 25 (Monocryl)
2.
Polydioxanone (PDS)
3.
Polyglactin-910 (Vicryl)
4.
Polyglycolic acid (Dexon)
Superficial, monofilament Nonabsorbable Sutures
1.
Nylon (Ethilon)
2.
Polypropylene (Prolene)

SUTURE SIZE
A.

B.
C.
D.
E.
F.
G.
H.

General
1.
Superficial facial lesions: 6-0 nylon
2.
Other superficial skin lesions
a.
Low skin tension areas: 5-0 nylon
b.
Higher skin tension areas: 4-0 nylon
Annotation for suture size indications below
1.
Skin: Superficial monofilament Nonabsorbable Suture
2.
Deep: Dermal Absorbable Sutures
Size O: Largest suture
Size 2-O: Can be used to suture in G-Tube or Chest Tube
Size 3-O
1.
Skin: Foot
2.
Deep: Chest, Abdomen, Back
Size 4-O
1.
Skin: Scalp, Chest, Abdomen, Foot, Extremity
2.
Deep: Scalp, Extremity, Foot
Size 5-O
1.
Skin: Scalp, Brow, Oral, Chest, Abdomen, Hand, Penis
2.
Deep: Brow, Nose, Lip, Face, Hand
Size 6-O

P Binkley, D Acevedo, A Bernaba, W Wiechmann

UC IRVINE EMERGENCY MEDICINE INTEREST GROUP

SUTURE WORKSHOP :: page 4

I.

1.
Skin: Ear, Lid, Brow, Nose, Lip, Face, Penis
Size 7-O: Smallest Suture
1.
Skin: Eyelid, Lip, Face

SUTURE INDICATIONS BY LOCATION

A.
B.
C.
D.
E.
F.

Scalp, Torso (chest, back, abdomen), Extremities

1.
Superficial Nonabsorbable Suture: 4-O or 5-O
2.
Deep Absorbable Suture: 3-O or 4-O
Face, Eyebrow, Nose, Lip
1.
Superficial Nonabsorbable Suture: 6-O
2.
Deep Absorbable Suture: 5-O
Ear, Eyelid
1.
Superficial Nonabsorbable Suture: 6-O
Hand
1.
Superficial Nonabsorbable Suture: 5-O
2.
Deep Absorbable Suture: 5-O
Foot or sole
1.
Superficial Nonabsorbable Suture: 3-O or 4-O
2.
Deep Absorbable Suture: 4-O
Penis
1.
Superficial Nonabsorbable Suture: 5-O or 6-O

Suggested Removal Times for Interrupted Skin Sutures

Area

Removal time (days)

Face

3 to 5

Neck

5 to 8

Scalp

7 to 9

Upper extremity

8 to 14

Trunk

10 to 14

Extensor surface hands

14

Lower extremity

14 to 28

P Binkley, D Acevedo, A Bernaba, W Wiechmann

UC IRVINE EMERGENCY MEDICINE INTEREST GROUP

SUTURE WORKSHOP :: page 5

P Binkley, D Acevedo, A Bernaba, W Wiechmann

UC IRVINE EMERGENCY MEDICINE INTEREST GROUP

SUTURE WORKSHOP :: page 6

P Binkley, D Acevedo, A Bernaba, W Wiechmann

UC IRVINE EMERGENCY MEDICINE INTEREST GROUP

SUTURE WORKSHOP :: page 7

P Binkley, D Acevedo, A Bernaba, W Wiechmann