From the Hope You Never Need It department: Someone you care about has been injured. You’ve gotten the bleeding stopped (using direct pressure instead of a tourniquet, naturally) and cleaned the wound up, perhaps using some of the debridement talked about here. But the edges of the wound aren’t closed, and you’re seeing things not meant to be looked at (or described over dinner, I’ve had it explained to me). Now What?
(As in previous posts, I’m still not a doctor and am not advising. I’m relaying information I’ve picked up from the medical literature, supplemented with stuff that was bouncing around in my skull from being in a medical-related field.)
To close or not to close?
You want to close wounds…except when you don’t. Reasons not to close include:
It’s a large, open wound. These should be debrided and covered to keep them clean, but not closed. (1) How big are we talking? The general idea is not to turn a pit into a pit with skin pulled over the top of it. The covered pit will tend to fill with blood or other fluids that get in the way of healing, and may breed microbes. The open pit will gradually fill with this pink stuff called ‘granulation tissue’ which is new cells and the blood vessels that are growing into the new cells, as well as scar tissue. Eventually that granulation tissue will organize itself as best it can. This use of lots of granulation tissue to fill gaps is called ‘healing by secondary intention’ and it works best if there’s no junk or infection in its way.
Wounds from explosions (including gunshot wounds) should be debrided carefully (because the high-speed movement of the wounding shrapnel or bullet pulls in nasty gunk with it, often) but not closed. (1) After that, it’s suggested to leave them open until the granulation tissue forms (usually takes several days to a week, depending on wound size); then the thing may be closed up if it still looks infection-free.
Bite wounds are treated like explosion wounds (1), but might be closed after a few days if they’re not too big and no signs of infection are evident. “Just in case” antibiotic therapy is often suggested for dirty wounds (1), but others have found little or no improvement in outcomes by this antibiotic use for gunshot wounds. (2)
Other kinds of wounds are generally closed.
How to close wounds, in general:
Remember we’re not trying to cover up pits. In some cases, that means deeper tissues (such as muscle) may need to be stitched together before the skin is closed. (1,3) This will reduce the tension on the skin, helping the wound stay closed, as well as promoting healing.
The idea is to get the edges of the wounds carefully aligned before you secure them in place. Skin is so stretchy that if you’re not careful, you’ll have a bulge of skin left over on one side of the wound once you’re out of skin on the other side. No bueno. Back in the dark ages when I was taught to do a little stitching, I was taught to put the first stitch in the middle of the wound, after lining all up carefully, then put each following stitch in the middle of the remaining gap. That reduced the tendency to run out of skin on one side before the other.
What method to use?
There’s more than one way to stitch a cat. Or glue, tape, or staple a cat. Each method has its strengths and weaknesses.
Tissue adhesive is a good choice for closing a lot of wounds, particularly neat (not jagged) lacerations that aren’t more than 5 cm long. Another post on tissue adhesives can be found on this site (or will be in a few days. I’m writing them at the same time.)
Tape, Steri-Strips or similar products, is nice for small wounds, and wounds that won’t be under much pressure. (3) . They aren’t as strong as either tissue adhesives or stitches, but they’re less prone to get infected than sutured wounds and applying the tape is much less harrowing for all concerned (especially if the potential stitcher is not expert). My Mom was fond of this method; I remember my brothers wearing ‘butterfly bandages’ that I wanted to color like real butterflies. Hey, I was maybe six. Waterproof sprays designed to be applied over dressings can be used to increase the tensile strength of a taped wound.
Sutures (stitches) are an oldy but a goody. They’re as strong as anything and work well for both interior tissue layers and skin. Of course, unless you use the absorbable kind, they have to be removed in 5-10 days. (Pros use absorbable ones for interior stitching, therefore.) Braided lines are more prone to infection than monofilament. Some tips on stitching from my sources (1,3) include:
- Don’t make the stitches too tight; the tissue’s going to swell.
- Use cutting needles for skin, round-tipped needles for easier-to-tear internal layers.
- Don’t handle the needles with your fingers, as it increases infection rates. Hemostats, commonly called fishing pliers, are a good choice.
I couldn’t find ‘real’ suture kits for sale online; I suspect they need a medical practitioner license, but I did see some ‘practice’ kits that had cutting needles with monofilament line, individually packaged in sterile single-use packs. Just FYI. Anyway, if you intend to put stitches in anyone for real, I’m sure they’d appreciate it if you had some practice beforehand. It’s not terribly hard; but not terribly easy either.
Staples – do you promise not to use paper staplers instead of wound staplers if I use this shorthand? — are often used these days to close surgical wounds; often stabilized further with tape. The wound clip applicators (I didn’t hear you promise!) require a medical license though I think, so I’m not going to go into those. They wouldn’t be my first choice anyway, as by the reading I did for this piece I didn’t see what advantage they had over, say, tissue adhesive, except for Looong lacerations. So let’s not get any of those?
(1) Leaper, D. J. (2006). Traumatic and surgical wounds. BMJ : British Medical Journal, 332(7540), 532–535.
(2) Papasoulis, E., Patzakis, M. J., & Zalavras, C. G. (2013). Antibiotics in the Treatment of Low-velocity Gunshot-induced Fractures: A Systematic Literature Review. Clinical Orthopaedics and Related Research, 471(12), 3937–3944. http://doi.org/10.1007/s11999-013-2884-z
(3) Al-Mubarak, L., & Al-Haddab, M. (2013). Cutaneous Wound Closure Materials: An Overview and Update. Journal of Cutaneous and Aesthetic Surgery, 6(4), 178–188. http://doi.org/10.4103/0974-2077.123395