Start

  • Introduce yourself.
  • Check the patient’s details.
  • Find out the nature of the injury and assess if the wound requires suturing.
  • Explain what you will do and why. 
  • Ask if the patient has any questions and answer appropriately. 
  • Ask if you have their consent to proceed.

 

Assessment

  • Wash your hands.
  • Make sure the wound is well lit.
  • Don a pair of non sterile gloves and inspect the wound.  Make sure the wound is deep enough for suturing. 
  • Obtain sufficient X-ray views if you suspect that a foreign body has entered the wound. 
  • Check distal neurovascular status is intact.

 

Preparation

  • Clean a trolley.
  • Wash your hands.
  • Assemble your equipment. You will need:

 

    1. Sterile Syringe 10ml
    2. Suture pack
    3. Sharps bin
    4. Sterile gloves
    5. Blue and green needles
    6. Lignocaine
    7. Antiseptic solution

     

    • Choose the appropriate non absorbable suture:

    Face

    Scalp, Trunk

    Arms or Legs

    Hands or Feet

     

    6/0

    3/0

    4/0

    5/0

     

     

    • Use a sterile technique open to suture pack.
    • Open the needles, syringe, glove packet and suture into this sterile field.
    • Pour the antiseptic solution into the pot (if no assistant is present then open the lignocaine and leave it on the side).
    • Ensure both you and the patient are in comfortable positions.

     

    Cleaning

    • Don the pair of sterile gloves.
    • Clean the wound working your way from the centre towards the peripheries using swabs that had been dipped in the solution.
    • If vigorous and therefore painful cleaning is required consider anesthetising at this point.
    • Tear a hole in the drape and cover the wound.

     

    Anesthetising

    • Screw the 21 G green needle on to the syringe and draw up 10 ML of 1% lignocaine.  Use assistance if available.  Lignocaine/adrenaline mixtures are available that prolong duration of anaesthesia, however these must not be used on an body part supplied by an end artery e.g. digits, nose or penis. Thios is due to the risk of ischaemia following vasoconstriction.
    • Dispose of the needle and attach the 25G blue needle.
    • Ask the patient to inform you if they experience symptoms of lignocaine toxicity (numbness around the lips, dizziness, metallic taste etc)
    • Choose points around the peripheries of the wound to inject blebs to ensure full coverage.
    • Insert the needle into the skin, and first withdraw to ensure you are not in a blood vessel. Inject a bleb and withdraw.
    • Repeat until full coverage is achieved.
    • After 3-5 minutes, use the toothed forceps to pinch the skin to test if anaesthesia has been achieved.

     

    Suturing

    The both forceps should be held like a pen. The needle holder should be held like so:

     

     

    It takes practice to use the locking mechanism.

    • Use the needle holder to pick up the needle which is often indicated by an arrow on the packet. The needle should be held 2/3 from the tip.
    • Extend your arm upwards pulling the entire suture out making sure it does not touch any non sterile surfaces.
    • Start your first suture in the centre of the wound on the far side.
    • Use the toothed forceps to pick up the skin.
    • Insert the needle 0.5 cm from this point. Rotate your wrist.

    Note that the needle should never be left freely in the skin and must always be in your grip. Do not release the needle holder.

    • With your other hand place the toothed forceps down and use the non toothed forceps to grip the needle.
    • Release the needle from the needle holder and pull the suture through slightly.
    • Grip the needle using the needle holder 2/3 from the tip again.
    • Replace the non toothed forceps and use the toothed forceps to grip the skin.
    • Using a rotational movement insert the needle below the skin aiming for the needle to appear through the skin 0.5cm from the edge.
    • Place the toothed forceps down and use the non toothed forceps to grip the needle.
    • Release the needle from the needle holder and pull the suture through leaving 3 cm between the skin and the end.
    • Keeping the needle holder still next the suture and the non-toothed forceps as a rotator, wrap the suture around the needle holder twice in a clockwise direction.
    • Use the needle holder to grip the 3 cm part near the skin.
    • Move both your hands in opposite directions to pull through forming a knot.
    • Pull it tight enough to gently oppose the edges but not so tight that the skin puckers.
    • Repeat this wrapping and tying of a knot but this time rotating in the anti clockwise direction once.
    • Finally repeat in the clockwise direction twice.
    • Use the scissors to cut both ends leaving around 1 cm to allow for easy removal.

     

    Plan your sutures by using the rule of halves. Your first suture was in the middle of the wound and each suture is placed at halfway points until closure is achieved:

    Completion

    • Dispose of the needle in the sharps bin.
    • Dispose of your equipment appropriately.
    • Thank the patient and advise them when to return to have the sutures removed:

     

    Face

    Scalp

    Trunk, Arms, Legs, Hands, Feet

     

    3-5 days

    7 days

    10 days

     

    • Ask if they have had a tetanus immunisation in the last 10 years.
    • Consider applying a dressing.
    • Document the procedure, detailing the time, date, location and suture used. Sign your name and designation.

     

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