What is the best type of suturing technique for wound laceration in an emergency setting?

Best Suturing Technique for Emergency Wound Laceration Closure

For emergency laceration repair, use slowly absorbable monofilament sutures with a simple interrupted or continuous technique, prioritizing tissue adhesives (octyl cyanoacrylate) for low-tension wounds to minimize pain and reduce procedure time.

Suture Material Selection

The optimal suture material for emergency laceration closure is slowly absorbable monofilament suture, which maintains adequate tensile strength during the critical 2-4 week wound healing period while eventually being absorbed by the body 1, 2.

Key Material Characteristics:

• Monofilament sutures significantly reduce incisional hernia risk compared to multifilament sutures in emergency settings, with 96.8% expert agreement and high-quality evidence (Level 1A) 1
• Slowly absorbable sutures maintain tensile strength of 171-182 N between days 14-28, which is critical for proper wound healing 2
• Antimicrobial-coated (triclosan-impregnated) sutures should be used when available, as they reduce surgical site infection rates significantly (OR 0.62,95% CI 0.44-0.88) in clean, clean-contaminated, and contaminated wounds 1, 2

Common Pitfall:

Avoid rapidly absorbable sutures for deep tissue closure, as they lose tensile strength before adequate wound maturation occurs, increasing complication risk 2

Suturing Technique

The simple interrupted technique is most commonly employed by emergency physicians and surgeons (>50% preference) for versatility across wound types 3.

Technical Specifications:

• Use the "small bite" technique (approximately 5mm from wound edges, 5mm between stitches) when performing continuous closure, as this reduces wound complications and incisional hernia rates 1
• Maintain a suture-to-wound length ratio of at least 4:1 for continuous closures to minimize complications 2
• The small bite technique includes only aponeurosis/fascia, avoiding fat and muscle inclusion that can lead to tissue devitalization and infection 1

Alternative Techniques by Clinical Context:

• Subcuticular continuous sutures are the second most common technique, particularly useful for cosmetically sensitive areas 3
• Vertical mattress sutures provide excellent wound edge eversion for areas under tension 3

Non-Suture Closure Options

Tissue adhesives (octyl cyanoacrylate) are superior for appropriate wounds, providing essentially painless closure for low-tension lacerations 1.

Advantages of Tissue Adhesives:

• Reduce ED length of stay by 26 minutes (95% CI 9-44 minutes) compared to sutures/staples 4
• Used in approximately 1 of 4 ED wound closures nationally 4
• Eliminate pain and anxiety associated with suture removal 1
• Significantly better than sutures for minimizing dehiscence (RR 3.35,95% CI 1.53-7.33) 2

When to Use Tissue Adhesives:

• Simple, linear lacerations under low tension 1, 4
• Facial wounds where cosmesis is important 1
• Pediatric patients to avoid removal-related anxiety 1

Contraindications for Tissue Adhesives:

• High-tension wounds 5
• Complex, nonlinear lacerations 5
• Wounds involving fingers, hands, scalp (high-movement areas), face with tension, or intraoral locations 5

Pain Management During Repair

Apply topical anesthetic (LET: lidocaine, epinephrine, tetracaine) at triage to provide excellent wound anesthesia in 20-30 minutes before repair 1.

Anesthetic Protocol:

• LET dosing: 3 mL for children >17 kg; 0.175 mL/kg for children <17 kg 1
• Place on open wound with occlusive dressing for 10-20 minutes until wound edges blanch 1
• For urgent situations requiring immediate infiltration: buffer lidocaine with bicarbonate, warm before injection, and inject slowly with small-gauge needle to minimize pain 1

Special Considerations for Pediatric Patients

• Use absorbable sutures for facial wounds to avoid the pain and anxiety of suture removal 1
• Tissue adhesives or Steri-Strips provide painless closure and are preferred when appropriate 1
• Topical anesthetics are safe even in neonates and preterm infants with appropriate dosing 1

Suture Removal Timing

Non-absorbable transcutaneous sutures should be removed 7-9 days post-repair to balance adequate wound healing with complication prevention 6. Removal before 7 days increases dehiscence risk, particularly in patients with obesity or diabetes 6.