POTD: Suture Choices

Hi everyone,

For today's POTD, I want to review the suture choices we have available when performing laceration repairs in the ED. Much of our training for laceration repairs is on-the-job, informal practice and learning, but I want to offer a more systematic approach. 

So, when you're getting all your equipment together for your laceration repair, what suture are you grabbing? And why? And whose "gut" are plain gut and chromic gut sutures coming from? We will go over questions to consider when making your choice, your suture options (with particular focus on what we have stocked at MMC), and some clinical examples for when you might choose each.

3 Questions to Consider When Choosing Your Suture

1) Tensile strength: How much tension is across the wound? A primary purpose of laceration repairs is to decrease tension across the wound. Remember everting edges? That's all in an attempt to give the wound a little extra skin to work with in case the tension does pull the edges apart as it heals. Whether to evert or not is controversial these days (definitely don't invert, though). But when it comes to sutures, the primary principle remains: choose the smallest size suture that can best fight the tension you're up against.

2) Site of laceration: Where on the body are you repairing? If it's going inside the body, aim for absorbable. If it's at the skin, you have more options.

3) Follow-up: What is the likelihood this patient can return for follow-up suture removal? For pediatric patients who have already gone through the trauma of getting stitches and whose parents have already had to somehow coordinate a single ED visit while a gaggle of other responsibilities awaits them at home, or patients with poor access to healthcare at baseline, consider sparing them a second ED visit for suture removal and trial absorbable sutures when possible.

Your Suture Options

Materials

There are two big buckets of suture materials: absorbable and non-absorbable. Within each of those buckets you have two main sub-types: braided/multifilament and monofilament. Braided essentially means that there are multiple strands woven together, and monofilament means a single strand. The more the strands means the tighter the knot... but also the more surface area for inflammation and infection. I've stuck to just remembering the brand names of the sutures, but you might come across the generic names; use whatever works for you. For the absorbable sutures, note that there is often a discrepancy between when the suture loses its strength and when the suture actually absorbs/falls off.

1) Absorbable: braided/multifilament, monofilament

a. Braided/multifilament: vicryl, vicryl rapide

i. Vicryl: buried, loses strength 21d

ii. Vicryl rapide: irradiated to speed up resorption, buried or used in skin, loses strength 10d

b. Monofilament: fast absorbing gut, plain gut, chromic gut

i. Fast absorbing gut: used in skin, great for face ("F"ast for "F"ace), loses strength 7d

ii. Plain gut: used in skin, loses strength 8-9d

iii. Chromic gut: coated in chromium to slow down resorption, used in skin, great for hands or oral lacs, loses strength 10-21d

**Fun fact: gut is short for "catgut" sutures. Cat lovers, don't be afraid; our suture materials aren't actually coming from cats' guts. But they are coming from cow, pig, and sometimes horse intestines, all of which are known to be highly collagenous, elastic, and strong.**

2) Non-absorbable: braided/multifilament, monofilament

a. Braided/multifilament: silk

i. Silk: used in skin, great for securing chest tubes/drains, must be removed

b. Monofilament: ethilon, prolene

i. Ethilon aka Nylon: used in skin, black in color, must be removed, OUR GO-TO SUTURE

ii. Prolene: used in skin, blue in color, great for black hair/beards, must be removed

Sizes

For thin sutures (which is most of what we stock in the ED), the smaller the number, the bigger the physical size. These range from 1-0 (pronounced "one-oh") to 12-0 (pronounced "twelve-oh). 1-0 is the biggest, and 12-0 is the smallest. We will mainly use size 2-0 to size 6-0.

For thick sutures, it is the opposite; the smaller the number, the smaller the physical size. These range from 0-10 (no "-oh" afterwards). 0 is the smallest, and 10 is the biggest. We have size 0 silk in the ED, but the other sizes are mostly for the surgeons.

Needle Types

Straight or curved is the main distinction to know. Straight you can use with your hands to secure drains/tubes. Otherwise we are using curved with our needle drivers. (Pro tip: I once saw Dr. Masoudi make a curved needle out of a straight needle by physically bending it with a needle driver himself and it was extremely cool).

Removal

The importance of removing sutures isn't just for appearance purposes; it's to decrease the risk of an inflammatory reaction to the foreign body currently embedded in the skin. So the quicker we can get them out, the better. When giving return instructions to our patients, take into account the size and location of the suture. A good rule of thumb is the average suture removal length is 7d, but that shortens to around 5d closer to the face and extends to around 10-14d further towards the extremities. Suture Man is always a helpful resource, too.

Examples for Suture Choices at MMC

Uncomplicated laceration in an adult patient? Non-absorbable monofilament, ethilon or prolene, size 6-0 for face and size 3-0/4-0/5-0 everywhere else

Face laceration in a pediatric patient? Absorbable monofilament, fast absorbing gut, size 5-0

Trunk/extremities laceration in a pediatric patient? Absorbable braided or monofilament, vicryl rapide or plain gut, size 4-0 or 5-0

Deep laceration >3cm that requires buried sutures? Absorbable braided, vicryl, size 4-0

Oral laceration? Absorbable monofilament, chromic gut, size 3-0 or 4-0

Laceration within or around hair? Non-absorbable monofilament, prolene, size 3-0 to 6-0

Figure 8 suture for brisk/arterial bleeding? Non-absorbable monofilament, ethilon, size 2-0 is our biggest

Chest tube securing? Non-absorbable braided, silk (straight needle), size 0

For practice, try to find each of these suture types below on our trauma metal shelving unit in resus room 51...

I highly recommend downloading the Suture app (https://www.suture.app/) on your phone to use on shift, which is an interactive tool that will tell you the appropriate suture material, size, and removal time depending on the location and tension of the wound. 

And, of course, we can't forget about skin glue (dermabond), steri strips, and the handy-dandy stapler. I am a die-hard fan of these quick, easy adjuncts for wounds that are low in tension and in an appropriate location for repair.

Happy suturing,

Kelsey

Resources:

1) https://canadiem.org/nice-threads-guide-suture-choice-ed/

2) https://www.ncbi.nlm.nih.gov/books/NBK539891/

3) https://www.emdocs.net/wounds-and-lacerations-in-the-ed-management-pearls-and-pitfalls-for-emergency-physicians/

4) https://coreem.net/core/suture-materials/

5) https://home.hippoed.com/blog/skin-deep-selecting-suture-material-for-the-skin-surface

6) https://www.aliem.com/pv-laceration-repair-and-sutures/

7) https://lacerationrepair.com/wound-blog/eversion/#:~:text=As%20it%20turns%20out%2C%20eversion,creating%20an%20optimal%20healing%20environment.

8) https://www.forbes.com/sites/quora/2018/09/26/what-is-catgut-really-made-from/

POTD: Fishhook Injury

Hi everyone,

Caroline and I have the great privilege of serving as your admin residents for this upcoming block. Throughout the next four weeks, if there are any topics floating in your head that you would like us to dive further into, send it our way!

For today's POTD, I wanted to explore the unfortunate case of a fishhook injury, with a particular focus on fishhook removal techniques if it ever maneuvers its way into your ED. Over the weekend, the south side team successfully removed a fishhook lodged in a patient's pinky finger, and, by the leadership of Dr. Sanjeevan and the grip strength of Dr. Weber, the patient was able to ambulate out of the ED with all digits intact and ready for another day of fishing in Red Hook.

Fishhook Anatomy

A fishhook is composed of the eyelet, shank, belly, barb, and tip. Most fishhooks are J hooks, with one shank and one barb, but occasionally you might see a treble hook, which is essentially multiple J hooks together all sharing a shank. The real troublemaker for fishhook injuries is the barb. Fear the barb. The sharp, reversed nature of the barb makes it so that a simple retrograde removal would be traumatic both to the surrounding tissue and the patient.

Preparation

1) Assess path of fishhook: Your removal technique will in part depend on the depth and location of the needle. Is the distal tip already near the surface? Is it going to hit any important structures on its way in or out? You may need further imaging to better clarify the track it took. If it involves the eye, consult ophtho. If it involves bone or tendon, consult ortho.

2) Local anesthetic/nerve block: Digital blocks work great for these when applicable.

3) Wound cleaning: Chlorhexidine or betadine like wild.

Techniques

1) Advance and Cut Technique: need hemostat, wire cutters/raptors, gauze, eye protection

a. Anesthetize.

b. Advance the fishhook further into the patient until the tip and the barb have both exited the skin.

c. Cut the barb off the fishhook with wire cutters or raptors. If using raptors, you can use the ring cutter function (shown below). Make sure you keep gauze over the barb and have eye protection on before you cut so as to avoid the cut barb from flying off and causing further injuries.

d. Reverse the hook back out of the skin.

2) String Technique: need string or strong suture, eye protection

a. Wrap a string or strong suture around the fishhook.

b. Push down on the shank to dislodge the barb as much as possible.

c. Pull on the string and jerk quickly. Watch out for the fishhook to come flying out of the skin.

3) Needle Technique: need 18 gauge needle

a. Anesthetize.

b. Advance an 18 gauge needle along the fishhook toward the tip and over the barb.

c. Reverse out both the needle and fishhook together as a unit.

4) Scalpel Technique: need scalpel, hemostat

a. Anesthetize.

b. Use #11 blade scalpel to cut down to the barb.

c. Grab barb with hemostat.

c. Pull entire fishhook up and out.

Post-Removal Care

1) Check for foreign bodies: Consider xray if any concern for retained objects.

2) Tetanus: Hit them with that tdap as indicated. 

3) Antibiotics: No trials have been done to study PO antibiotics after fishhook injury. You might consider adding on systemic antibiotics for immunocompromised folks, infection-prone areas, or contaminated hooks. At the very least, topical bacitracin and instructions on local wound care are always a good call.

Happy fishing,

Kelsey

Resources:

1) https://www.aliem.com/trick-fishhook-removal-techniques/

2) https://www.uptodate.com/contents/fish-hook-removal-techniques?search=fish%20hook%20removal&source=search_result&selectedTitle=1%7E1&usage_type=default&display_rank=1#H13

3) https://www.tampaemergencymedicine.org/blog/fish-hook-removal

4) https://www.emra.org/emresident/article/angling-for-success-techniques-for-fishhook-removal-in-the-ed

5) https://www.emrap.org/episode/ucprocedures/ucproceduresfishhookremoval

6) https://www.emrap.org/episode/fishhookremoval1/fishhookremoval1

7) https://www.emrap.org/episode/fishhookremoval/fishhookremoval