LEARNING OBJECTIVE: Recognize the different types of suture material and their uses; recall topical, local infiltration and nerve-block anesthetic administration procedures; and identify the steps in wound suturing and suture removal.

The care of the wound is largely controlled by the tactical situation, facilities available, and the length of time before proper medical care may be available. Normally, the advice to the medical technician regarding the suturing of wounds is DO NOT ATTEMPT IT. However, if  days are expected to elapse before the patient can be seen by a surgeon, the medical technician should know how to use the various suture procedures and materials, and how to select the most appropriate of both.

Before discussing the methods of coaptation (bringing together), some of the contraindications to wound closing should be described.


To a certain extent, firm pressure dressings and immobilization can obliterate hollow spaces. If tendons and nerves do not seem to be involved, absorbable sutures may be placed in the muscle. Be careful to suture muscle fibers end-to-end and to correctly appose them. Close the wound in layers. This is extremely delicate surgery, and the medical technician should weigh carefully the advisability of attempting it–and then only if he has observed and assisted in numerous surgical operations.

The area around the wound should be cleansed and then prepared with an antiseptic. The wound area should be draped, whenever possible, to maintain a sterile field in which the medical technician will work. The medical technician should wear a cap and mask, scrub his hands and forearms, and wear sterile gloves.

Suture Materials

In modern surgery, many kinds of ligature and suture materials are used. All can be grouped into two classes: non-absorbable sutures and absorbable sutures.

NONABSORBABLE SUTURES.—These are sutures that cannot be absorbed by the body cells and fluids in which they are embedded during the healing process. When used as buried sutures, these sutures become surrounded or encapsulated in fibrous tissue and remain as innocuous foreign bodies. When used as skin sutures, they are removed after the skin has healed. The most commonly used sutures of this type and the characteristics associated with each are listed below.

ABSORBABLE SUTURES.—These are sutures that are absorbed or digested during and after the healing processes by the body cells and tissue fluids in which they are embedded. It is this characteristic that enhances their use beneath the skin surfaces and on mucous membranes.

Surgical gut fulfills the requirements for the perfect sutureease of manufacture, tensile strength, and variety available more often than any other material.

Table 4-3.—Absorption Times of Various Types of Surgical Gut

Type Gut Absorption Time
A: Plain 10 days
B: Mild chromic 20 days
C: Medium chromic 30 days
D: Extra chromic 40 days

Suture Needles

Suture needles may be straight or curved, and they may have either a tapered round point or a cutting edge point. They vary in length, curvature, and diameter for various types of suturing. Specific characteristics of suture needles are listed below.

Preparation of Casualty

Before suturing the wound(s) of any victim, the following steps should be taken to prepare the casualty.

  1. Examine the casualty carefully to determine what materials are needed to properly close the wound.
    1. Select and prepare sterile instruments, needles, and suture materials.
    2. Position the patient securely so that access to the wound and suture tray is optimal. It is usually not necessary to restrain patients for suturing.
    3. Make sure a good light is available.
  2. Strictly observe aseptic wound preparation. Use mask, cap, and gloves. Thorough cleaning and proper draping are essential.
  3. Select an anesthetic with care. Consider the patient’s tolerance to pain, time of injury, medications the patient is taking or has been given, and the possible distortion of the tissue when the anesthetic are infiltrated.

SELECTION OF ANESTHESIA.—The most common local anesthetic used is Xylocaine®, which comes in various strengths (0.5%, 1%, 2%) and with or without epinephrine. Injectables containing epinephrine must never be used on the fingers, toes, ears, nose – any appendage with small vessels – because of the vasoconstricting effect of the epinephrine. Epinephrine is also contraindicated in patients with hypertension, diabetes, or heart disease.

The three methods of anesthestia administration are topical, local infiltration, and nerve block. Topical anesthetics are generally reserved for ophthalmic or plastic surgery, and nerve blocks are generally accomplished by an anesthesiologist or anesthetist for the surgical patient. For a medical technician, topical anesthesia is limited to the instillation of eye drops for mild corneal abrasions after all foreign bodies have been removed. DO NOT attempt to remove embedded foreign bodies. Nerve blocks are limited to digital blocks wherein the nerve trunks that enervate the fingers or toes are anesthetized. The most common method of anesthesia used by a medical technician is the infiltration of the anesthetizing agent around a wound or minor surgical site.

ADMINISTRATION OF ANESTHESIA.— Performing a digital block is a fairly simple procedure, but it should not be attempted except under the supervision of a physician or after a great deal of practice. The first step is cleansing the injection site with an antiseptic solution. The anesthetizing agent is then infiltrated into the lateral and medial aspects at the base of the digit with a small bore needle (25- or 26-gauge), taking care not to inject into the veins or arteries. Proper placement of the anesthesia should result in a loss of sensitivity in a few minutes. This is tested by asking the patient if he can distinguish a sharp sensation or pain when a sharp object is gently applied to the skin.

Administering local anesthesia is similar except you are anesthetizing nerves immediately adjacent to where you will be working instead of nerve trunks. There are two generally accepted methods of infiltrating the anesthesia. One is through the skin surrounding the margin of the wound and the other is through the wound into the surrounding tissue. In either case, sufficient quantities must be infiltrated to effect anesthesia approximately 1/2 inch around the wound, taking care not to inject into a vein or artery.


The maximum recommended amount of Xylocaine to be used is 50 cc for a 1% solution or the equivalent.

General Principles of Wound Suturing

Wounds are closed either primarily or secondarily. A primary closure takes place within a short time of when the wound occurs, and it requires minimal cleaning andpreparation. A secondary closure, on the other hand, occurs when there is a delay of the closure for up to several days after the wound's occurrence. A secondary closure requires a more complex procedure. Wounds 6 to 14 hours old may be closed primarily if they are not grossly contaminated and are meticulously cleaned. Wounds 14 to 24 hours old should not be closed primarily. When reddening and edema of the wound margins, discharge of pus, persistent fever, or toxemia are present, do not close the wound.

Do not use a primary closure for a large, gaping, soft-tissue wound. This type of wound will require warm dressings and irrigations, along with aseptic care for 3 to 7 days to clear up the wound. Then a secondary wound closure may be performed.

The steps to perform a delayed wound closure are outlined below.

  1. Debride the wound area and convert circular wounds to elliptical ones before suturing. Circular wounds cannot be closed with satisfactory cosmetic results.
  2. Try to convert a jagged laceration to one with smooth edges before suturing it. Make sure that not too much skin is trimmed off; that would make the wound difficult to approximate.
  3. Use the correct technique for placing sutures. The needle holder is applied at approximately one-quarter of the distance from the blunt end of the needle. Suturing with a curved needle is done toward the person doing the suturing. Insert the needle into the skin at a 90° angle, and sweep it through in an arclike motion, following the general arc of the needle.
  4. Carefully avoid bruising the skin edges being sutured. Use Adson forceps and very lightly grasp the skin edges. It is improper to use dressing forceps while suturing. Since there are no teeth on the grasping edges of the dressing forceps, the force required to hold the skin firmly may be enough to cause necrosis.
  5. Do not put sutures in too tightly. Gentle approxi­mation of the skin is all that is necessary. Remember that postoperative edema will occur in and about the wound, making sutures tighter. Figure 4-33 illustrates proper wound-closure techniques.

    Figure 4-33.—Suturing.

  6. If there is a significant chance that the sutured wound may become infected (e.g., bites, delayed closure, gross contamination), place an iodoform (anti-infective) in the wound. Or place a small rubber drain in the wound, and remove the drain in 48 hours.
  7. When suturing, the best cosmetic effect is obtained by using numerous interrupted simple sutures placed 1/8 inch apart. Where cosmetic result is not a consideration, sutures may be slightly farther apart. Generally, the distance of the needle bite from the wound edges should be equal to the distance between sutures.
  8. When subcutaneous sutures are needed, it is proper to use 4-0 chromic catgut.
  9. When deciding the type of material to use on skin, use the finest diameter that will satis­factorily hold the tissues. Table 4-4 provides guidance as to the best suture to use in selected circumstances.

    Table 4-4.—Suture Guide

    Wound Suture Material/Size
    Children under 3 years 6-0
    All other faces 5-0
    Body 4-0
    Feet, elbows, knees #34 or #36 wire, or 4-0
    Child’s scalp 4-0
    Adult’s scalp 3-0
    Lip 6-0 or 5-0


  10. When cutting sutures, subcutaneous catgut should have a 1/16-inch tail. Silk skin sutures should be cut as short as is practical for removal on the face and lip. Elsewhere, skin sutures may have longer tails for convenience. A tail over 1/4 inch is unnecessary, however, and tends to collect exudate.
  11. The following general rules can be used in deciding when to remove sutures:
    1. Face: As a general rule, 4 or 5 days. Better cosmetic results are obtained by removing every other suture and any suture with redness around it on the third day and the remainder on the fifth day.
    2. Body and scalp: 7 days.

    3. Soles, palms, back, or over joints: 10 days, unless excess tissue reaction is apparent around the suture, in which case they should come out sooner.

    4. Any suture with pus or infection around it should be removed immediately, since the suture's presence will make the infection worse.

When wire is used, it maybe left in safely for 10to 14 days.


Many kinds of accidents cause injuries to bones, joints, or muscles. In giving first aid or emergency treatment to an injured person, you must always look for signs of fractures (broken bones), dislocations, sprains, strains, and contusions.

An essential part of the emergency treatment for fractures consists of immobilizing the injured part with splints so that the sharp ends of broken bones will not move around and cause further damage to nerves, blood vessels, or vital organs. Splints are also used to immobilize severely injured joints or muscles and to prevent the enlargement of extensive wounds. You must have a general understanding of the use of splints before going on to learn the detailed first aid treatment for injuries to bones, joints, and muscles.