UUCI Health · Department of Neurology
APP Class II · Procedural Competency Series · 2026
●  Procedure 08·Wound care / dermatology·Standard tier
08.

Wound

Suturing.

Simple lacerations · scalp staple placement.
Chadwycke R. Smith, MSN, NP, AGACNP-BC
APP Education · Department of Neurology
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology
Version 2.0 · 2026-05-11
Source-of-truth: 01_Suturing_Learning_Objectives.docx
Suturing · UCI Neurology APP Class II
01 / 21
UUCI · APP Class II
Procedure 08 · Suturing
02 · Why this matters
High-volume bedside procedure · low-MED risk tier
≤5%
institutional wound-infection ceiling — technique-dependent and tractable to OPPE monitoring. Most APP closures at UCI are scalp wounds after EVD or LD removal.
  • Decision architecture matters more than knot mechanics — the triage in the first 90 s determines whether you close or refer.
  • Three principal hazards drive the FPPE design: missed deep-structure injury, LAST from lidocaine overdose, epi at a forbidden site.
  • Wound-outcome OPPE indicators tracked at ≤5% infection, ≤3% dehiscence, ≤5% return-to-ED.
  • LAST events tolerated at zero — a single prodrome triggers mandatory focused review of the index case plus 3 subsequent closures.
Forsch RT, Little SH, Williams C. Am Fam Physician. 2017;95(10):628–636
StatPearls NBK470598 · Wound Closure Techniques
Full laceration-repair workflow: see Procedure 15 — Laceration Repair — for wound assessment, anesthesia + LAST recognition, irrigation/debridement, tetanus prophylaxis, and wound-care discharge instructions.
Suturing · Why this matters
02 / 21
UUCI · APP Class II
Procedure 08 · Suturing
03 · Course objectives

What you'll leave with — six anchor competencies.

C-1 · C-3 · Cognitive

Triage & scope.

List the golden-period windows (face ≤6 h, trunk ≤12 h, scalp ≤24 h); distinguish wounds within APP scope from those requiring referral.

C-2 · Cognitive

Deep-structure screen.

Examine distal pulse, capillary refill, tendon ROM against resistance, two-point discrimination, joint capsule integrity — refer on any positive.

C-4 · C-5 · Cognitive

Lidocaine & LAST math.

Calculate the maximum dose — 4.5 mg/kg plain, 7 mg/kg with epi; identify the epi-forbidden sites: fingers, toes, ears, nose, penis.

P-5 · P-6 · P-7 · Psychomotor

Closure technique.

Execute simple interrupted, running, and vertical / horizontal mattress sutures with eversion, equal bite, and knots laid to the side of the wound.

P-8 · Psychomotor

Scalp stapling.

Clip (not shave) hair, approximate edges with Adson forceps, fire staples perpendicular at 5–7 mm spacing without strangulating tissue.

A-2 · A-4 · Affective

Time-out & escalation.

Lead a TJC UP.01.03.01 time-out with calculated dose and allergy check; activate the ASRA LAST protocol on any prodrome.

Suturing · Course objectives
03 / 21
UUCI · APP Class II
Section I of IV
I.
Section one

Tissue principles
& triage.

The hard part of suturing is the ninety-second triage that happens before the kit is opened. Layered closure, eversion, dead-space management — and the wound you should not close at the bedside.
Objectives C-1 · C-2 · C-3 · C-6 — slides 5–8
Suturing · Section I
04 / 21
UUCI · APP Class II
Procedure 08 · Suturing
04 · Wound assessment

Every laceration · four screens.

ScreenWhat you doDisposition
Mechanism & time Date the injury; assess contamination level (clean / contaminated / grossly contaminated); ask about retained foreign material (glass, gravel, soil). Within golden period — proceed; over window — delayed primary or secondary intention; gross contamination — irrigate, pack, close at 3–5 d.
Size · depth Measure length in cm; probe depth; describe wound bed and edges (clean-edged vs ragged / stellate). Ragged or stellate edges → conservative debridement; depth involving deep fascia → layered closure with absorbable deep layer.
Vascular integrity Distal pulse; capillary refill at the digit / nail bed distal to the wound; brisk vs delayed. Any deficit — refer: named-vessel involvement is outside APP scope.
Deep-structure screen † Tendon ROM against resistance at the affected site; two-point discrimination distal to the wound; joint capsule integrity; foreign-body imaging if mechanism warrants. Any positive → refer to ED, Hand Surgery, or Plastic Surgery. Critical action on the Skills Validation Checklist.
Golden-period windows: face ≤ 6 h · trunk ≤ 12 h · scalp ≤ 24 h · Forsch RT et al. Am Fam Physician. 2017;95(10):628–636 · StatPearls NBK470598.
Suturing · Wound assessment
05 / 21
UUCI · APP Class II
Procedure 08 · Suturing
05 · Indications · contraindications

When to close — and when to refer.

Indications · within APP scope
  • Simple, clean-edged adult laceration within golden period
  • No deep-structure involvement on screen
  • No bite mechanism; no gross contamination
  • Scalp closure after EVD / lumbar drain removal — most frequent inpatient use case at UCI
  • Trunk & extremity simple lacerations
  • Uncomplicated facial laceration not crossing landmarks
Scope is deliberately narrow per 01_Suturing_Learning_Objectives.docx §1.
Contraindications · refer
  • Absolute: tendon, nerve, named vessel, or joint capsule involvement
  • Absolute: animal or human bites — primary closure raises infection risk
  • Absolute: grossly contaminated wound requiring operative debridement — irrigate & pack, delayed primary at 3–5 d
  • Refer: vermilion border crossings, eyelid, alar rim, ear cartilage
  • Refer: facial lacerations requiring plastic-surgery cosmesis
  • Refer: wounds beyond golden period — secondary intention
StatPearls NBK470598 · PMC10163751 · PMC11886599
Suturing · Indications & contraindications
06 / 21
UUCI · APP Class II
Key fact · LAST prevention
ASRA 2020 Local Anesthetic Systemic Toxicity Checklist
4.5mg/kg
plain 1% lidocaine ceiling. With epinephrine: 7 mg/kg.
70-kg adult, 1% (10 mg/mL):
• Plain: 315 mg ≈ 31 mL
• With epi: 490 mg ≈ 49 mL
Epi-FORBIDDEN sites · plain lidocaine only
Fingers · toes · ears
nose · penis.
End-arterial / distal-appendage beds — vasoconstriction risk ischemia.
LAST prodrome · STOP & ACTIVATE

Perioral numbness · tinnitus · metallic taste · diplopia · seizure · arrhythmia. 20% lipid emulsion 1.5 mL/kg bolus, then 0.25 mL/kg/min per ASRA 2020.

Neal JM, Neal EJ, Weinberg GL. ASRA LAST Checklist · 2020 · Reg Anesth Pain Med. 2021;46(1):81–82
07 / 21
UUCI · APP Class II
Procedure 08 · Suturing
06 · Kit · setup

What's on the tray — before you scrub.

Encyclopaedia Britannica 1911 plate illustrating multiple historical needle-holder designs used for surgical suturing
EB1911 Surgical Instruments — Needle-holdersPublic domain · Wikimedia Commons
Mayo-Hegar needle driver is the UCI bedside default — the box-lock and ratchet hold a 3-0 to 6-0 needle without rolling in the jaw.
Tray checklist
  • Mayo-Hegar needle driver
  • Adson tissue forceps (toothed)
  • Iris scissors · suture scissors
  • Suture pack matched to site
  • Skin stapler (scalp only)
  • Sterile drape · sterile gloves
  • 1% lidocaine vial + epi vial (separately racked)
  • 10 mL syringe · 27 g infiltration needle
  • 30–60 mL irrigation syringe
  • 18 g angiocath or splash shield
  • Sterile saline bottle (≥ 500 mL)
  • CHG-alcohol prep · gauze
Suture selection by site
Face5-0 or 6-0 nylon / polypropylene · simple interrupted
Scalp3-0 or 4-0 nylon or staples
Trunk4-0 nylon / polypropylene
Extremity4-0 or 5-0 nylon
Deep layer4-0 Vicryl or Monocryl (absorbable)
Suturing · Kit & suture selection
08 / 21
UUCI · APP Class II
Procedure 08 · Suturing
07 · Pre-procedure · time-out

Before you cut — the last gate.

  • 01
    Consent documented. Indication, alternatives including referral for out-of-scope wounds, material risks — infection, dehiscence, cosmetic result, keloid, LAST — and the patient's right to decline.
  • 02
    Allergy & tetanus check. Lidocaine · CHG · latex. Td / TdAP status — per CDC, q10 y; q5 y if dirty wound and > 5 y since last booster.
  • 03
    Lidocaine dose calculated. Compute the mg ceiling for the patient's weight BEFORE drawing up; state the mL ceiling for the 1% solution; defer if proposed dose exceeds ceiling.
  • 04
    Epi-forbidden zones verbalized. If any anesthetic is being prepared, state the forbidden-site list aloud as an audible safety pause.
  • 05
    Time-out called. Per TJC UP.01.03.01 — correct patient · procedure · site / laterality · calculated dose · allergy check · consent confirmed aloud.
TJC standard

UP.01.03.01

Pre-procedure verification, site identification, formal time-out. The time-out is one of four critical actions † on the Skills Validation Checklist — a Coaching or Unable rating blocks competency sign-off.
The Joint Commission. Universal Protocol UP.01.03.01.
UCI APP Class 2 Training Plan Process · TJC HR.01.06.01.
Suturing · Pre-procedure verification
09 / 21
UUCI · APP Class II
Section II of IV
II.
Section two

Technique
sequence.

Seven steps from prep to dressed wound. Eversion · equal bite · depth equal to width · knots laid to one side. Violate one of the four principles and you produce the scar.
Objectives P-1 → P-9 — slides 11–15
Suturing · Section II
10 / 21
UUCI · APP Class II
Procedure 08 · Suturing
08 · Steps 1–3

Prep, irrigate, infiltrate.

01

Prep ·
sterile field.

  • CHG-alcohol — concentric circles, center out
  • Allow appropriate dry time, do not blot
  • Drape; sterile gloves; tray laid out
  • Adequate lighting; ergonomic positioning
  • Povidone-iodine if CHG contraindicated
02

Irrigate ·
volume drives outcome.

  • ≥ 50–100 mL sterile saline per cm of wound
  • Moderate pressure — splash shield or 18 g angiocath on 30–60 mL syringe
  • State volume aloud
  • Tap water acceptable if saline unavailable
03

Infiltrate ·
wait for onset.

  • Through wound edges (less painful) — or intact skin if heavily contaminated
  • Aspirate before injecting; inject slowly
  • Wait 60–90 s for onset before cutting
  • Monitor for LAST prodrome continuously — pause on any report
Forsch RT et al. Am Fam Physician. 2017;95(10):628–636 · StatPearls NBK470598 · Neal JM (ASRA LAST 2020)
Suturing · Steps 1–3
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UUCI · APP Class II
Procedure 08 · Suturing
09 · Step 04 · debridement

Selective debridement, then choose the suture.

04

Selective sharp debridement.

  • Remove only clearly devitalized or necrotic tissue
  • Preserve viable tissue — over-debridement raises tension and worsens cosmesis
  • Iris scissors for fine work
  • If mechanism suggests retained foreign material — obtain imaging and defer closure pending result
  • Address dead space before skin closure — absorbable deep layer if needed
Suture selection · principles
  • Monofilament (nylon, polypropylene) — lower infection risk, slides through tissue cleanly
  • Braided (silk, Vicryl) — better knot security but harbors bacteria; reserved for deep layers
  • Absorbable for deep / buried layers (Vicryl, Monocryl); non-absorbable for skin (removed at the timing window)
  • Smaller caliber on cosmetically visible skin — face = 5-0 / 6-0
  • Larger caliber on hair-bearing scalp where tension > cosmesis
StatPearls NBK470598 · PMC10163751 · PMC11886599 — suture material selection by site.
Suturing · Step 4 · debridement & selection
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UUCI · APP Class II
Procedure 08 · Suturing
10 · Step 05 · simple interrupted

The workhorse stitch — surgeon's knot.

  • a
    Perpendicular entry. Drive the needle through one edge at 90° to the skin; equal bite on both sides; depth equal to width creates eversion.
  • b
    Mirror exit. Exit through the opposite edge at the matching depth; pull through smoothly with the needle driver.
  • c
    Surgeon's knot · 2-1-1. Double throw first (holds tension while flat), then single, then single — three throws total for nylon / polypropylene.
  • d
    Lay knots to the side. Knots rest off the wound line, not over it — reduces inflammation at the apposition.
  • e
    Approximate, do not strangulate. Snug enough for edges to touch and gently evert; not so tight that tissue blanches.
Critical-action focus on the Skills Validation Checklist — item 11.
Step-by-step diagram of surgeon's knot tying sequence with doubled first throw followed by single throws
Surgeon's Knot (tying)CC BY-SA 3.0 · Wikimedia Commons
Doubled first throw resists slippage while the second throw is set flat — the geometric reason the knot exists.
Suturing · Step 5 · simple interrupted
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UUCI · APP Class II
Procedure 08 · Suturing
11 · Step 06 · running & mattress

Pick the technique that fits the wound.

Running
Continuous suture pattern diagram showing repeating loops across wound
Continuous variantCC BY-SA · Uwe Gille / O. Remesz

Long · clean · low-tension.

  • Anchor with an interrupted knot
  • Continuous stitches ~5 mm apart
  • Final knot tied to a loop
  • Avoid on high-tension, contaminated, or cosmetic facial wounds
  • Long trunk & scalp lacerations only
Vertical mattress
Vertical mattress suture schematic — far-far near-near pattern on same side
Far-far · near-nearCC BY-SA 2.5 · Olek Remesz

High tension · everts edges.

  • Far-far, near-near on the same side
  • Distributes tension across two depths
  • Forces edge eversion in inverting wounds
  • Remove earlier than interrupted to avoid track marks
Horizontal mattress
Horizontal mattress suture schematic — across the wound then back parallel
Across · then parallelCC BY-SA 2.5 · Olek Remesz

Thin skin · hemostasis.

  • Across the wound, then back parallel
  • Spreads tension along the wound line
  • Useful for thin atrophic skin
  • Hemostatic — compresses bleeding edge
  • Same early-removal discipline
StatPearls NBK470598 · PMC10163751 · PMC11886599 — technique selection by wound length, tension, and contamination.
Suturing · Step 6 · running & mattress
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UUCI · APP Class II
Procedure 08 · Suturing
12 · Step 07 · staples · scalp only

Fast, clean, well-suited to hair-bearing scalp.

  • a
    Confirm scope. Staples are scalp only in APP scope. Wound must be clean-edged, within golden period, no deep-structure involvement, no gross contamination.
  • b
    Clip — do not shave. Razor shaving is associated with higher surgical-site infection risk vs clippers — moderate-certainty evidence (Cochrane: Tanner J, Melen K, 2021); Forsch 2017 (AFP) notes shaving is rarely necessary. Bailey 2025 (Eplasty) literature review on scalp-laceration repair supports staples as a hair-sparing closure. Verbalize the rationale.
  • c
    Approximate edges. Adson forceps with teeth; pull edges together without crushing.
  • d
    Fire perpendicular. Stapler held perpendicular to the wound line; place at ~5–7 mm spacing; approximate without strangulating tissue.
  • e
    No ointment under staples. Dressing is gauze or simple non-adherent — no antibiotic ointment under staples.
When staples win
  • Anticoagulated scalp laceration — fewer manipulations near a bleeding edge; faster operator time
  • Post-EVD / post-LD exit-site closure on the inpatient ward
  • Trade-off: less refined cosmetic appearance, acceptable on hair-bearing scalp
Case context: see Q13 of 04_Suturing_Post_Test.docx — anticoagulated scalp wound, staples preferred over running suture.
Staple placement scope · scalp only at UCI
Suturing · Step 7 · scalp staples
15 / 21
UUCI · APP Class II
Procedure 08 · Suturing · Critical checkpoint
Critical · eversion technique & removal timing

Evert the edge. Remove on time.

Eversion · why & how

Edges that turn outward heal flush. Edges that invert heal depressed. Achieve eversion by perpendicular needle entry, depth equal to width, and gentle tissue handling with toothed Adson forceps.

Removal timing · by site
Face5 days
Scalp7–10 days
Trunk7–10 days
Extremity10–14 days
High-tension / joint10–14 days + steri-strips after removal
Photograph of a sutured surgical wound at day 3 post-closure showing apposed edges with no separation or purulence
CTR scar, day 3 post-closure · Martix (M. van der Laan)CC BY-SA 4.0 · Wikimedia Commons
Day-3 appearance — apposed edges, no separation, no purulence. Removing too late → cross-hatched track marks.
Suturing · Eversion & removal
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UUCI · APP Class II
Section III of IV
III.
Section three

Complications
& pitfalls.

Most complications are technique-dependent and most are preventable. Wound infection, dehiscence, and cosmetic morbidity are the OPPE wound-outcome triad. LAST is the pharmacologic catastrophe.
Objectives C-8 · A-4 — slide 18
Suturing · Section III
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UUCI · APP Class II
Procedure 08 · Suturing
13 · Complications & pitfalls

Five events. Four errors we see.

Complications
01 · Wound

Infection.

Cellulitis, abscess, or purulent drainage. OPPE ceiling ≤ 5% over rolling 12 mo.

02 · Wound

Dehiscence.

Separation at / before scheduled removal. OPPE ceiling ≤ 3%.

03 · Cosmetic

Hypertrophic / keloid.

Patient-specific risk — anterior chest, deltoid, earlobe. Counsel pre-procedure.

04 · Cosmetic

Suture track marks.

Left too long or tied too tight. Mattress sutures removed earlier than interrupted.

05 · Pharmacologic · zero tolerance

LAST.

Single prodrome triggers mandatory focused review of the index case + 3 subsequent closures. Activate ASRA 2020 protocol; 20% lipid emulsion 1.5 mL/kg bolus then 0.25 mL/kg/min.

Pitfalls · documented in real cases
  • 01
    Skipping the deep-structure screen. Highest-harm error in the procedure — closes a tendon or nerve laceration beneath an intact-appearing skin closure. Critical action †.
  • 02
    Knots over the wound · tied too tight. Track marks and depressed scar. Lay knots to the side; approximate, do not strangulate.
  • 03
    Running suture on high-tension wound. Dehiscence — running redistributes tension along a single strand; interrupted compartmentalizes failure.
  • 04
    Epi at a forbidden site. Trigger for ad-hoc focused review regardless of patient outcome — fingers, toes, ears, nose, penis: plain lidocaine only.
Suturing · Complications & pitfalls
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UUCI · APP Class II
Procedure 08 · Suturing
14 · Section IV · UCI FPPE · OPPE

Your competency pathway.

StageTriggerScope
FPPEBoard approval of suturing / staple privilegeFirst 3 independent cases · scalp + extremity + face mix where volume allows · within 6 mo
OPPEContinuous baselineEvery 6 mo · 10% sample (min 2, max 10) · 100% review of any complication-flagged case
Trigger reviewLAST · epi-forbidden site · missed deep-structure · I&D-level infectionIndex case + next 3 closures reviewed
Reinstatement< 10 closures in rolling 24 moStream B skills checklist + 1 proctored case rated Independent
RenewalBiennial · 22 CCR §70703 (CA)OPPE indicators aggregate · Chair sign-off
Tracked OPPE indicators
  • Wound infection rate ≤ 5% rolling 12 mo
  • Dehiscence rate ≤ 3% rolling 12 mo
  • Return-to-ED for wound issue ≤ 5%
  • LAST event rate = 0 (single event → focused review)
  • Epi-forbidden-site adherence 100%
  • Documentation completeness 100%
LOW-MED risk tier Simulation recommended, not required.
05_Suturing_FPPE_OPPE_Plan.docx · TJC MS.08.01.01 · MS.08.01.03 · HR.01.06.01 · 16 CCR §1474 / §1399.541
Suturing · FPPE / OPPE pathway
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UUCI · APP Class II
Procedure 08 · Suturing
15 · References & acknowledgments

Sources of truth.

  1. 01Forsch RT, Little SH, Williams C. Laceration repair: a practical approach. Am Fam Physician. 2017;95(10):628–636.
  2. 02Neal JM, Neal EJ, Weinberg GL. ASRA Local Anesthetic Systemic Toxicity Checklist: 2020 Version. Reg Anesth Pain Med. 2021;46(1):81–82.
  3. 03StatPearls. Wound Closure Techniques. NBK470598. Treasure Island, FL: StatPearls Publishing; updated 2024.
  4. 04Li L, Shao Q, He W, Wang T, Wang F. Close orthopedic surgery skin incision with combination of barbed sutures and running subcuticular suturing technique for less dermal tension concentration: a finite element analysis. J Orthop Surg Res. 2023;18(1):333. PMID: 37147669 · PMC10163751.
  5. 05Alijani M, Jamshidi S, Nadripour R, Kamyari N, Heidari A. The use of cyanoacrylate tissue adhesives in various wound suturing techniques to enhance the healing process of surgical wounds: an animal study. Clin Exp Dent Res. 2025;11(1):e70057. PMID: 40052462 · PMC11886599.
  6. 06Bailey V, Kherallah K, Warner J, Moffit S, Moore M. Mitigating Hair Loss Among Scalp Laceration Repair Techniques: Review of the Literature. Eplasty. 2025;25:e29. PMID: 40661091 · PMC12257963.
  7. 06aTanner J, Melen K. Preoperative hair removal to reduce surgical site infection. Cochrane Database Syst Rev. 2021;(8):CD004122. doi:10.1002/14651858.CD004122.pub5 · PMID: 34437723.
  8. 07The Joint Commission. Universal Protocol UP.01.03.01 — pre-procedure verification, site identification, time-out. TJC Hospital Accreditation Standards; 2024.
  9. 07aThe Joint Commission. Universal Protocol UP.01.01.01 — preprocedure verification; use a standardized list (H&P, signed consent, nursing & preanesthesia assessment, labeled imaging, required equipment/devices). National Patient Safety Goals (HAP); effective January 2025.
  10. 07bThe Joint Commission. NPSG.01.01.01 EP 1 — use at least two patient identifiers (room number is not an identifier) before any treatment or procedure. National Patient Safety Goals (HAP); effective January 2025.
  11. 07cThe Joint Commission. NPSG.07.01.01 EP 1 — implement CDC and/or WHO hand-hygiene categories IA, IB, IC. National Patient Safety Goals (HAP); effective January 2025.
  12. 07dThe Joint Commission. Universal Protocol UP.01.02.01 — mark the procedure site; mark by the accountable licensed practitioner (APRN/PA delegation permitted per institutional policy); unambiguous, visible after prep & drape. National Patient Safety Goals (HAP); effective January 2025.
  13. 07eThe Joint Commission. NPSG.03.04.01 — label all medications, medication containers, and solutions on and off the sterile field (name, strength, amount, diluent, expiration). EP 4 requires two-individual verification when preparer ≠ administrator. National Patient Safety Goals (HAP); effective January 2025.
  14. 08The Joint Commission. HR.01.06.01 — competence verified before care. TJC Hospital Accreditation Standards; 2024.
  15. 09The Joint Commission. MS.08.01.01 & MS.08.01.03 — FPPE / OPPE for privileged practitioners. TJC Medical Staff Standards; 2024.
  16. 10California Code of Regulations 16 CCR §1474 (Standardized Procedures, NP) · §1399.541 (PA scope). State of California; current.
  17. 11UCI APP Class 2 Training Plan Process. Department of Neurology, University of California, Irvine. April 2026.
  18. 1201_Suturing_Learning_Objectives.docx · v1.0 · 2026-04-23 — Appendix A of the Suturing Training Plan (authoritative objectives + mapping table).
  19. 1303_Suturing_Competence_Assessment.docx · 22-item Skills Validation Checklist · 4 critical actions (†) — UCI APP Education, 2026.
Suturing · References
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UUCI · APP Class II
Procedure 08 · Suturing
End of module · Procedure 08

Now —
the post-test.

Stream A
15-item post-test
≥ 12/15
Stream B
22-item skills
checklist · all I
Stream C
Simulation
recommended
Live
3 proctored
independent cases
Routing: APP Director → Department Chair → IDPC → Credentials Committee → MEC, per UCI Medical Staff Bylaws.
Approving authority: Claire Henchcliffe, MD, DPhil · Chair, Department of Neurology.
UCI Health · APP Education
Version 2.0 · 2026-05-11
Suturing · End
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