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Suture for hemostasis?

Discussion in 'Surgery and Surgical Subspecialties' started by agranulocytosis, Jan 1, 2010.

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  1. agranulocytosis

    agranulocytosis All neutropenic about it

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    Do you use a simple interrupted or something else? I am currently doing an EM rotation and I had the opportunity to place a couple stitches to this guy's facial wound to stop the bleeding of a somewhat deep abrasion. Only knowing how to tie simple interrupted and running sutures, I did just that, but after the fact it seemed that something else would have been better, perhaps a figure of eight?

    What do you guys normally do?
  2. skiz knot

    skiz knot Legendary Dr. X

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    It doesn't sound like any special stitch technique was necessary for the problem you have described. Unless a major vessel is injured the bleeding will soon stop on its own with pressure. Suturing the edges of the wound together is one way to apply pressure. Your repair was more for cosmetic and sanitation reasons than hemostasis.
  3. pseudoknot

    pseudoknot

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    I was taught that the running locked stitch was useful for hemostasis (you can look it up, but it is sort of like a continuous version of a figure of eight), but that it shouldn't be used on delicate tissue such as skin or fascia since it will impair perfusion and thus healing.
  4. Winged Scapula

    Winged Scapula Cougariffic! Administrator SDN Senior Moderator Lifetime Donor

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    A running locked is good for hemostasis and can used for something quick and dirty but I wouldn't use it on the face unless it was coming out in a few minutes.
  5. DoctorCthulhu

    DoctorCthulhu Polyphemus-like

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    This. Running sutures tend to put more pressure on the wound margin. But if you tie your knots tight enough, any suture can be "hemostatic." This may be necessary for diffuse bleeding, but it's generally bad for wound healing, so you should keep these sutures for a bit longer, and avoid them like the plague in aesthetically sensitive areas. Remember that "hemostatic suture" and "ischaemic suture" are two names for the same thing!

    Facial lacerations often bleed profusely, but it really pays off to spend a few extra minutes compressing the bleeding wound. When I was swamped with consults and floor calls, I'd sometimes infiltrate with 1% lidocaine (I never use lidocaine with adrenaline, but YMMV), clean the wound, and apply a compressive wound dressing and an ice pack (and possibly send patient off for ATT or something). Then I'd go off to see a consult or two, and return 30-60min later to find a wound which I could then suture sans cumbersome bleeding.

    Scalp lacerations, which may also bleed profusely, can usually be sutured with running locked sutures, with relative impunity (unless patient is bald!). Same goes for perineal lacerations - however, keep an eye out for the proximity of important structures (urethra, rectal sphincter) which may be injured. When in the least doubt, take the patient to the OR for exploration and repair under mild sedation; better safe than sorry, and I speak from personal experience.

    This really brings me back to my glory days and sleepless nights in the acute care service. Aah the memories. :D
  6. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor

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    Everyone approaches these sorts of things differently.

    - I've been told that lido-epi can be used anywhere on the body. None of that avoid fingers, nose, etc stuff they teach in med school

    - We routinely close our parotid incisions (modified Blair incision--> face lift incision) with a running, locking prolene on the skin (vicryl's deep). The key is to remove it in 5 days. Never had any problems with wound healing/cosmesis.

    - The scalp should always be stapled. More than that is overkill.
  7. pseudoknot

    pseudoknot

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    The literature shows that lido is safe for digital blocks (see http://www.ncbi.nlm.nih.gov/pubmed/17886362 for review) but I've been told in person that it shouldn't be used...I guess fear of phantom lawsuits always trumps scientific evidence.
  8. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator

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    I'd be careful with the locking suture on the face -- a little bit of ischemia along there could be problematic. Of course, you aren't undermining the skin a lot.
  9. Pir8DeacDoc

    Pir8DeacDoc Cerumen Extractor

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    I find it interesting too but it's advocated by our facial plastics attending so I go with it. So far, so good!
  10. DoctorCthulhu

    DoctorCthulhu Polyphemus-like

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    Yes, there's some evidence on that.

    I prefer not to use epi, personally, because I've had patients returning for proper surgical hemostasis after the epi wore off. :mad:

    I too had a Plastics attending who favored running (not locked) sutures for skin incisions. Of course, the tricks are (1) to use the least amount of tension necessary to approach the wound borders, and (2) keep 'em for a few extra days (14 for most trunk incisions).

    Mind you, I didn't do a lot of face surgery.

    Not all of us work at places that can afford skin staplers. :oops:
  11. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator

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    In regards to Epi, there is no evidence of epi causing digital ischemia. The only reports of local causing ischemia were from a long time ago in the age of "real" Novocaine (procaine). Procaine has a MUCH shorter shelf life than current locals (Lidocaine & Marcaine) and when it degraded it became much more acidic. Back in the "good old days" when people didn't have expiration dates on drugs, procaine was used probably long beyond what would have been a reasonable expiration date. This was probably the cause of digital ischemia, not Epi.

    There are several papers from high volume hand surgeons on the safety of using Epi in the fingers. The two caveats that I would give you are:

    1. Don't use it in a vasculopath.

    2. Know where the vessels are and stay away from them.

    Also, Epi can be reversed using injectable Phentolamine. I believe the dose is 1 mg, but I'd have to check.
  12. maxheadroom

    maxheadroom Rhinestone Cowboy Moderator

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    And I do running closures all the time, I just don't lock them.
  13. Fah-Q

    Fah-Q Senior Member

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    I never locked a facial suture in training as I was told it was "bad". There was even one attending who only used subcuticular closures. The 2 busiest facial plastics guys in my area both routinely use running-locking sutures on the face. It's not for me but there are some very experienced and talented surgeons who use it all the time with great results.

    I inject a ton of 1:100,000 epi for any nasal or ear procedure. I've never had a problem.
  14. dilated

    dilated Fought Law; Law Won

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    Is there a perceived upside for doing this? I can see it not being terribly problematic (especially if you used Rapide or something), but I don't see what advantage locking it gives you. It's not like your facelift incision needs it for hemostasis.
  15. skiz knot

    skiz knot Legendary Dr. X

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    Donatti suture technique (combo of vertical mattress and subcuticular stitch) is a good cosmetic stitch that decreases wound ischaemia and nicely everts the wound edge while providing enough strength to hold.
  16. Fah-Q

    Fah-Q Senior Member

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    Usually prolene or nylon is used.

    Most people use a particular suture technique because it provides the best wound edge eversion in their hands. I don't think the running locking stitch is any different...it does help a little with eversion.

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