Wound closure


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Wound closure

  1. 1. Tactical Combat Casualty Care (TCCC) Todd De Voe EMT-P/Emergency Services
  2. 2. Introduction • The three goals of Tactical Combat Casualty Care (TCCC) are: –1. Save preventable deaths –2. Prevent additional casualties –3. Complete the mission
  3. 3. Introduction • This approach recognizes a particularly important principle: – To perform the correct intervention at the correct time in the continuum of Tactical Care – A medically correct intervention performed at the wrong time in combat may lead to further casualties
  4. 4. Combat Deaths • KIA: 31% Penetrating head trauma • KIA: 25% Surgically uncorrectable torso trauma • KIA: 10% Potentially surgically correctable trauma • KIA: 9% Hemorrhage from extremity wounds • KIA: 7% Mutilating blast trauma • KIA: 5% Tension pneumothorax • KIA: 1% Airway problems • 12% Mostly from infections and complications of shock
  5. 5. PREVENTABLE CAUSES OF COMBAT DEATH • 60% Hemorrhage from extremity wounds • 33% Tension pneumothorax • 6% Airway obstruction e.g., maxillofacial trauma • * Data is extrapolated from Vietnam to present day Iraq and Afghanistan
  6. 6. Factors influencing combat casualty care • Enemy Fire • Medical Equipment Limitations • Widely Variable Evacuation Time
  7. 7. STAGES OF CARE: 3 Distinct Phases • Care Under Fire • Tactical Field Care • Tactical Casualty Evacuation Care (TACEVAC)
  8. 8. Care Under Fire • “Care under fire” is the care rendered by the Tactical Medic or Tactical Operator at the scene of the injury while still under effective hostile fire • Available medical equipment is limited to that carried by the medic or first responder in his/her aid bag
  9. 9. Tactical Field Care • “Tactical Field Care” is the care rendered by the medic once no longer under effective hostile fire • Also applies to situations in which an injury has occurred, but there has been no hostile fire • Available medical equipment still limited to that carried into the field by medical personnel • Time to evacuation may vary considerably
  10. 10. TACTICAL EVAC • “Tactical Evacuation” is the care rendered once the casualty has been picked up by evacuation vehicles • Additional medical personnel and equipment may have been prestaged and available at this stage of casualty management
  11. 11. Care Under Fire
  12. 12. Care Under Fire • “The best medicine on any battlefield is fire superiority” • Medical personnel’s firepower may be essential in obtaining tactical fire superiority • Attention to suppression of hostile fire will minimize the risk of additional injuries or casualties
  13. 13. Care Under Fire • Medical personnel may need to assist in returning fire instead of stopping to care for casualties • Wounded operators who are unable to fight should lay flat and motionless if no cover is available or move as quickly as possible to any nearby cover. Self Aide should be rendered.
  14. 14. Care Under Fire • No attention to airway at this point because of need to move casualty to cover quickly • Control of hemorrhage is essential since injury to a major vessel can result in hypovolemic shock in a short time frame • Remember the “Average” person can exsaguinate in 3-5 minutes with a major vessel injury i.e. Femoral Artery Disruption
  15. 15. Massive Hemorrhage ..My VideosTCCCMS-Combat-Gauze-Z-Fold-V2.flv
  16. 16. Care Under Fire • Hemorrhage from extremities is the 1st leading cause of preventable combat deaths • Prompt use of tourniquets to stop the bleeding may be life-saving in this phase
  17. 17. Tourniquets
  18. 18. Care Under Fire • All personnel engaged in High Threat missions should have a suitable tourniquet readily available at a standard location on their gear and be trained in its use • The tourniquet should be placed as high up on the extremity as possible, ignoring the clothing
  19. 19. Combat Application Tourniquet (CAT) WINDLASS OMNI TAPE BAND WINDLASS STRAP
  20. 20. Care Under Fire • Conventional litters may not be available for movement of casualties • Consider alternate methods to move casualties such as a SKEDD/Drags • Smoke, shields and vehicles may act as screens to assist in casualty movement • Armored Vehicles may also be employed as a means of egress
  21. 21. KEY POINTS • • • • Return fire as directed or required If able, the casualty(s) should also return fire Try to keep from being shot Try to keep the casualty from sustaining additional wounds • Airway management is best deferred until the Tactical Field Care phase • Stop any life threatening hemorrhage with a commercially available tourniquet (CAT) • Reassure the casualty
  22. 22. Tactical Field Care
  23. 23. Tactical Field Care • Reduced level of hazard from hostile fire or enemy action • Increased time to provide care • Available time to render care may vary considerably
  24. 24. Tactical Field Care • In some cases, tactical field care may consist of rapid treatment of wounds with the expectation of a reengagement of hostile fire at any moment • In some circumstances there may be ample time to render whatever care is available in the field • The time to evacuation may be quite variable from minutes to hours
  25. 25. Tactical Field Care • If a victim of a blast or penetrating injury is found without a pulse, respirations, or other signs of life, DO NOT attempt CPR • Casualties with confused mental status should be disarmed immediately of their weapon.
  26. 26. Tactical Field Care • On going assessment in this phase is: A.B.C – Airway – Breathing – Circulation
  27. 27. Tactical Field Care: Airway • Open the airway with a chin-lift • If unconscious and spontaneously breathing, insert a nasopharyngeal airway • Place the casualty in the recovery position
  28. 28. Nasopharyngeal Airway
  29. 29. A survivable airway problem?
  30. 30. Tactical Field Care: Breathing • Traumatic chest wall defects should be closed quickly with an occlusive dressing without regard to venting one side of the dressing • Also may use an “Asherman Chest Seal” or HyFin TM (North American Rescue Products) • Place the casualty in the sitting position or on effected side.
  31. 31. Sucking Chest Wound
  32. 32. "Asherman Chest Seal"
  33. 33. Tactical Field Care: Breathing • Progressive respiratory distress in the presence of unilateral penetrating chest trauma should be considered tension pneumothorax • Tension pneumothorax is the 2nd leading cause of preventable death on the battlefield • Cannot rely on typical signs such as shifting trachea (late sign and very difficult to appreciate) • Needle chest decompression is life-saving ( 14 gauge 3.25 inch catheter)
  34. 34. Needle Chest Decompression
  35. 35. Tactical Field Care: Circulation • Any bleeding site not previously controlled should now be aggressively addressed. • Only the absolute minimum of clothing should be removed, although a thorough search for additional injuries must be performed
  36. 36. Tactical Field Care: Circulation • Once the tactical situation permits, a new tourniquet can be applied 2-3 inches above wound on bare skin. Distal pulse should be checked, If present, tighten tourniquet until distal pulse is absent • Initiate IV access
  37. 37. Hemostatic Dressing • Apply directly to bleeding site and hold in place 2 minutes • If dressing is not effective in stopping bleeding after 4 minutes, remove original and apply a new dressing • Additional dressings cannot be applied over ineffective dressing • Pack wound with gauze (enough to fill cavity) • Apply a battle dressing/bandage to secure hemostatic dressing in place • If bleeding controlled, do not remove dressing
  38. 38. Hemostatic Dressing
  39. 39. Tactical Field Care: IV fluids • FIRST, STOP THE BLEEDING! • IV access should be obtained using a single 18-gauge catheter because of the ease of starting. Rapidly consider I/O access • IV fluids be administered in amounts enough to maintain systolic B/P between 70-80 mmHg with 0.9 NS (Hextend?) • A saline lock may be used to control IV access in absence of IV fluids • Ensure IV is not started distal to a significant wound
  40. 40. Tactical Field Care: Additional injuries • Splint fractures as circumstances allow while verifying pulse and prepare for evacuation (SAM SPLINT) • Continually reevaluate casualties for changes in condition while maintaining situational awareness • Consider Emergency Airway
  41. 41. Tactical EVAC
  42. 42. Tactical EVAC • At some point in the operation the casualty will be evacuated • Time to evacuation may be quite variable from minutes to hours • The tactical medic may be among the casualties or otherwise debilitated • A MASS CALSULTY EVENT may exceed the capabilities of the medic
  43. 43. Tactical EVAC • Higher level medical personnel MAY accompany the TAC EVAC vehicle • Additional medical equipment MAY be brought in with the TAC EVAC asset, which may include – Electronic equipment for monitoring of the patient’s blood pressure, pulse, and pulse oximetry – Oxygen is usually available during this phase
  44. 44. Summary • There are three categories of casualties on the battlefield: 1. Operators who will live regardless 2. Operators who will die regardless 3. Operators who will die from preventable deaths unless proper life-saving steps are taken immediately (60% Hemorrhage, 33% Tension Pneumo and 6% Airway Obstruction • This is the group MEDICS can help the most.
  45. 45. Organizations Recognizing TCCC • American College of Surgeons (ATLS) • National Association of EMT’s (found in PHTLS Manual) • National Tactical Officers Association( advocating for a national standardized curriculum) • Adopted by US Army and Navy (Marines) for service wide curriculum
  46. 46. QUESTIONS?
  47. 47. Tactical Combat Casualty Care (TCCC) Todd De Voe EMT-P/Emergency Services
  48. 48. Basic Suturing Workshop Lianne Beck, MD Emory Family Medicine January 2013
  49. 49. Objectives • • • • • • • • Describe the principles of wound healing Identify the various types and sizes of suture material. Choose the proper instruments for suturing. Identify the different injectable anesthetic agents and correct dosages. Demonstrate various biopsy methods: punch, excision, shave. Demonstrate different types of closure techniques: simple interrupted, continuous, subcuticular, vertical and horizontal mattress, dermal Demonstrate two-handed, one-handed, instrument ties Recommend appropriate wound care and follow-up.
  50. 50. Critical Wound Healing Period Tissue Skin 5-7 days Mucosa 5-7 days Subcutaneous 7-14 days Peritoneum 7-14 days Fascia 14-28 days 0 5 7 14 21 Tissue Healing Time/Days 28
  51. 51. Model of Wound Healing • (1) Hemostasis: within minutes post-injury, platelets aggregate at the injury site to form a fibrin clot. • (2) Inflammatory: bacteria and debris are phagocytosed and removed, and factors are released that cause the migration and division of cells involved in the proliferative phase. • (3) Proliferative: angiogenesis, collagen deposition, granulation tissue formation, epithelialization, and wound contraction • (4) Remodeling: collagen is remodeled and realigned along tension lines and cells that are no longer needed are removed by apoptosis.
  52. 52. Wound Healing Concepts • • • • • • • Patient factors Wound classification Mechanism of injury Tetanus/antibiotics/local anesthetics Surgical principles and wound prep Suture/needle/stitch choice Management/care/follow-up
  53. 53. Common Patient Factors • Age • Blood supply to the area • Nutritional status • Tissue quality • Revision/infection • Compliance • • • • • Weight Dehydration Chronic disease Immune response Radiation therapy
  54. 54. CDC Surgical Wound Classification • Clean: (1-5% risk of infection) uninfected operative wounds in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed, and if necessary, drained with closed drainage. Operative incisional wounds that follow nonpenetrating (blunt) trauma should be included in this category if they meet the criteria. • Clean-contaminated: (3-11% risk) operative wounds in which the respiratory, alimentary, genital, or urinary tract is entered under controlled conditions and without unusual contamination. Specifically, operations involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection or major break in technique is encountered.
  55. 55. CDC Surgical Wound Classification • Contaminated: (10-17% risk) open, fresh, accidental wounds, operations with major breaks in sterile technique or gross spillage from the gastrointestinal tract, and incisions in which acute, nonpurulent inflammation is encountered. • Dirty or infected: (>27% risk) old traumatic wounds with retained devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the operative field before the operation.
  56. 56. Surgical Principles • • • • • • Incision Dissection Tissue handling Hemostasis Moisture/site Remove infected, foreign, dead areas • Length of time open • Choice of closure material/mechanis m • Primary or secondary • Cellular responses • Eliminate dead space • Closing tension • Distraction forces and
  57. 57. Suture Materials • Criteria – Tensile strength – Good knot security – Workability in handling – Low tissue reactivity – Ability to resist bacterial infection
  58. 58. Types of Sutures • • • • Absorbable or non-absorbable (natural or synthetic) Monofilament or multifilament (braided) Dyed or undyed Sizes 3 to 12-0 (numbers alone indicate progressively larger sutures, whereas numbers followed by 0 indicate progressively smaller) • New antibacterial sutures
  59. 59. Non-absorbable • Not biodegradable and permanent – Nylon – Prolene – Stainless steel – Silk (natural, can break down over years) Absorbable • Degraded via inflammatory response – Vicryl – Monocryl – PDS – Chromic – Cat gut (natural)
  60. 60. Natural Suture Synthetic • Biological • Cause inflammatory reaction – Catgut (connective from cow or sheep) – Silk (from silkworm fibers) – Chromic catgut • Synthetic polymers • Do not cause inflammatory response – Nylon – Vicryl – Monocryl – PDS – Prolene
  61. 61. Monofilament • Single strand of suture material • Minimal tissue trauma • Smooth tying but more knots needed • Harder to handle due to memory • Examples: nylon, monocryl, prolene, PDS Multifilament (braided) • Fibers are braided or twisted together • More tissue resistance • Easier to handle • Fewer knots needed • Examples: vicryl, silk, chromic
  62. 62. Suture Materials
  63. 63. Suture Selection • Do not use dyed sutures on the skin • Use monofilament on the skin as multifilament harbor BACTERIA • Non-absorbable cause less scarring but must be removed • Plus sutures (staph, monocryl for E. coli, Klebsiella) • Location and layer, patient factors, strength, healing, site and availability
  64. 64. Suture Selection • Absorbable for GI, urinary or biliary • Non-absorbable or extended for up to 6 mos for skin, tendons, fascia • Cosmetics = monofilament or subcuticular • Ligatures usually absorbable
  65. 65. Suture Sizes
  66. 66. Surgical Needles • Wide variety with different company’s naming systems • 2 basic configurations for curved needles – Cutting: cutting edge can cut through tough tissue, such as skin – Tapered: no cutting edge. For softer tissue inside the body
  67. 67. Surgical Needles
  68. 68. Surgical Instruments
  69. 69. Scalpel Blades
  70. 70. Anesthetic Solutions • Lidocaine (Xylocaine®) – Most commonly used – Rapid onset – Strength: 0.5%, 1.0%, & 2.0% – Maximum dose: • 5 mg / kg, or • 300 mg – 1.0% lidocaine = 1 g lidocaine / 100 cc = 1,000mg/100cc – 300 mg = 0.03 liter = 30 ml • Lidocaine (Xylocaine®) with epinephrine – – – – – Vasoconstriction Decreased bleeding Prolongs duration Strength: 0.5% & 1.0% Maximum individual dose: • 7mg/kg, or • 500mg
  71. 71. Anesthetic Solutions • CAUTIONS: due to its vasoconstriction properties never use Lidocaine with epinephrine on: – Eyes, Ears, Nose – Fingers, Toes – Penis, Scrotum
  72. 72. Anesthetic Solutions • BUPIVACAINE (MARCAINE): – Slow onset – Long duration – Strength: 0.25% – DOSE: maximum individual dose 3mg/kg
  73. 73. Local Anesthetics
  74. 74. Injection Techniques • 25, 27, or 30-gauge needle • 6 or 10 cc syringe • Check for allergies • Insert the needle at the inner wound edge • Aspirate • Inject agent into tissue SLOWLY • Wait… • After anesthesia has taken effect, suturing may begin
  75. 75. Wound Evaluation • • • • • Time of incident Size of wound Depth of wound Tendon / nerve involvement Bleeding at site
  76. 76. When to Refer • Deep wounds of hands or feet, or unknown depth of penetration • Full thickness lacerations of eyelids, lips or ears • Injuries involving nerves, larger arteries, bones, joints or tendons • Crush injuries • Markedly contaminated wounds requiring drainage • Concern about cosmesis
  77. 77. Contraindications to Suturing • • • • • • • • Redness Edema of the wound margins Infection Fever Puncture wounds Animal bites Tendon, verve, or vessel involvement Wound more than 12 hours old (body) and 24 hrs (face)
  78. 78. Closure Types • Primary closure (primary intention) – Wound edges are brought together so that they are adjacent to each other (re-approximated) – Examples: well-repaired lacerations, well reduced bone fractures, healing after flap surgery • Secondary closure (secondary intention) – Wound is left open and closes naturally (granulation) – Examples: gingivectomy, gingivoplasty,tooth extraction sockets, poorly reduced fractures • Tertiary closure (delayed primary closure) – Wound is left open for a number of days and then closed if it is found to be clean – Examples: healing of wounds by use of tissue grafts.
  79. 79. Wound Preparation • Most important step for reducing the risk of wound infection. • Remove all contaminants and devitalized tissue before wound closure. – IRRIGATE w/ NS or TAP WATER (AVOID H2O2, POVIDONE-IODINE) – CUT OUT DEAD, FRAGMENTED TISSUE • If not, the risk of infection and of a cosmetically poor scar are greatly increased • Personal Precautions
  80. 80. Basic Laceration Repair Principles And Techniques
  81. 81. Langer’s Lines
  82. 82. Principles And Techniques • Minimize trauma in skin handling • Gentle apposition with slight eversion of wound edges – Visualize an Erlenmeyer flask • Make yourself comfortable – Adjust the chair and the light • Change the laceration – Debride crushed tissue
  83. 83. Types of Closures ● Simple interrupted closure – most commonly used, good for shallow wounds without edge tension ● Continuous closure (running sutures) – good for hemostasis (scalp wounds) and long wounds with minimal tension ● Locking continuous - useful in wounds under moderate tension or in those requiring additional hemostasis because of oozing from the skin edges ● Subcuticular – good for cosmetic results ● Vertical mattress – useful in maximizing wound eversion, reducing dead space, and minimizing tension across the wound ● Horizontal mattress – good for fragile skin and high tension wounds ● Percutaneous (deep) closure – good to close dead space and decrease wound tension
  84. 84. Simple Interrupted Suturing • Apply the needle to the needle driver – Clasp needle 1/2 to 2/3 back from tip • Rule of halves: – Matches wound edges better; avoids dog ears – Vary from rule when too much tension across wound
  85. 85. Simple Interrupted Suturing Rule of halves
  86. 86. Simple Interrupted Suturing Rule of halves
  87. 87. Suturing • The needle enters the skin with a 1/4inch bite from the wound edge at 90 degrees – Visualize Erlenmeyer flask – Evert wound edges • Because scars contract over time
  88. 88. Suturing • Release the needle from the needle driver, reach into the wound and grasp the needle with the needle driver. Pull it free to give enough suture material to enter the opposite side of the wound. • Use the forceps and lightly grasp the skin edge and arc the needle through the opposite edge inside the wound edge taking equal bites. • Rotate your wrist to follow the arc of the needle. • Principle: minimize trauma to the skin, and don’t bend the needle. Follow the path of least resistance.
  89. 89. Suturing • Release the needle and grasp the portion of the needle protruding from the skin with the needle driver. Pull the needle through the skin until you have approximately 1 to 1/2inch suture strand protruding form the bites site. • Release the needle from the needle driver and wrap the suture around the needle driver two times.
  90. 90. Simple Interrupted Suturing • Grasp the end of the suture material with the needle driver and pull the two lines across the wound site in opposite direction (this is one throw). • Do not position the knot directly over the wound edge. • Repeat 3-4 throws to ensuring knot security. On each throw reverse the order of wrap. • Cut the ends of the suture 1/4-inch from the knot. • The remaining sutures are inserted in the same
  91. 91. Simple, Interrupted http://www.youtube.com/watch?v=PFQ5-tquFqY
  92. 92. The trick to an instrument tie • Always place the suture holder parallel to the wound’s direction. • Hold the longer side of the suture (with the needle) and wrap OVER the suture holder. • With each tie, move your suture-holding hand to the OTHER side. • By always wrapping OVER and moving the hand to the OTHER side = square knots!!
  93. 93. Two Handed Tie
  94. 94. Two Handed Tie
  95. 95. One-Hand Tie
  96. 96. One-Hand Tie
  97. 97. Continuous Locking and Nonlocking Sutures http://www.youtube.com/watch?v=xY4cAqk30K4 http://cal.vet.upenn.edu/projects/surgery/5000.htm
  98. 98. http://www.youtube.com/watch?v=sgOaBojcX-c
  99. 99. Vertical Mattress Good for everting wound edges (neck, forehead creases, concave surfaces)
  100. 100. http://www.youtube.com/watch?v=824FhFUJ6wc
  101. 101. Horizontal Mattress Good for closing wound edges under high tension, and for hemostasis.
  102. 102. Horizontal Mattress http://www.youtube.com/watch?v=9DdaooEXshk
  103. 103. http://www.youtube.com/watch?v=I7C7nsl5Tuk
  104. 104. Suturing - finishing • After sutures placed, clean the site with normal saline. • Apply a small amount of Bacitracin or white petroleum and cover with a sterile non-adherent compression dressing (Tefla).
  105. 105. Suturing - before you go… • Need for tetanus globulin and/or vaccine? – Dirty (playground nail) vs clean (kitchen knife) – Immunization history (>10 yrs need booster or >5 yrs if contaminated) • Tell pt to return in one day for recheck, for signs of infection (redness, heat, pain, puss, etc), inadequate analgesia, or suture complications (suture strangulation or knot failure with possible wound dehiscence) • It should be emphasized to patients that they return at the appropriate time for suture removal or complications may arise leading to further scarring or subsequent surgical removal of buried sutures.
  106. 106. Patient instructions and follow up care • Wound care – After the first 24-48 hours, patients should gently wash the wound with soap and water, dry it carefully, apply topical antibiotic ointment, and replace the dressing/bandages. – Facial wounds generally only need topical antibiotic ointment without bandaging. – Eschar or scab formation should be avoided. – Sunscreen spf 30 should be applied to the wound to prevent subsequent hyperpigmentation.
  107. 107. Suture Removal • Average time frame is 7 – 10 days – – – – – – FACE: 3 – 5 d NECK: 5 – 7 d SCALP: 7 – 12 days UPPER EXTREMITY, TRUNK: 10 – 14 days LOWER EXTREMITY: 14 – 28 days SOLES, PALMS, BACK OR OVER JOINTS: 10 days • Any suture with pus or signs of infections should be removed immediately.
  108. 108. Suture Removal • • • • Clean with hydrogen peroxide to remove any crusting or dried blood Using the tweezers, grasp the knot and snip the suture below the knot, close to the skin Pull the suture line through the tissue- in the direction that keeps the wound closed - and place on a 4x4. Count them. Most wounds have < 15% of final wound strength after 2 wks, so steri-strips should be applied afterwards.
  109. 109. Topical Adhesives • Indications: selection of approximated, superficial, clean wounds especially face, torso, limbs. May be used in conjunction with deep sutures • Benefits: Cosmetic, seals out bacteria, apply in 3 min, holds 7 days (5-10 to slough), seal moisture, faster, clear, convenient, less supplies, no removal, less expensive • Contraindicated with infection, gangrene, mucosal, damp or hairy areas, allergy to formaldehyde or cryanoacrylate, or high tension areas
  110. 110. Dermabond® • A sterile, liquid topical skin adhesive • Reacts with moisture on skin surface to form a strong, flexible bond • Only for easily approximated skin edges of wounds – punctures from minimally invasive surgery – simple, thoroughly cleansed, lacerations
  111. 111. Dermabond® • • • • Standard surgical wound prep and dry Crack ampule or applicator tip up; invert Hold skin edges approximated horizontally Gently and evenly apply at least two thin layers on the surface of the edges with a brushing motion with at least 30 s between each layer, hold for 60 s after last layer until not tacky • Apply dressing http://www.youtube.com/watch?v=oa13wriWTus&feature=related http://www.youtube.com/watch?v=YhyPxFsYtXk&NR=1
  112. 112. Follow Up Care with Adhesives • No ointments or medications on dressing • May shower but no swimming or scrubbing • Sloughs naturally in 5-10 days, but if need to remove use acetone or petroleum jelly to peel but not pull apart skin edges • Pt education and documentation
  113. 113. Biopsy Methods • Punch & Shave: http://www.youtube.com/watch?v=7CzDE ok8Wmo • Elliptical Excision: http://www.youtube.com/watch?v=BAhXu oB0wMo&feature=related
  114. 114. References • • • • • • • • • http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Han dout.pdf Thomsen, T. Basic Laceration Repair. The New England Journal of Medicine. Oct. 355: 17. Edgerton, M. The Art of Surgical Technique. Baltimore, Williams & Wilkins, 1988. www.uptodateonline.com; 2009, topic lacerations, etc. http://dermnetnz.org/procedures/pdf/suturing-dermnetnz.pdf http://www.mnpa.us/handouts/Session%2005%20%20%20%20Basic%20Suturing%20%202010%20MNPA.pdf http://www.practicalplasticsurgery.org/docs/Practical_01.pdf http://health.usf.edu/NR/rdonlyres/ABB54A41-80A1-4E2B-8AE87EB5D06CE8DF/0/wound_healing_manual.pdf Jackson, E. Wound Care – Suture, Laceration, Dressing: Essentials for Family Physicians. AAFP Scientific Assembly. 2010. http://www.aafp.org/online/etc/medialib/aafp_org/documents/cme/courses/c onf/assembly/2010handouts/071.Par.0001.File.tmp/071-072.pdf