Suturing and tetanus prophylaxis

Suturing Guidelines

For Uncontaminated, Uncomplicated Lacerations

LET (Lidocaine-Epinephrine-Tetracaine)

- Works in ~ 30 minutes

- Use only on broken skin (won’t work on intact skin)

- Don’t use on mucous membranes (risk of toxicity)

- CAUTION with fingertips, toes, penis, nose, or pinna b/c of epi

EMLA (Eutectic Mixture of Local Anesthetic)
ELA-max
Use only on intact skin (NOT on lacerations!)

ELA-max works in 30 minutes, EMLA takes an hour

OK to use on areas of distal circulation because no epi

Lidocaine

1% lidocaine = 10 mg/ml
2% lidocaine =  20 mg/ml

Max dose - lidocaine WITH epi = 7 mg/kg (up to 280 mg)

Max dose - lidocaine WITHOUT epi = 4 mg/kg (up to 280 mg)

w/ epi DO NOT use on fingertips, toes, penis, nose, pinna

To buffer with bicarb: 1:10 solution with 8.4% sodium bicarbonate
(9ml of lidocaine + 1ml bicarb)

Location	Percutaneous (Skin)	Deep (Dermal)	Days to removal (percutaneous only)
Scalp	Staples or 5-0/4-0 Prolene/Ethilon	4-0 Vicryl/Chromic Gut	7-10
Ear	6-0 Prolene/Ethilon – SEE NOTE*		5-7
Eyelid	7-0/6-0 Prolene/Ethilon.  If low on lid, consult Ophtho.		5-7
Eyebrow	6-0/5-0 Prolene/Ethilon	5-0 Vicryl/Chromic Gut	5-7
Nose	6-0 Prolene/Ethilon - SEE NOTE*	5-0 Vicryl/Chromic Gut	5-7
Lip	6-0 Prolene/Ethilon	5-0 Vicryl/Chromic Gut	5-7
Oral mucosa	---	4-0 or 5-0 Vicryl/Chromic Gut	---
Tongue	Suture if significant step-off or through and through laceration
Other face/ forehead	6-0 Prolene/Ethilon – SEE NOTE*	5-0 Vicryl/Chromic Gut	4-5
Trunk	5-0/4-0 Prolene/Ethilon	3-0 Vicryl/Chromic Gut	8-10 (Chest/Abd) 12-14 (Back)
Extremities	6-0/5-0/4-0 Prolene/Ethilon	4-0 Vicryl/ Chromic Gut	8-10
Hand	6-0/5-0 Chromic	5-0 Vicryl/ Chromic Gut	8-10; 10-12 (tip)
Extensor tendon	Refer to plastic surgeon
Foot/sole	4-0/3-0 Prolene/Ethilon	4-0 Vicryl/ Chromic Gut	12-14
Vagina	---	4-0 Vicryl/Chromic Gut	---
Scrotum	---	5-0 Vicryl/Chromic Gut	---
Penis	5-0 Prolene/Chromic	---	7

*Consider use of Fast Absorbing Gut (5-0/6-0) on Ear, Eyelid, Eyebrow, Nose, Lip and Face if anticipated difficulty with suture removal (Note: follow up still required for wound evaluation)

NOTE:  If cartilage involved, strongly consider plastic surgery consult.  Always treat with antibiotics

NOTE:  If human/animal bite, cleanse, dress, treat with antibiotics, and follow-up with Plastics.  If tendons are involved, start antibiotics and consult Plastics.  See ‘Bugs and Drugs’ section (page 63-64) for specific treatment guidelines.

Tetanus administration

Immunization history	Dirty, Tetanus prone:  >6 hrs since injury; stellate or avulsion injury; missile, crush, burn, frostbite; >1 cm deep; devitalized /contaminated.		Clean, Non-tetanus prone: ≤6 hours since injury; linear injury; sharp surface (glass, knife); ≤1 cm deep; No devitalized or contaminants
	TdaP (Adacel)	TIG	TdaP (Adacel)	TIG
Unknown or <3 doses	Yes	Yes	Yes	No
3 or more doses	No, unless >5 yrs since booster	No	No, unless >10 yrs since booster	No