• All relevant infection control methods to be utilised.
• Control bleeding as per Haemorrhage Clinical Practice Guideline
• Contact appropriate Medical Officer and give full status of patient and description of the wound. Send photo if able to do so.
• Prepare equipment required:
  • Sterile dressing pack
  • 5 or 20mL syringe
  • 1-4 x 5mL ampoule 1% lignocaine (warmed to body temperature)
  • 2 x 18g needle or blunt needle
  • 23g needle
  • Suture material (sterile) silk or nylon
  • Sterile dissecting forceps (tweezers)
  • Sterile needle holder
  • Curved reverse cutting needle
  • Sterile fine sharps (scissors)
  • Alcohol swabs
  • Sterile surgical gloves
  • Sharps container
  • 50mL syringe
  • Sterile dressing material
  • Normal saline 30mL steritube
  • Chlorhexidine 30mL steritube
  • Iodine (Betadine) diluted 1:10 in saline
• Open dressing pack with the tips of your fingers and spread out on sterile work surface. Peel open all packaging, dropping contents onto sterile dressing field without handling. Pour cleaning solution into pot.
• Draw up 5-20mL of 1% lignocaine using an 18g needle in a 10 or 20mL syringe. Dispose of 18g needle and replace with a 23g needle. Place 18g needle in outer 5cm of sterile dressing field.
• Position patient supine/semi-recumbent.
• Place incontinence sheet under wound.
• Wash hands thoroughly, dry and apply non-sterile gloves.

Wound cleaning

• Remove all contaminants and devitalised tissue before wound closure to decrease the risk of infection and a cosmetically poor scar.
• Wash hands.
• Open sterile glove (inner packet).
• Gloves are marked left and right. Place dominant hand into correct glove. Use other hand to pull on the glove by holding the glove from the inside cuff. Repeat with the other hand, except pull the glove on by grabbing the cuff from the outside face of the glove.
• Using one sterile forcep soak gauze or cotton in cleaning solution and with another forcep transfer gauze to other hand. Clean the wound in a circular motion working from the centre of the wound and moving outwards, changing swabs regularly.
• Irrigate with sterile saline (50-100mL saline/cm of laceration) drawn-up and administered by an 18g needle attached to a 50mL syringe. Irrigate away from the clean area to prevent contamination, until all visible particles are removed.
• Use a scalpel/scissors to debride (remove) dead tissue, firmly adherent wound contaminants (e.g. grease or paint), macerated or ragged wound edges.
• Dry intact skin with sterile gauze. The wound should appear pink and viable with no visible contaminants.
• When finished dispose of forceps and swabs.
• Using a sterile sheet, find the middle and tear/cut a small hole through which the wound can be visualised.

Anaesthetic

• Before suturing a local anaesthetic must be given.
• Using lignocaine syringe with bevel up on a slight angle insert the needle with a short sharp movement into the subcutaneous tissue (not intradermal which is more painful) near the end of the wound. Draw back and if clear inject local anaesthetic whilst slowly withdrawing the needle, leaving a "track" of anaesthetic.
• Continue injections as per numbered area (1) placing the needle in the direction of the arrows. Depending on the length and shape of the wound numbers 2,3,5 and 6 may not be necessary, or more injections may be required.
• Place unused lignocaine in the outer 5cm of dressing pack in case it is required later.
• Allow 10 minutes for lignocaine to work.
• Remove and dispose of dirty gloves.

Suturing

• Ensure wound is numb, if not administer more anaesthetic.
• Select suture size:
  • Gauge 2.0 (3 metric) for scalp lacerations,
  • Finer 4.0 (1.5 metric) for hand lacerations,
  • 5.0 or 6.0 (0.7) for facial wounds.
• The thicker the gauge of suture the greater the amount of foreign body introduced into the wound and potential for scarring.
• Using a sterile needle holder pick up the suturing needle (2).
• The needle must NOT be held near the end or it will bend and possibly break in the tissues.
• Match the wound edges looking for identifying marks. Place one suture somewhere near the middle of the wound and observe how the wound ‘comes together’. If this does not ‘look right’ then cut the suture and try again.
• Throw the first stitch. Aim to close the wound fully by placing the suture at the deepest part of the wound (3).
• Bite deep into the wound down to the base.
• The greater the distance from the wound edge to the needle entry point, the deeper the bite of the needle.
• Distance from the stitch to the wound edge much be equilateral[4], otherwise a step will occur at the adjoining edges of the laceration.
• Assume the suture has been placed starting from the right moving left across the wound. Take the needle in the left hand with the needle holder in the right.
• The needle holder lies against the suture. Wrap the suture over and around the instrument three times away from you.
• Take hold of the end of the suture with the jaws of the needle-holder.
• Pull this first ‘throw’ down. The left hand goes to the right and vice versa (cross the hands). The knot should now lie ‘flat’. Tension the suture to align the wound edges (approximate).
• Let the end of the suture go. The ‘short end’ should now lie to the left with the knot flat across the wound.
• Bring the suture against the needle-holder and wrap the suture around the needle three times toward you.
• Take hold of the ‘short end’ with the needle-holder.
• Pull this second ‘throw’ down onto the first. The left hand pulls to the left, the right to the right.
• Tension the knot off so that the knot lies to the left of the wound (5).
• Cut the suture 0.5cm from the wound. Take care with nylon which will tend to slip. Leave longer or put an extra knot on.
• Continue stitches until the wound is fully closed, tying off to the left of the wound.
• Cover with appropriate sterile dressing and bandaging.
• Detail follow-up, any abnormalities or complications, appointments and care of the wound with the patient.
• Record all details.

Suture Removal

• The location of the wound and the state of wound healing determine when sutures are removed. Sutures should be removed early enough to avoid suture marks but late enough to prevent the wound from reopening.
  

• Expose the wound.
• Examine for possible infection or other problems (contact Medical Officer).
• Check wound is ready for suture removal. If not, leave for 2 days and reassess. Consider removing every other suture or reinforce wound edges with Steri Strips.
• Using forceps/tweezers grab hold of the knot.
• Pull slightly up allowing for one side of the suture to be exposed.
• Using scissors cut the suture directly under the knot closest to the skin (6).
• Pull, removing the suture though the wound.
• Clean surface of wound with normal saline.
• Reapply dressing and bandaging if required.
• Record details, instruct patient to return if any further problems occur.
• Inspect at 1, 3 and 5 days for swelling, pain or bleeding.

Steri-Strips

• These paper adhesive strips are widely used as they are quick and painless to apply and are less likely to cause tissue ischemia.
• They are very useful in:
  • Conjunction with sutures.
  • Children.
  • Flap lacerations, especially in pre–tibial lacerations in the elderly.
  • Some finger injuries.
  • Skin closure in wounds where a deep layer of sutures has approximated the skin edges.
• However, they should not be used as a ‘short cut’ in wound care. It is essential that proper wound cleaning and exploration be carried out if indicated.
• Expose and clean the wound.
• Apply Antiseptic Medi-Prep Cetrimide around the perimeter of the wound and leave for 30 seconds to dry.
• Apply Steri Strip (7) to one edge of the wound, align and bring the wound together. Use as many strips as necessary.
• Protect wound with appropriate sterile dressings and bandaging.
• Inspect at 1, 3 and 5 days for swelling, pain or bleeding.
• Leave a space between each steri strip for exudate to escape.

Steri-Strip Removal

• Remove strips by lifting the edges from either end of the strip (8) bringing the two ends together carefully.
• Continue to lift away, changing direction along the wound (9), pull away until free.