How to Read an EKG Rhythm Strip

How to Read an EKG Rhythm Strip

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Learning how to read an EKG rhythm strip is an essential skill for nurses!

This skill becomes especially handy for nurses on Med-Surg, Telemetry, the Emergency Department, or Critical Care units.

If reading an EKG rhythm strip is new to you – this is the perfect place to start!

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What is a Rhythm Strip?

An EKG or ECG stands for Electrocardiography, which is the electrical activity of the heart traced on paper (or a monitor).

A rhythm strip is at least a 6-second tracing printed out on graph paper which shows activity from one or two leads.

Leads are “views” of the heart. There are 12 leads that are traditionally obtained with a 12-lead EKG, but most portable and bedside monitors only monitor 3-5 leads at a time.

Luckily – interpreting a single rhythm strip is much easier than a 12-lead EKG. Most rhythm strips are interpreted from Lead II as this gives a great view of the heart.

The goal of reading an EKG rhythm strip is to determine the rate and rhythm of the patient. This is great for identifying baseline cardiac rhythm as well as any arrhythmias or ectopy that may occur (like a premature beat).

A 12-lead EKG also looks at the rate and rhythm, but additionally gives nearly a complete 360° view of the heart.

This means it can be used to assess for things like cardiac ischemia or infarction, conduction delays, and even enlarged chamber size.

The ECG Rhythm Strip Tracing

As I said earlier – an ECG Rhythm tracing is the electrical activity of the heart recorded on paper or a monitor.

This is traditionally printed out on a 6-second strip. This can make it easy to determine the rate of an irregular rhythm if it is not given to you (count the complexes and multiply by 10).

Thick black lines are printed every 3 seconds, so the distance between 3 black lines is equal to 6 seconds.

As you can see, a printed ECG rhythm strip is comprised of boxes – both small boxes and large boxes. 5 small boxes make up one large box.

Each small box is 1mm wide, signifying 0.04 seconds or 40 milliseconds (ms).

Each large box is 5 small boxes, signifying 0.20 seconds or 200ms.

This becomes important to remember when determining the rate of regular rhythms. The boxes and lines are also important in recognizing whether a rhythm is regular or irregular.

The PQRST

Okay so that covers the paper, but what about the actual tracings? That’s where the alphabet comes into play. By alphabet – I mean PQRST.

An electrical tracing of the heart is made up of waves, lines, complexes, and intervals, and each of these represents specific conduction within the heart. This is the key to interpreting a rhythm strip.

P WAVES

P waves represent atrial depolarization. This means that the electrical signal that starts in the SA node (the normal pacemaker of the heart) is traveling through both atria (top chambers of the heart) during the P wave.

A P wave should look smooth and upright in most leads including lead II.

The 3 things you’ll want to specifically look for in P waves in a rhythm strip are:

  • Are there P waves before each QRS complex?
  • Are there any P waves that do not have a QRS complex that follows?
  • Do all the P waves look the same / have the same shape?

Keeping these 3 questions in mind will help you determine where the rhythm originates from (i.e. the sinus node), if there are any potential extra beats, or if there could be certain heart blocks present.

An inverted P wave means there is anterograde conduction to the atria (backwards direction). This means the electrical impulse originates from near, at, or below the AV node. Examples of this include Junctional rhythm, certain PACs, and PJCs.

QRS COMPLEXES

The QRS complex represents ventricular depolarization. This means that the electrical signal is traveling through both ventricles (the bottom chambers of the heart). In a healthy heart – this should correlate with the pulse.

The QRS complex is actually made up of 1-3 waves, the Q wave, the R wave, and the S wave. Depending on which lead you look at and the specific heart, any combination of these waves may be present.

In lead II, usually all three waves are present. This includes an initial downward deflection (Q wave), an upward deflection (R wave), followed by a downward deflection (S wave).

The presence of a QRS complex indicates that the ventricles are receiving the electrical signal. These should follow shortly after a P wave in a sinus rhythm.

The main abnormality that can occur is a wide QRS complex. This either means that there is aberrant conduction (like a bundle branch block), or that the electrical signal starts in either the left or right ventricle (i.e. a PVC or Ventricular Tachycardia).

A bundle branch block just means there is a delay in the conduction tissue transmitting the signal to either the right or left ventricle. If the widened QRS is preceded by a P wave, it is probably a sinus rhythm with a BBB.

If there is no preceding P wave, you may have a PVC or even VTACH if it is sustained.

T WAVES

The T wave represents ventricular repolarization. This means that the myocardial cells within the ventricles are recovering and “getting ready for the next beat”.

This should be smooth and upright in most leads, including lead II.

Sometimes, the T wave can be inverted or flipped. This is nonspecific but can indicate cardiac ischemia or infarction, especially if it is in at least 2 contiguous leads (pertaining to the same anatomical area of the heart).

People may have flipped waves in certain leads at baseline after a heart attack, with a bundle branch block, or with a PVC, VTACH, or ventricular paced rhythms.

Tall or tented T waves are those that are > 1 large box in lead II and may be particularly pointed. This could be normal for the patient, but can also indicate hyperkalemia (high potassium).

PR INTERVAL

The PR interval is from the beginning of the P wave to the beginning of the QRS complex. This represents the time it takes for the electrical signal to reach the ventricles from the SA node.

This should be 3-5 small boxes or 120-200ms. If longer, this is considered a first degree AV block.

A short PR interval could be from a a PAC, a junctional rhythm (associated with an inverted P wave), or Wolff-Parkinson-White syndrome.

QT INTERVAL

The QT interval is the time between the start of the QRS complex to the end of the T wave. This will change depending on the heart rate, so a QTc (QT corrected) is calculated.

This should be 350-440ms in men, and 350-460ms in women. A QT interval >500ms predisposes the patient to deadly ventricular arrhythmias such as Torsades de Pointes.

QT prolongation can be caused by ischemia, electrolyte abnormalities, or from medications such as psych medications, Zofran, Azithromycin, Cipro, etc.

While you can calculate the QT interval from a single strip, a 12-lead EKG should be obtained and it will be listed on the EKG for you. Otherwise, there are online calculators which can be used to determine the corrected QT interval for the heart rate.

Arrhythmias on the ECG Rhythm Strip

An arrhythmia is any abnormal rhythm other than normal sinus rhythm – the baseline rhythm of the heart. This can be a benign variant (like sinus arrhythmia), or it could be deadly (like ventricular fibrillation).

In order to know how to read an EKG rhythm strip, you need to first be able to understand what normal sinus rhythm (NSR) looks like.

You should be comparing every rhythm strip to NSR. Recognizing where the rhythm differs from NSR will help you identify the rhythm.

Normal Sinus Rhythm (NSR)

Normal sinus rhythm is the gold standard. This is what a normal functioning heart beat should look like.

The “sinus” in the name indicates that the electrical signal is coming from the Sinoatrial node (SA node), the “normal” pacemaker of the heart.

The presence of sinus rhythm means the cardiac conduction system is functioning appropriately (although certain blocks may still be present).

The rate of NSR is 60-100 bpm.  Slower is sinus bradycardia, and faster is sinus tachycardia. This just means that the heart is functioning at altered rates, possibly due to sleep, medications, infection, exercise, etc.

All sinus rhythms should be regular, meaning each of the QRS complexes are mapping out.

You can do this by measuring the R-R interval between any two beats, and then making sure the R-R interval stays constant throughout the strip. Some people use calipers, but I recommend a good old-fashioned alcohol pad or piece of paper and a pen.

Additionally, a P wave should precede each QRS complex.

The QRS complex should be narrow unless there is a bundle branch block present.

The ECG Rhythm Strip Interpretation

To read an EKG rhythm strip, you should do so in a systematic way, so that you don’t miss anything.

  1. Is the rhythm regular? Is every R-R interval equal?
  2. What’s the rate? This is usually printed for you
  3. P wave: Are there P waves before every QRS?
  4. PR interval: Is it wide >200ms?
  5. QRS: Is the QRS narrow or wide (>100-120ms)?
  6. T waves: Are the T waves upright and normal-appearing?

Using this systematic approach should help you interpret what each rhythm is. But you need to be familiar with most of the arrhythmias out there.

Systematic approach to reading a rhythm strip

Other Sinus Rhythms

Other sinus rhythms are rhythms that may still “normal”. I include paced rhythms in this section as this replaces NSR once a pacemaker is placed.

Sinus Bradycardia (SB)

Sinus bradycardia is the same as NSR, but the HR is <60bpm.

This can be normal for well-conditioned individuals like athletes, can be normal if the patient is on a beta-blocker or similar medication, and can also be normal while sleeping.

The most important thing when the patient has SB is

  1. Is it new or severe (<40bpm or so)
  2. Are they symptomatic? (dizziness, lightheadedness, syncope, SOB, chest pain, etc)

Since this is often a normal variant – if the patient is asymptomatic there’s usually nothing that needs to be done.

Make sure a slow HR is actually SB and not a heart block!

Sinus Tachycardia (ST)

Sinus tachycardia is the same as NSR, but the HR is >100bpm and usually <150bpm, at least while at rest.

This can often be seen with exercise, but ST at rest often indicates anxiety, certain drugs, sepsis, dehydration, or volume loss. ST is usually a response to an underlying cause within the body.

You never treat the ST, but rather treat the underlying issue (i.e. give fluids with volume depletion).

Paced Rhythm

Paced rhythms will look different depending on the location of the leads. If the lead is in the right atria, the rhythm will appear like NSR but with a pacer spike before the P wave.

If the lead is in the right ventricle, it will look like a slow VTACH with a pacer spike before the QRS. There can also be both of these at the same time.

Some monitors only show the pacer spike if you turn that function on – if you see a very slow VT – ask the patient if they have a pacemaker and adjust the monitors appropriately.

Other Cardiac Arrhythmias

Heart Blocks

Heart blocks are when there is significant delay or blockage in transmitting the signal from the atria to the ventricles. This is usually associated with a junctional or ventricular escape rhythm.

First degree AV block is generally “no big deal” and common in older age and with beta-blockers. The PR interval is consistently >200ms.

Second degree type 1 AV block or Wenckebach, is when there is a progressive lengthening of the PR interval which eventually leads to a dropped QRS complex.

Second degree type 2 AV block or Mobitz II is when there is a consistent PR interval but QRS complexes are randomly dropped.

Third degree AV block or complete heart block is when there is complete dissociation of the atria and the ventricles.

Atrial Fibrillation (AF)

Atrial Fibrillation is a very common type of arrhythmia that you will definitely run into in the hospital. AF could be new-onset, RVR (rapid ventricular response), could be intermittent (paroxysmal), or chronic/persistent.

AF is an irregularly irregular rhythm, meaning that there is no rhyme or reason for the regularity of each QRS complex.

This is usually from a structurally diseased heart where both atria are quivering rapidly, termed fibrillation. This leads to fast ventricular rates (AF RVR), as well as poor blood flow through the atria – predisposing the patient to blood clots.

This is why these patients are started on rate-control medications such as metoprolol or Cardizem, and usually anticoagulants like heparin, Eliquis, etc.

AF will not have p waves but instead, have a fibrillatory baseline. The QRS complexes will usually be narrow, and will not map out with each other in any way.

Rates >100bpm are considered AF RVR.

Atrial Flutter

Atrial Flutter (Aflutter) is similar to Atrial fibrillation and is treated largely the same.

This is when the atria aren’t fibrillating but rather “fluttering”. This is usually from a reentrant loop near the AV node.

This will usually lead to a conduction ratio of 2:1, and a HR around 150bpm. Conduction ratios can be 3:1 (100bpm), 4:1 (75bpm) and variable as well.

You will see saw-tooth P waves termed “f waves”. Depending on the conduction ratio, you will see 2 (3 or 4) F waves per QRS complex. Aflutter is usually regular.

Supraventricular Tachycardia (SVT)

Supraventricular Tachycardia is an umbrella term referring to any fast tachycardia that originates above the ventricles. However, in clinical terms, this usually refers to AV Nodal Reentrant Tachycardia (AVNRT).

This occurs when there is an abnormal pathway of conduction tissue near/within the AV node, termed a “reentrant loop”.

If a PAC or PVC comes at the wrong time, this can send the electrical signal around and around this loop of conduction tissue, leading to very fast heart rates.

SVT can be as “slow” as 140bpm to as fast as 220bpm. The faster the heart rate, the more symptomatic the patient usually is.

In SVT, P waves are usually not present, there is usually ST depression, and the rhythm is regular with narrow QRS complexes.

Treatment for this involves vagal maneuvers and often adenosine or Cardizem.

Ventricular Tachycardia (VTACH or VT)

Ventricular Tachycardia is a fast tachyarrhythmia originating within the ventricles. This leads to very fast heart rates with or without a perfusing rhythm.

This means the patient may not have a pulse and may be a code blue. Either way, VT is a very serious arrhythmia.

VT is usually caused by Coronary heart disease, like a previous or current MI.

The rhythm is regular, and the rate is anywhere from 100-330bpm, and the QRS complex is wide (>140ms).

P waves are usually absent or undetectable, but 60% of cases can have AV dissociation present.

If there is no pulse, you use ACLS cardiac arrest algorithm.

If there is a pulse, you utilize the ACLS Adult tachycardia with a pulse algorithm.

Ventricular Fibrillation (VF or VFIB)

Ventricular Fibrillation is a deadly ventricular arrhythmia. There will not be a pulse, and the patient will be coding.

VF is a similar concept as AF, except the ventricles are the ones fibrillating. Coronary artery disease is again one of the main causes of VF. Severe electrolyte abnormalities can also cause VF.

VF is irregular and has no pattern. There is either coarse or fine fibrillation, eventually degenerating into asystole if not shocked back into a normal rhythm.

These patients need fast defibrillation, high-quality CPR, Epinephrine, antiarrhythmics, etc (Code blue algorithm).

Asystole

Asystole is the absence of cardiac activity. This is essentially a straight wavy line but may have occasional p waves initially. The patient is dead. Follow ACLS algorithms as above.

Pulseless Electrical Activity (PEA)

PEA appears like a normal rhythm (Usually NSR or SB), but there is no actual mechanical contraction (no pulse). The patient will be unresponsive, pulseless, and this is a code blue as well (follow ACLS).

Want to learn more?

Hopefully this gave you a good idea about how to read an EKG rhythm strip. Unfortunately, I couldn’t include every single arrhythmia or detail, but this definitely should give you a good understanding of the basics!

If you want to learn more, I have a complete video course “ECG Rhythm Master”, made specifically for nurses which goes into so much more depth and detail.

With this course you will be able to:

  • Identify all cardiac rhythms inside and out
  • Understand the pathophysiology of why and how arrhythmias occur
  • Learn how to manage arrhythmias like an expert nurse
  • Become proficient with emergency procedures like transcutaneous pacing, defibrillation, synchronized shock, and more!

I also include some great free bonuses with the course, including:

  • ECG Rhythm Guide eBook (190 pages!)
  • Code Cart Med Guide (code cart medication guide)
  • Code STEMI (recognizing STEMI on an EKG)

You can use the code “SPRING2021” for a limited time 15% discount, exclusive to my readers!

Check out more about the course here!

You may also like:

Heart Blocks EKG Rhythm Infographic

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How to Start an IV

How to Start an IV

*This post may contain affiliate links. Please see my affiliate disclosure for more information*

Learning how to start an IV is a very important skill that every nurse needs to know. Inpatient and ER nurses deal with IVs every day – whether they are inserting them, removing them, or administering fluids or medications through them. If you are new to nursing, then you will need to learn how to insert an IV with confidence and knowledge!

How to start an IV: Feat

When to put in an IV

The short answer to this is “when an IV is ordered”. However, it is important to critically think as a nurse, and anticipate what will need to be done. Especially as an ER nurse, you may see your patient before the Provider and can start placing an IV if indicated.

If you work as an inpatient nurse, most patients should have at least an IV, midlines, PICC lines, or other central access. These IVs often go bad, and you will need to know how to start an IV in these settings as well.

Indications for an IV:

  • IV fluids or medications – this is the usual reason
  • Diagnostic Imaging – CTs or MRIs often require an IV for IV contrast to help visualize the anatomy and any potential pathology
  • Inpatient Admission – usually required unless refusal

Contraindications:

There is no outright contraindication to placing an IV, but certain factors will exclude specific locations. These include extremities with:

  • AV Fistulas or grafts (dialysis patients)
  • Previous mastectomy or lymph node dissection
  • Blood clots
  • Significant burns or edema
  • Overlying infection (cellulitis)

It may be best to avoid limbs with significant motor or sensory deficits, as there is unclear evidence that may suggest increased DVT in these extremities. If their arm is numb, they also may not feel when it is infiltrated.

Choosing the IV Size

The IV gauge will determine how big the actual needle and catheter are. The bigger the IV – the faster fluid can be administered. Unfortunately, bigger sizes are also more painful and usually more difficult to insert. Bigger IVs also come with increased risk of phlebitis and can cause some serious irritation to the vein.

24 gauge: The Baby Needle

These are typically used for babies and generally should be avoided in adults. They are very short, flimsy, and won’t last long.

  • Good for: Infants
  • Bad for: Most other scenarios

22 gauge: The Safe Choice

This is used for many kids and adults, especially older adults with fragile “easily-blown” veins. These are usually OK for IV contrast dye as well, but not for CTA. These are also generally easier to place.

  • Good for: Peds, many Med-Surg adult patients, easily blown veins
  • OK for: IV contrast, blood return
  • Bad for: Massive trauma or fluid resuscitation needs, CT Angiography

20 gauge: The One-Size-Fits-All

20g IVs are an ER nurse’s best friend. This is because a 20g IV is adequate for multiple fluid boluses, IV medication infusions, and most CTA requirements. They often give great blood return and labs can often be drawn without hemolysis.

  • Good for: Most adult patients, CT Angiography
  • OK for: Emergency situations (code blues, RRTs)
  • Bad for: Massive trauma or fluid resuscitation needs

18 gauge: The Big Daddy

18g IVs are your standard “large bore” IV. These are great in critical situations as they provide for rapid administration of fluids or blood products, rapid infusion of critical medications. The down-side is they tend to be a little more difficult to place in the absence of large veins.

  • Good for: Critical or emergency situations, rapid fluid administration, CTA, severe sepsis, burns, acute MI, etc
  • Bad for: Small, fragile veins

14-16g: The Monsters

The 16g and 14g IVs are very large, and unnecessary for most indications. However, in critical situations these may serve you well.

  • Good for: Rapid fluid resuscitation or critical situations as above
  • Bad for: Small veins – Unnecessary for most indications

Clinical Tip: Some nurses may tell you to place the largest IV catheter that the vein can support. However, this is contrary to good nursing judgment. If you ask my friend Brian (@TheIVGuy), he will tell you that you should choose your size based on the appropriate ordered therapy and anticipated needs. This means that for most patients, a 20-22 gauge is likely the best and safest choice.

How-to-start-an-IV-IV-gauges

IV Insertion Equipment

Before learning how to start an IV, you need to first know which equipment you will need. This becomes like second nature, but when starting out as a new nurse, this is often important to memorize. For an IV insertion, you will need:

  • IV Insertion Kit, which usually includes:
    • Chlorhexidine / ETOH swab
    • Tegaderm dressing +/- securement device
    • 2×2 gauze
    • Tourniquet
  • IV catheter of choice (18-22g)
  • Blood transfer device (Vacutainer) – if drawing blood
  • Extension Loop or cap
  • 1-2 10cc flush
  • Tape

Once you have your equipment, you are ready to know how to start an IV.

How to Start an IV

Prepare the Patient

To start an IV, you will first want to wash your hands (always the right starting point). You will also want to use universal precautions, so put on a pair of clean gloves as you will be possibly interacting with the patient’s blood.

You should already have an idea of where you are going to place the IV and which size IV catheter you are going to use.

Place the tourniquet on the patient’s arm proximal to the area of cannulation. Look for straight, large veins. Palpate them as veins may not always be visible but can still be felt. Strong veins will have a good amount of bounce to them.

Once you are happy with your vein selection, you can start prepping your area. Use a chlorhexidine (CHG) or alcohol swab to gently clean the surrounding area for 30 seconds, and allow to completely dry. Start with the center and move outward in a circular fashion with alcohol, while CHG requires a back and forth scrubbing action.

With deeper non-visible veins, some nurses will also apply alcohol to a finger of their non-dominant hand to help palpate during the procedure without “contaminating” the site. Please note that this is not the best practice for infection control. You should never tear off the finger of your glove either, instead – learn to palpate with your gloves on.

Preparing the IV

While your site is drying, open your 10cc flush and your extension loop and/or cap. If you are drawing blood, hook up the blood transfer device to the dry extension loop or cap. Otherwise, you can connect the flush and prime the loop or cap. Set this aside back into your kit to keep it clean.

Open up your IV, take off the needle cap, and twist the end of the catheter to make sure it is loose and ready for cannulation.

Inserting the IV

Hold the skin taut with your non-dominant hand to secure the vein. This helps to stabilize the vein and prevent it from rolling. Place the tip of the needle against the skin at a 10-30 degree angle. If the vein is deeper, use a slightly more angular approach initially. With the bevel up, puncture the skin and advance through to the vein.

If done correctly, you should see a flashback of blood in the flash chamber and/or catheter. This location will depend on the brand and size of the specific IV catheter. Once flashback is seen, lower the angle even more parallel with the skin, and advance the whole unit about 2-6mm. Now advance only the catheter forward, sliding it off of the needle and cannulating the vein. If done correctly, the catheter should easily slip into the vein without resistance. If there is dimpling of the skin, the IV is likely within the extravascular space.

Clinical Tip: If you initially don’t see flash of blood, pull the needle and catheter both out almost completely (but do not leave the epidermis). Re-palpate the vein, adjust your angle and advance again. This is termed “digging” and some patients will not tolerate this well. However, oftentimes it may only take 2 or 3 “digs” until success.

Before pressing the activation button to retract the needle – take off the tourniquet and apply digital pressure beyond the catheter tip. Some brands will have a septum or shield function with gauges 20-24, which prevents the backflow of blood and negates the need for venous compression. Press your activation button to retract the needle.

Draw Blood

If ordered, now is the point where you will draw your blood. Hook up your loop/cap with the blood transfer device to the IV hub. Draw your blood tubes, and flush with a 10cc pulse flush afterward.

Clinical Tip: Blue Tops for coags (PT/PTT) are often drawn first, and it is necessary to fill these tubes up completely for the lab to run the tests. If you have an extension loop, that .5-1cc in the loop can unfortunately cause the tube not to be full enough and you will need to redraw it. Best practice is to waste a tube first.

If you are not drawing blood, skip this step and instead just connect the primed cap or extension loop to the IV and flush. After flushing a few mLs, make sure you can pull back blood return. This is reassurance that the IV is in the correct place. Then pulse flush the remaining amount through.

Secure the IV

Secure the IV with a securement device or tape, and a dressing like Tegaderm. Make sure the insertion site is covered. If you used an extension loop, secure the loop with tape as this can easily get caught on something and pull out the IV.

If the patient is confused or may try pulling the IV out, wrap the IV with Coban, only leaving the cap accessible.

Administer any medications or fluids through the IV as ordered.

How to start an IV: infographic

How to Remove an IV

If the patient is discharged or if there is a compilation with the IV, it will need to be removed. Removing the IV is easier, and can be performed by a nurse or a patient care assistant.

1. Collect 2×2 gauze and tape or bandaid

2. Wash your hands and don clean gloves

3. While holding the catheter in place, start peeling off the Tegaderm and/or tape. Use an alcohol pad if very sticky and painful.

4. Once the dressing is no longer secured to the skin, place a 2×2 gauze over the insertion site, and pull out the IV in a smooth fashion.

5. Hold pressure for 1-2 minutes until bleeding as stopped

6. Dress with gauze and tape or bandaid

    How to start an IV

    How to Suture: Simple Laceration Repair

    How to Suture: Simple Laceration Repair

    This post may contain affiliate links, which means I get a commission if you decide to purchase through my links, at no cost to you. Please read affiliate disclosure for more information

    Knowing how to suture is imperative for a nurse practitioner or any other provider, especially within Emergency, Urgent Care, and family practice settings. Your experience suturing during clinical will vary depending on your rotations, but unfortunately many NP students graduate without solid suture experience. Many job interviews will ask if you are comfortable suturing, and your answer could literally make or break the interview.

    Hopefully this full breakdown of how to suture will help you be able to confidently know how to suture

    How to suture: Thumbnail

    As a heads up, this article is long and full of helpful infographics, so to please feel free to use the Table of Contents to navigate this page if it helps!

     When to Suture?

    Even if you know how to suture, don’t forget to recognize when to suture. Suturing is not always indicated. Sometimes there are other alternative wound closure options, and sometimes it is best to let the wound heal by itself (termed secondary intention).

    Where is the Laceration?

    The location of the laceration will help determine the need for sutures, as well as the size of sutures needed and when they should be removed. Sutures are commonly used for simple lacerations of the hands, feet, extremities, and face. Lacerations of the scalp are often better suited for closure with staples. Staples can also be used in areas where cosmetic results are not necessary, especially when the laceration is >5cm.

    Depth of the Laceration

    Superficial lacerations that do not extend through the epidermis often do not need to be sutured closed and will heal without difficulty with good cosmetic results. Additionally, some well-approximated lacerations that aren’t under areas of tension can be better closed with steri-strips or dermabond. Deeper gaping lacerations may need to have the subcutaneous tissue approximated with internal absorbable sutures first, then closed with non-absorbable sutures at the surface.

    How Old is the Laceration?

    The age of the laceration will have a major impact on your decision to suture. Clean, uninfected lacerations can be closed up to 18 hours following an injury. Facial wounds can be closed after the incident up to 24 hours, or even 48-72 hours in some cases with no risk factors for infection.

    Mechanism of Injury

    How the laceration occurred is also a very important part of the history in a patient with a laceration. This can cue you in on the need for X-rays to determine a foreign body or to rule out a possible fracture. A fracture with overlying open skin is considered an open fracture, and these should not be closed and are usually treated with at least one dose of IV antibiotics and Ortho consultation.

    The mechanism of injury can also give you a better indication of the degree of contamination, although proper assessment of the wound should too. Seriously contaminated wounds require extensive irrigation and often prophylactic antibiotics with delayed closure.

    Animal Bites

    Animal bites (including human bites), especially in non-cosmetic areas such as the hands or feet, should NOT be closed as these are at high risk for infection. However, in some instances, primary wound closure can be done such as with certain dog bites. If the patient has diabetes or venous stasis, delayed closure is even more highly recommended. Be sure to give rabies immunoglobulin and vaccine when bitten by strays or unvaccinated animals that cannot be quarantined.

    Cat Bites

    Cat bites should be left open and treated with prophylactic antibiotics (usually Augmentin), and can be referred for delayed closure in 3 days if needed. However, cat bites on the face can be closed if within 24 hours prior to closure. Puncture wounds should not be closed.

    Dog Bites

    Dog bites have also traditionally been recommended to treat with prophylactic antibiotics and refer for delayed closure. However, recent literature seems to support primary closure of many of these wounds as a reasonable alternative. Most dog bites on the face, trunk, and extremities can be sutured, as long as <12 hours old, or <24 hours for the face. Bites on the hands or feet should not be closed, but rather referred in 3 days for potential delayed closure and of course treated with antibiotics as above.

    Human Bites

    Similar to cat bites, human bites should never be initially closed unless on the face that is less than 24 hours old. These wounds also warrant prophylactic antibiotics.

    Make Sure Tetanus is Up To Date

    Updating tetanus shots is necessary to prevent the patient from developing tetanus disease. Tetanus is a disease that can occur after contamination of a wound which causes painful muscle stiffness and spasms. In order to make sure the patient’s tetanus is up to date, you need to ask the patient when their last tetanus vaccination was. Many patients will not know.

    Update Tetanus Vaccination if: 

    • Received < 3 doses in their lifetime
    • Last dose > 10 years in clean and minor lacerations/ wounds
    • Last dose > 5 years in contaminated/complex* wounds (see below)

    Give tetanus immune globulin if:

    • Less than 3 Tetanus vaccinations in past (or unknown) AND contaminated/complex* wounds
    • HIV positive patients or those with severe immunocompetence

    *Contaminated wounds are those contaminated with feces, soil, dirt, or saliva. Complex wounds include puncture wounds, avulsions, crush injuries, or burns.

    Clean Wound Dirty** Wound
    <3 Tdap* or unknown Tdap Tdap + TIg
    >3 Tdap but LKD >10y Tdap Tdap
    >3 Tdap but LKD >5y None Tdap
    Tetanus UTD None None

     *Tdap or Td (tetanus containing vaccination)
    TIg = Tetanus Immune Globulin | LKD = Last Known Dose | UTD = Up To Date
    **Dirty wounds are those contaminated with feces, soil, dirt, or saliva; puncture wounds, avulsions, crush injuries, or burns.

    How to suture - tetanus ppx
    How to suture: Animal bites

    Perform Appropriate Wound Assessment

    A good assessment of the laceration is also necessary. Be sure to assess their distal neurovascular status. Assess the tendon function in hand lacerations – make sure full ROM is maintained distal to the injury. Make sure no visible tendons are lacerated. Assure the wound does not appear infected or grossly contaminated. Observe for any signs of foreign bodies and ensure that bleeding is controlled. Measure the laceration’s length, width, and depth. These are all part of a good wound/laceration assessment and necessary for adequate documentation.

    Laceration Documentation Example: “4x1x1 cm laceration noted to the right posterior proximal forearm. Wound appears clean with smooth edges and scant bleeding. There are no foreign bodies or debris noted. No tendons are visualized. Distal neurovascular status intact including pulse, cap refill, color, temperature, sensation, and ROM.”

    How to Suture

    So now we know it is appropriate to suture, we’ve updated the patient’s tetanus if needed, and we have done a proper assessment of the patient’s laceration. We can finally learn how to suture a laceration. In this article, I will be overviewing the most common suturing method, which is the simple interrupted suture, which is appropriate for most simple lacerations.

    1. Collect your Equipment

    Before you’re able to suture, you will need to collect all of your equipment to irrigate, clean, anesthetize, suture, and dress the wound.

    Irrigation Equipment:

    • Bottle of NS (50-100cc per cm) or an equivalent volume of tap water (One 250ml NS bottle usually sufficient)
    • 30-60cc syringe
    • 18g IV catheter (remove the needle)
    • Absorbable pads or towels
    • Kidney basin
    • Splash guard

    Suture Kit: (Often already collected and packaged)

    • Sterile drapes / field
    • Gauze (4×4)
    • Needle Driver
    • Tweezers or small toothed forceps
    • Scissors

    Gloves:

    • 1 pair of clean gloves (for cleaning, irrigation, and anesthetizing)
    • 1 pair of sterile gloves (for suturing)

    Sutures: See below

    Anesthetic Material:

    • Lidocaine with or without Epinephrine
    • 3-10cc syringe
    • 25-30g needle
    • Blunt needle

    Choosing the Suture Type

    There are many different suture types, those that are either absorbable or nonabsorbable. Each suture type will change the suture’s properties including tensile strength, knot strength, elasticity, and whether or not they will absorb on their own.

    Nonabsorbable Sutures

    Nonabsorbable sutures have been the standard for simple laceration repairs, and they are what I almost always use. These can be used anywhere and have good tensile strength, knot security, are easy to work with, and have minimal tissue reactivity (aside from silk). Nonabsorbable sutures include:

    Nylon: High tensile strength, elastic, minimal tissue reactivity, low cost, requires 3-4 knot throws.

    Polypropylene (Prolene): High tensile strength, low tissue reactivity, requires 4-5 knots. Can come in blue color which is helpful in the scalp or dark-skinned individuals

    Polybutester (Novafil): Similar to above, but has greater elasticity so can be helpful if significant wound edema is expected

    Silk: Not as strong, higher tissue reactivity, but still used for central lines, chest tubes, etc

    Absorbable Sutures

    Absorbable sutures used to only be used for deep sutures, and are still used for internal sutures with very deep lacerations. However, some advocate for its use in primary closure of percutaneous lacerations in adults and children using fast-absorbing gut sutures. This is especially useful in children who will fight against suture removal. Some common absorbable sutures are:

    Chromic gut: retains tensile strength for 10-14 days, often used for oral mucosa, but has increased tissue reactivity for subcutaneous internal sutures.

    Vicryl: Retains tensile strength 3-4 weeks, complete absorption in 60-90 days. Ideal choice for subcutaneous sutures.

    Vicryl Rapide: Retains tensile strength 10-14 days, “falls off” in 7-10 days. Useful for under casts, can be used as an alternative to nonabsorbable sutures , but possible risk of infection and tracking vs nonabsorbable although was NOT statistically significant in research.

    Absorbable vs Nonabsorbable?

    While nonabsorbable are generally recommended for wound closure, a meta-analysis found equivalent cosmetic outcomes and no significant difference in wound infection or dehiscence, although follow-up was insufficient in several studies. Department culture will often dictate what you use. You will not gro wrong with nonabsorbable nylon interrupted sutures of the appropriate size.

    How to suture absorbable vs nonabsorbable sutures

    Choosing the Suture Size

    The size of the sutures will determine how big the needle and thread are. Depending on the location, certain sizes are recommended. The larger the number, the smaller the size and lower the strength. 1-0 are the largest, and 10-0 are the smallest, but most simple laceration repairs will use anywhere between 3-0 to 6-0.

    To choose your size, simply assess where the laceration is. See the table below for more information.

    Location Suture Size When to Remove
    Face 6-0 preferred,
    5-0 acceptable
    5 days
    Scalp 4-0 or 5-0
    staples preferred
    7 days
    Eyelid 6-0 or 7-0 5-7 days
    Eyebrow 5-0 or 6-0 5-7 days
    Oral Mucosa 5-0 (chromic gut) NA
    Arm 5-0, 4-0 near joint 7-10 days
    Hand 5-0 7-10 days
    Leg 4-0 7-10 days
    Foot 4-0 12-14 days
    Chest/Abdomen 4-0 or 5-0 12-14 days
    Back 4-0 or 5-0 7-10 days

     

    How to suture - suture size and removal

    Choosing the Anesthetic

    To suture, you will need to numb the surrounding area as you will be sticking a needle in their skin multiple times. Your main decision will be whether or not to use the lidocaine with or without epinephrine.

    Lidocaine 1-2%

    Lidocaine is the go-to anesthetic for laceration repair. Max dose is 5mg/kg (max 300mg), which you won’t come close to with smaller basic lacerations. The 1% comes in at 10mg/mL, and the 2% is 20mg/mL. Lidocaine will begin working in 45-90 seconds, and will last for 30-90 minutes.

    Lidocaine is usually injected via local infiltration. Enter the subcutaneous space from the inside of the wound, slowly making your way around the entire laceration circumference. Most basic lacerations will only require between 1-3cc of lidocaine.

    Local infiltration will give the patient a “pinch and a burn” while injecting. One way to decrease pain is to mix 1cc of bicarb with 10cc of lidocaine. However, in adults the lidocaine injections are usually tolerable, so this may be more wasteful than helpful. Alternatively, frequent pinching of the skin has been found to decrease discomfort.

    Lidocaine 1-2% with Epinephrine 1:100,000

    Lidocaine with Epi is great for wounds that are bleeding or are more likely to bleed while suturing. These include highly vascular areas like the face. This is because the epinephrine causes local vasoconstriction. It also blanches the skin, which makes it easy to see where you’ve numbed after a few minutes. The addition of epinephrine also causes decreased systemic absorption, causing a longer duration of action of the lidocaine (~3 hours).

    Traditionally Lido w/ Epi was avoided in areas like the fingers, nose, or ears as the worry is causing vasoconstriction and risking skin necrosis. However, the evidence is lacking so Uptodate basically says you can. However, it is still recommended to avoid injecting the digits with epinephrine-containing lidocaine in those with peripheral vascular disease.

    How to suture: LIdocaine with vs without epinephrine infographic

    2. Anesthetize the Area

    Prepare the area with 1 or 2 absorbable pads and have clean gauze ready, as local infiltration will often cause mild bleeding of the wound as well as leakage of the anesthetic agent.

    Clean the wound surface with an alcohol wipe (which will sting) or diluted betadine (1:10 iodine to NS solution). This is to briefly clean the area before injecting, as you likely have not irrigated the wound yet. Do not use betadine surgical scrub as this can be toxic to the wound.

    Use a blunt needle to draw up your anesthetic into a 3cc or 5cc syringe. Replace the needle with a fresh 25-30g needle. Inject the dermal area just inside the edge of the wound, locally infiltrating the anesthetic. You should be able to see the surrounding skin “swell” up. Note that sometimes the anesthetic has a tendency to leak out the wound – catch this with your clean gauze. Remove the needle and inject it again, slowly making your way around the wound. Be sure to use the previously numbed tissue that you just injected. It won’t be fully numb yet, but it will be less painful for the patient with subsequent pokes.

    For lacerations on the distal digits, a digital block will likely be the best choice, as there is usually not much space to infiltrate in these areas. These are also very sensitive, and local infiltration can be very uncomfortable for the patient.

    3. Irrigate the Laceration

    Irrigation of a laceration is essential to prevent infection and clear any foreign bodies or debris. Cleaner wounds will need less irrigation, whereas more contaminated wounds will need more irrigation. Generally, it is acceptable to irrigate 50-100cc per cm of the laceration.

    To irrigate, make sure your absorbable pads are in place as this can get the patient pretty wet.

    Open a sterile NS bottle or alternatively use tap water, and fill a 30-60cc syringe. Attach an 18g catheter to the end of the syringe – this is to increase the pressure of the irrigation. Inject the water or saline into the wound with high pressure, catching any water with a kidney basin if possible. The use of a splash guard is helpful to prevent splashback.

    Once cleaned, it is often easier to measure the dimensions of the wound.

    4. Set up Sterile Field

    Once the laceration has been anesthetized and irrigated, you can begin setting up your sterile field.

    Maintaining a sterile environment is another important factor in preventing infection. However, it might not be as necessary as once thought when suturing a simple laceration. Multiple randomized control trials (RCTs) have found clean gloves did not have higher infection rates than sterile gloves. Nonetheless – sterile technique is still often recommended and is considered the “standard”.

    Most suture kits will have sterile drapes within them. Open your suture kits in a sterile fashion. Drop your open sutures onto the kit or field in a sterile manner. Drop any other necessary equipment (gauze) if needed.

    Clinical Tip: You can pour some sterile NS into small containers or the sterile kit itself onto the gauze. This is optional but I find it personally useful to have wet gauze when wiping away scant bleeding during the procedure.

    Remove your clean gloves, wash your hands, and apply sterile gloves. Set up your sterile drapes – have the patient lift their arm or leg to assist you if needed. Some kits will have a sterile perforated drape to help focus your sterile field, which is optional. Once you are all set up, you can finally start suturing.

    5. How to Suture the Wound

    To begin suturing, you first need to decide which type of suture technique you are going to use. Most simple lacerations can be repaired with simple interrupted sutures. This is what I use 99% of the time in the Emergency Department.

    Before placing sutures, make sure the bleeding has stopped, as continued bleeding after closure can lead to hematoma formation.

    To perform the simple interrupted stitch, insert the needle at a 90° angle (side A). You should start about 5mm (0.5cm) from the edge of the laceration, 5mm deep, and come out 5mm on the other side of the wound. Facial lacerations require a finer touch and are recommended to be 2.5mm from edge, 2.5mm deep, and 2.5mm apart.

    I usually place the first suture in the center of the laceration. You will often need 2 bites for the first stitch – one for each side of the wound, as the edges of the wounds are usually not well approximated. However, I find that often after the first stitch the other sutures can usually be achieved within one bite.

    Clinical Tip: You can use toothed or untoothed forceps in your suture kit to help manipulate the skin – but I find this is usually unnecessary and leads to more local trauma to the wound.

    Once you pull your needle through the other side (side B), pull the thread through until you leave a short tail on the original side. Place your needle driver in the middle, parallel to the wound. Wrap the long-tail side B around the needle driver with two loops for the first throw. Grab onto the short tail of Side A with the needle driver, pulling toward side B while simultaneously pulling the long-tail side B toward side A. Pull tight enough to approximate the skin but not too tight. This creates a square knot. Be sure to pull the knot to one side of the wound so that it is not overlying the laceration. Perform this same knot throw about 3-4 more times, except you only need to loop around the needle driver once instead of twice for subsequent throws in the same knot.

    Clinical Tip: When tying the knots, be sure to do most of the pulling with the long-tail and your hand, as pulling too hard on the short-tail with the needle driver can elongate the tail and lead to wasted suture material. As far as number of knots, a good rule of thumb is to use the same amount of knot throws as the size of the sutures (3 knots for 3-0, 4 knots for 4-0, 5 knots for 5-0, etc).

    When you have thrown the appropriate number of knots, use the scissors in your kit to cut both ends at approximately 5mm length.

    For your next stitch, you can start working in either direction about 5mm away from the first (2.5mm on the face), or you can bisect each remaining side until the wound is closed.

    6. Dress the Wound

    Once the laceration is closed, the last step is to dress the wound. Apply bacitracin or Neosporin directly to the wound, and then apply a nonadherent dressing. I use a Telfa dressing covered by dry gauze, then wrapped with Kerlix. Other nonadherent dressings can be used as well (nonadherent sterile gauze), and even a simple bandaid can be used for small lacerations (works well for the face).

    Suture Discharge instructions?

    Wound instructions

    Providing excellent discharge instructions is imperative, as there is usually a good amount of necessary follow-up that needs to occur.

    Tell the patient to leave the dressing in place for 24-48 hours, and can then be opened to air. The wound should be covered if possible contamination is expected (such as while at work). Nonabsorbable stitches can be cleaned gently with soap and water twice a day. Half-strength hydrogen peroxide can be used twice daily to prevent crusting over sutures, especially on the face. The patient can use an OTC antibiotic ointment or white petroleum ointment twice a day as well if desired, which can help prevent scar formation and promote healing. It is generally recommended to avoid submerging the wound in water until it is healed.

    My Patient Discharge Instructions: Keep the wound clean and dry for 24-48 hours, then you can wash it gently twice a day with soap and water, but otherwise do not submerge wound in water. You may use Neosporin if desired to help prevent infection and scab formation. Please return for a wound check in 2-3 days if red/swollen/or if there is discharge from the wound, otherwise your sutures will need removed in X days. This can be done at your doctor’s office, an urgent care, or back here in the ED.

    Follow-up

    Always recommend a wound check in 2-3 days if the patient has any noticed redness, swelling, or discharge of the wound. Otherwise – they will need to follow-up when the sutures will need to be removed (which will depend on the location as stated above).

    If the patient is high-risk for infection (Diabetes, on chemo, renal disease, etc) or if the wound was highly contaminated, a wound check in 2-3 days should be recommended regardless.

    Prophylactic PO antibiotics can be given for contaminated wounds, animal or human bites, patients with vascular insufficiency, or immunocompromise.

    That concludes how to suture! There are other suture methods, and there isn’t always a “one size fits all”. If you are still confused, there are plenty of videos on youtube which you can check out as well! Let me know if you have any questions below and I’ll try to answer them. For more in-depth reading, check out the Uptodate articles listed in the references below!

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