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Question about suturing

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Hey everyone, currently on an EM rotation and had a question about controlling bleeding while suturing.

 

I had a few lacs recently that were bleeding so much that I constantly had to keep wiping the wound with gauze and it was preventing me from getting a good view at the laceration.

 

Is there anything I can do to help control the bleeding to make suturing easier? I know I can try epi, but didn't want to use it on a finger lac..

 

Also, is it OK if the wound is still bleeding after I finish placing the sutures?

 

THANKS

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A patient once came in with a bleeding finger lac that he placed a tourniquet on proximal to the wound while at home. Foolish student in me took the tourniquet off and it bled worse. So I directly applied pressure with my off hand, dabbed it to get a quick glimpse and placed my first suture. Each suture I placed progressively decreased the bleeding until the repair was complete.

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Finger tourniquet and fast suturing.   May need additional sutures or pressure dressing.  All bleeding eventually stops as they say. 

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Within reason (and depending upon the nature of the tissue involved) it is usually good practice to get a fairly dry field. If you trap a hematoma it might get infected.

 

As folks above have noted, well-placed sutures will usually gradually achieve hemostasis. Just don't crush the heck out of the wound edge hoping to stop bleeding - you need some capillary flow along the edge to get the healing process going. For messier stuff:

  • I have very rarely had to use a throw away pen-tip cautery in the ER. It can work well on small "pumpers."
  • One or twice I did a stick tie on a small, severed superfical vessel.
  • A light pressure dressing/ACE wrap for the first day can help prevent a hematoma.
  • I haven't used finger tourniquets much. There are some commercial ones that work pretty well. I was always concerned about crushing nerves with a penrose and a clamp. One trick it to put a sterile surgical glove on the affected hand, snip the glove tip off on the affected finger, and then roll the glove finger down to the base of the finger.

I have never used lido with epi. No good reason. I never really had a need, and I hate seeing blanched wound edges. The plastics guys use it all the time so my fear is irrational. I would never use it in any appendage that sticks out or in a wound flap.

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1/4" Penrose fixes all bleeding ills.  Problem bleeder in other areas?  Practice your iceskating skills and throw in a figure eight, even if you can't see the source.  While plastics will now tell you that you can use epi, if you can obtain adequate hemostasis why poke the bear with a stick and even raise the question?

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For wedge resection of ingrown toenails, I use a penrose and hemostat as tourniquet and job the start time down on something - table paper, something. Try to keep it under 8 minutes tops - usually five. I put it on before the ring block and it keeps the meds down in the distal toe. NEVER epi on fingers, nose, penis toes - not in my world. Plastics can go out on that limb if they like.

 

For bleeding wounds that are hard to get closed due to bleeding into the field - Pressure, irrigation. Even irrigated with lido w epi on small wounds to get the epi local. Use a quick figure of 8 or mattress if needed to close gaping and get some pressure. If the wound is big enough to see the bleeder and it is venous - zap it with cautery stick or grab it with hemostat if absolutely necessary.  Never a problem to throw in a stitch and then pull it once you have approximation and the wound is aligned decently. All the patient will ever see if the final stitch closure and alignment is key. Not possible with chain saws and other serrated implements....

 

Have the patient with the hand elevated - on top of their head - while applying pressure before you even get to the room. Gravity is wonderful. Or elevate the extremity if possible. 

 

Remember to look at their blood pressure and meds, too. Just like a nosebleed - you can't hope for hemostasis if they are 190/110 or on coumadin.

 

Tired old 2 cents.................

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For those who may (or may) not care, I had a SP that self injected an Epi-pen into their thumb. No sequela though no consistent treatment recommendation (UC and an ED physician) until they spoke with hand directly who said not to worry about.

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A bloodless field is key with hand/finger lacerations to avoid missing things like tendon injuries or foreign bodies.  In our department we use a commercial finger tourniquet called the Tourni-Cot which works very well ( http://www.medline.com/product/Tourni-Cot-Tourniquet-by-Mar-Med-Co/Z05-PF31078).  If you don't stock these, I'll apply a manual BP cuff to the forearm and crank the pressure high enough to act as a temporary tourniquet.  Just have the patient pinch off the tubing to prevent pressure loss, and keep an eye on the clock!

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Epinephrine in fingers/toes is fine...short list of references below.  Another myth right there up there with CVP as an effective tool for fluid volume status. (52% AUC)

Muck AE, Bebarta VS, Borys DJ, Morgan DL: Six years of epinephrine digital injections: Absence of significant local or systemic effects. Ann Emerg Med 2010;56():270-274

Fitzcharles-Bowe C, Denkler K, Lalonde D: Finger injection with high-dose (1:1,000) epinephrine: Does it cause finger necrosis and should it be treated? Hand (N Y) 2007;2():5-11

Denkler KA: A comprehensive review of epinephrine in the finger: To do or not to do. Plast Reconstr Surg 2001;108():114-124

http://www.cochrane.org/CD010645/ANAESTH_use-of-adrenaline-with-lidocaine-for-surgery-on-fingers-and-toes

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General Surgeon I work with has stated that using epi in areas of terminal circulation is fine also. One of those oldschool things that will never die though.

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