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I recently received an email from a practicing emergency physician posing the question:

“I’ve been charged with revamping our suture supplies in a small critical access hospital. I’m a bit ashamed to be somewhat clueless as to needle types. I’ve always just viewed then in terms of “small versus big,” eyeballing them for the appropriate size. Never mind trying to understand the purposes behind different shapes of needles.

Now, however, I feel I should better understand these various options and aspects of suture material before I go ordering a bunch of potentially unneccessary or even incorrect needle shapes. Basically I’m looking for the best, most versatile materials and needle types, without mistakenly ordering seldom used types.

I do appreciate any help or advice you can provide. Thanks again for a great teaching site.”

Kyle Stevens, DO, FACEP
Medical Director, Emergency Department
Molokai General Hospital

Does your suture cart make sense?
Does your suture cart make sense?

Thanks Dr. Stevens! Many great questions packed in to this email. In this two-part post, I first discussed needles and suture types in general. In this part, I will discuss some considerations in stocking for your clinical setting; teach you how to read your suture packaging; and, summarize what I think is the ideal suture cart for the average ER or Urgent Care treating traumatic skin lacerations.

Sutures worth stocking

Please note, the list below is derived from my own research and understanding of current applications of suture types for use in emergency departments and urgent care settings.  This is not an endorsement of any particular manufacturer or specific suture type.  In fact, many of the sutures mentioned are only representative of a class of suture that can be used, and can easily be substituted with a like suture.  For example, vicryl is actually a trademarked polyglactin suture made by Ethicon.  While I will refer to it as vicryl for the remainder of the post, recognize that other synthetic absorbable sutures (such as Polysorb or Dexon) could easily be substituted.

The sutures below are categorized by anatomic region:

Face:

  • Epidermal closure: 5-0 nylon (high tension), 6-0 nylon (low tension), 6-0 fast absorbing plain gut (without planned removal)
  • Deep layer closure: 5-0 synthetic absorbable suture (eg vicryl, polysorb)
  • An adequate supply of single aliquots of tissue adhesive glue
  • An adequate supply of tissue adhesive tape, smaller size

Extremities/Trunk:

  • Epidermal closure: 4-0 nylon (or comparable non-absorbable suture for high tension), 5-0 nylon (for low tension), 4-0 and 5-0 vicryl rapide (without planned removal)
  • Deep layer closure: 4-0 synthetic absorbable suture (eg vicryl, polysorb)
  • An adequate supply of single aliquots of tissue adhesive glue
  • An adequate supply of tissue adhesive tape, larger size

Special situations:

  • Tongue lacs: 3-0 and 4-0 chromic gut suture
  • Nailbed lacs: for nailbed repair: 4-0/5-0/6-0 chromic gut
  • A thicker, stronger suture for special situations (such as tying in a chest tube) is useful to stock depending on volume of this procedure in your practice setting; 1-0 or 2-0 nylon is a good choice
  • A few 3-0 or 4-0 nylon sutures on a tapered needle point are handy for the emergency situation of a life-threatening hemorrhage from a dialysis fistula (the last think you want to do is enter a friable vessel wall with a cutting needle–see Part I for further explanation!)*
  • A colored suture for facial lacerations over hair bearing areas on the face, such as on the chin of a bearded person with black hair. Polypropylene (Prolene, dyed blue) is a good choice.

How much to stock

One of the first considerations in answering this question is to think about your particular work environment.  For instance, a ski clinic is likely to see a different distribution of laceration types than a tent at an outdoor music festival which will be different from an average community urgent care center.

But, all things being equal, studies historically show that 50% of lacerations in adults occur in the head and neck region; 35% in the upper extremities; and the remainder occur in the lower extremities.  This said, roughly half of your suture supply should be geared towards facial wounds, and the other half should be geared towards everything else.  Children, however, tend to have a relatively greater percentage of facial lacerations compared with adults, so this may not hold true in a pediatric ED or urgent care.

Restocking & Monitoring

No matter how you stock initially, an important point is that monitoring of your suture usage through an organized system is the best way to keep the supplies well-stocked, usable (suture material does have a shelf life), and avoid unnecessary stockades of seldom-used materials.  An ED manager or supply champion may be best suited for this role.  This interesting report details one nurse manager’s experience trying to organize and account for the sutures used in her hospital’s operating rooms.  The lessons learned are very generalizable to any ER or Urgent Care setting.

What is my suture package trying to tell me?

If you aren’t in charge of stocking, but want to make sure you are appropriately stocked, it pays to understand a little but about how to read suture packaging.  Grab a few sutures from your cart and take a look at the details on the package.  This schematic breaks down everything you need to know to understand your sutures, in terms of some of the important details we’ve discussed in this post.

Suture packaging, deconstructed.
Suture packaging, deconstructed.

Summary

While every practice setting is unique, general principles apply in terms of how to stock your department to be ready to handle commonly seen wounds.  A basic knowledge of needles and sutures most applicable to a given situation can help you as a clinician or manager to supply effectively and efficiently.

*Credit to Dr. Stevens who, after reading this post, suggested the need to stock a few sutures on taper needles for the unique situation of fistula/vessel ligation.  This is more pressing in a rural or austere practice setting. I appreciate any comments from other readers on can’t-forget-to-stock sutures I may have missed!

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