Assuming one's not going to perform any internal surgery (I hope), what is a good standard size suture and thread material to include in my 72 hour kits (I already have butterfly bandage/sutures). I see there are many available on ebay with sizes ranging from tiny to large and threads form silk to monofilament. Any suggestions from someone in the medical field?

This might be an easier alliterative Cabelas Stapler

20

Like you said, I'm assuming you don't intend to perform major surgery, but close wounds. The finer the gauge, the more easily it pulls out. For external sutures you really want monofilament. 16 -20 gauge monofilament, in my opinion is, is perfect for basic suturing. They're big enough to hold most non-life threatening wounds and small enough for most people to endure without local anestetic. Keep in mind that closing a dirty wound will be worse than just covering with clean gauze and anti bacterial ointment. I carry a very complete medical kit with a surgical kit, but will always question myself as to whether or not to close a wound or just scrub thoroughly and cover.

Duct tape.

If you can't fix it with duct tape, you are in over your head. That is going to go on my personal (not the family) coat of arms one, when I finally have a need for one.

You can also carry a small amount of Krazy glue and just glue the skin flaps together. (Don't get it into the wound itself)

I would say that if you have to ask what size/type sutures to use, you shouldn't be suturing in the fist place. No offense intended.

Besides, why would you want to suture a wound in the field? Your risk of infection goes way up. Leave it open. Keep it clean.

I want to be a paramedic, so I already collected a huge medical kit,devided into 2 trauma-backpacks. In this kit I use 3-0 Ethilon suture kits.
The trauma-backpacks aren't for survival use, it's just a hobby. I wouldn't reccomend suturing in a survival situation, because of the infection-risk, so I would use super-glue and lots of antibiotic ointment and betadine.
I believe that if you use duct-tape on a wound for a time, it can cause a allergic reaction(???).

Just stick to your Band-Aids <img src="/images/graemlins/smile.gif" alt="" />

Disclaimer, I don't have the level of medical knowledge that some of you have on this site. My WFA certification is not anywhere near the level of the paramedics we have here.

That said, in most of the wilderness texts and training I have had, they strongly caution against closing wounds in the field, because of the difficulty in really cleaning/irrigating properly, disinfecting, etc in the field. It seems like after you get any profuse bleeding stopped, the general course in the field is to keep the wound covered, with frequent changes of the dressing to absorb all the goop that's going to ooze out until you can reach more capable medical care. (I think that's one reason why you see 4x4's in high numbers in most decent kits, they are the universal slimy ooze absorber.) Letting things bleed and ooze is ugly, but, it's the body's way of getting all of the little nasty things out of the wound.

Ok, wasn't that a nice thought for Mother's Day! (My house is still all asleep, have to wake up the boy to make mom breakfast in bed soon)

I'd be interested in hearing a response from some of our paramedics about the concept of whether you close a wound in the field, and some of the considerations.

You're jumping to conclusions; I've already sutered in the field using monofilament and a sewing needle. Neither suturing or disinfecting are dificult tasks, in fact, if you take care of your own wounds you've learned over the years how to properly clean and disinfect. With Betadine and sterile water (iodine) a wound can be cleansed. I just though I should hear from a few who know the many forms and sizes of needles, what might be the best for mu SPK SAK, instead of having to use a sewing needle....again.

bona fides: 10 yrs. as a paramedic and ER RN, then 20 yrs. as a physcian including some ER.

#1) appropriate training (don't need to be a doc, just trained). If you have to ask what size of suture, you probably need more training. (If you're planning ahead : 3-0 monofliament would probably be the best).

I carry a pack or 2 of 3-0 mono, but have never used it in 30 yrs. (safety blankie?)(yes. I rotate.), including some travel, days from standard medical care.

I carry a dozen butterfly closures. easy to use, they work and will not be as painful to apply! If there is a wound that is beyond their capability, the patient needs to be treated by a pro. Lots of 4x4 bandages, kling gauze and butterflys, that is my prefernce.

WARNING: for informational purposes only. Do not attempt without proper training!

Ethicon Suture Manual (everything you wanted to know about suturing and probably more.) http://www.jnjgateway.com/public/USENG/Ethicon_WCM_Feb2004.pdf [color:"red"] [/color] [color:"red"] [/color]

For most situations you are best not closing the wound and just stopping the bleeding, cleaning the wound and then dressing it with sterile bandages. Closing wound in the wilderness and other non sterile environments will increase the risk of getting a foreign object in the wound.
If you must close a wound most untrained folks are best using wound closure strips; you can improvise this with duct tape.
There is actually no need to suture; most wounds will heal on their own. Stiches are mostly used to prevent excessive scaring and are best left to professionals.
Unless you are an RN, medic or MD you don't need sutures.

Finally! An answer to my question. Thank you Marduk!

3-0 monofilament.........check!

My background: Army Medic x 5 years, Physician Assistant 7 years - I've seen/treated a lot of wounds.

Suturing is deceptively simple - it's a relatively easy skill to learn, but takes a bit of practice to perfect. First, you really should have some training. Through training you'll discover that irrigating your wound w/ betadine, peroxide, alcohol, etc... are no-nos - all retard wound healing and damage healthy tissue to some extent. You will also learn proper closure technique - including wound prep (irrigation, debridement, local anesthetic choise & usage), suture selection, placement of sutures, types of sutures, types of knots, etc... Unfortunately, this type of training is not something you find at the local YMCA. It's typically available only to those whose professions demand the skill - physicians, nurse practitioners, PAs (in some areas "advanced practice" paramedics, and occasionally nurses - although these skills are not typically used by such)

Most wounds will heal fine w/o sutures - even very deep ones - as long as they are cared for properly - regular dressing changes, packing if necessary, etc... (again, this is covered w/ proper training).

So if wounds heal w/o sutures, why do we suture wounds? Sutures offer a few benefits:
- they produce cosmetic result (generally) than healing by secondary intention
- they restore function to torn ligaments/tendons/fascia (when used properly
- they speed the healing process in clean wounds (they decrease the degree of epithlialization, as well as contraction, needed to heal a wound)

The major pitfall, especially in traumatic wounds, where the degree of cleanliness may be questionable, is an increased risk of infection. Some infections are minor, and will be contained/eliminated by the body's immune system adequately. Some require opening the wound to allow for drainage. Some are life-threatening, and require extensive tissue debridement & antibiotics (do a search on necrotizing fasciitis - you can get a similar infection from a simple scratch).

my personal opinion - don't suture in the field - you more than likely will not be able to maintain a clean field, much less a sterile one - you are going to drag contaminated material (the suture) through the wound, innoculating it w/ bacteria (unless you have been trained in aseptic technique, and brough along a sterile drape, sterile gloves, etc..). don't use superglue in the field (it's not the same as Dermabond, either). Irrigate w/ the cleanest water available, remove any debris, irrigate again cover w/ dry dressing, monitor for signs of infection (redness, swelling, increased pain, increased temperature, drainage), seek professional care. Closure of minor lacerations may be possible w/ steri-strips or buterflies (or strips of tape, etc...) - many wounds can be closed this way, and since the skin is not artificically sealed, it can drain as needed (and if it becomes infected, you can easily remove the tape/steris/etc...

All that said, probably the best all around sutures to have would be 3-0 & 5-0 nylon (3-0, 5-0 refer to the size of the material, 3-0 being significantly larger than 5-0) on a cutting needle (sutures come on a variety of needles - cutting are used for skin, where tapered needles are used for more delicate tissues). 3-0 is fine for most parts of the body, and 5-0 would work for palces like the face, hands, etc..., where you would want to minimize the scars appearance. Really deep or long lacerations will probably require more than one layer of sutures, or something likea vertical mattress suture to close properly - again covered in formal training (or informal if you can find someone truly knowledgeable on the subject who is willing to teach you).

Stay safe

Flotsam:

Thank you for your very thorough post on this subject. A few questions:

Betadine and other cleansers are not used in the wound, but for the surrounding tissues...correct? Flushing a wound with sterile water is good once the wound is cleaned of debris? What about the use of treated water, (iodine) and what about the use of Neosporin or other antibiotic ointments?

The reason I want a couple of sutures in my PSK/FAK, is to offer another treatment option; not necessarily for me but for someone else to administer as well (like someone with more experience). During a backpacking trip years ago, I cut my hand in an area where a butterfly bandage would not work. I was not coming off the mountain for a week, and I needed the use of my hand, so I cleaned it, and sutured it myself with monofilament and a sewing needle (just four sutures), covered it with Neosporin, gauze and duct tape. By the time I was off the mountain a week later it was almost completely healed. Had I not sutured the wound, it would have been a major pain in the a** for the entire week.

While most wounds may be closed with bandages, I'd rather have a couple sutures in my kits, just to have that added option of treatment.

In that case, a stapler may be easier (and more hygienic) to use. I know that Ethicon makes several staplers that are affordable (around $10), that have either 5 or 15 staples, and are fairly compact. mooremedical.com is a good source. It's very hard to keep a sterile field in the boonies - w/ a stapler, you can keep a clean work environment & reduce the risk of bacterial innoculation.

Irrigating w/ treated (potable) water is fine, and at least one study has shown that the results are just as good as irrigation w/ sterile saline (considered the "gold" standard). Application of bacitracin is fine - and you really don't need to apply more often than 2x/day. I would avoid it if the skin appears macerated. Plain soap & water is fine for cleaning a wound as well.

If you ever have the occasion to use a real suture needle, it's much sharper than the average sewing needle (the cutting needles have 3 sharpened edges that work as blades to cut through the skin, making driving the needle much easier).

The best thing you can do is find someone who does this regularly, ask them to show you how to do it properly, and then practice (I used pig's feet in school). A set of "floor grade" instruments is pretty cheap, and you could practice w/ expired sutures (often available cheap off ebay)

I once had to suture a deep cut on my calf (leg, not young cow) myself. I couldn't get it to stop bleeding, and butterflies wouldn't hold because of the stretching of the muscle when I walked. Fortunately I had been carrying a couple of sutures in my FAK. It ended up working out great, gave me full mobility and healed in record time.

The location of the cut made it very difficult to do - you need both hands. If it had been an inch further back, I probably couldn't have done it. Because of that I now have a skin stapler as well as sutures in my FAK. The sutures are a general purpose 3-0 monofiliment with a curved cutting (FS-1) needle.

Later on, the first question everyone had was "didn't it hurt to do that?" Well it already hurt, the suturing was minor. Cleaning it out was another story. A lot of gritting teeth and Arrrghhs. A bottle of saline solution for contact lenses would have made irragating the wound a lot easier. If you wear contacts, you should probably have that with you already. If you don't wear contacts, it's a good idea anyway. You can also use it to get dirt, bits of debris, ash from the fire out of your eyes.

There was already a link to the Cabela's skin stapler and staple remover kit. Most staplers are big, honking, hand filling things. The DS-15 in the Cabela's kit is really compact, and it beats trying to tie a not in an awkward position.

When in doubt, pee in it. Unless you have a bladder infection, urine is sterile. If you're squimish, use your own.

Flotsam is so right. good info.

5.0 is about the same as 23 guage. This s*$#t is like a razor. Good for deeper layered surtured wounds which i hope the un-trained won't try. Please don't use duct tape to close a wound, It doesn't allow for seepage and actually keeps the germs condensed in a small area. i did a search and found a good source of info on sutures Take a look http://www.emedicine.com/ent/topic38.htm

There are a lot of different opinions on this, learn what you can and make your choice. I still think that 3.0 which is around 14 gauge is the smallest most people wan't to go. if I'm wrong please say so.

When I talk about duct tape with a wound, I'm generally thinking of either (a) using it becuase it's around and steristrips aren't, (b) as a form a dressing tape that actually holds something in place, or (c) as big bandaid with gauze over the wound, checked at every pause (or few hours if stationary) or if it gets painful.

The only other way I use it on me is for hotspots that I catch before they turn into blisters. Put down a little bit of gauze, and then a patch of duct tape. Or if I'm wearing dress shoes (which always blister my ankles), put it on before hand under the socks. :P

What I will say is, sutures are technically a minor surgical procedure. Not hard, but neither is putting in an IV. If you know how. If you don't, I can think of several ways you could make the wound more interesting trying to stitch. (Too shallow and it tears, don't keep it sterile, et al) And I'm sorry, you just won't learn that from a book or webpage. Take the blasted course and practice, or use strips or staples.

Or pray, if that's your thing.

15 yrs Nursing /10 yrs Wilderness Paramedic/Guide

If i were to pick one I'd go with 4-0 Eithilon
small enough for general , yet strong enough for larger needs.

Flotsam, since you appear to be the expert:

Can you reduce the pain by applying a anhestetic on the suture needle
(like Benzalkonium Chloride). Or does it take to long before it starts working?

Flotsam - what is your opinion on (1) the Israeli Bandage, (2) QuikClot, (3) using them in tandem?

This is HORRIBLE advice. Yes urine is sterile but it is a very very good medium for bacteria. So in essence you asking for any of the myrid of bacteria on your skin. So basically It wouldn't be very wise.
cheers

Get some tinture of Iodine solution and apply it to the area around the wound then use steri-strips. If you do not have the training etc then you should not be doing sutures. Also I do not know of any sutuation where sutures would be better then normal wound care in the field to justify suturing.
cheers

As several have stated in this thread and in several other threads; closing a wound in the field is not generally recommended, due to the risk of infection. With that in mind, I would steer clear of suturing in any case. Too tight and you run the risk of causing localized tissue damage and subsequent necrosis. Too loose and (on of the man reason to use sutures is to promote wound healing by primary intention-minimal scaring) and you will still have wound healing by secondary intention, which in the field is probably a better idea anyway (wound heals from the inside out, towards the surface-just leaves a bigger scar). If for some reason you must absolutely close a wound in the field, you need to make sure you have properly cleansed the wound, have oral antibiotics on hand. The use of Steri-strips or butterfly closures would be better to use, if you do not have the appropriate training.

Pete

I am far from being an expert, but I like to think I am a competent professional, and wound care is a large part of what I do on a daily basis.

Unfortunately, I have no experience w/ quikclot or the israeli bandage - we were still using the older style of trauma dressing when I was a medic. By reports, the Israeli dressing is quite good (and apparently there's a new version of the cinch-tight dressing that is getting good reviews as well). Quikclot - studies show that it does work, but the only study I've read involved a surgically lacerated femoral artery in a pig - I'd want to see a study w/ a truly traumatic injury (clean edges on vessels tend to seal much better than the ragged edges you would expect from a blast injury). Anecdotal evidence is mixed, from what I have read.

I wouldn't use urine as an irrigant. Aside from questionable sterility, it's also fairly concentrated & contains waste products - not something I'd desire to use as an irrigant.

ATOZ gave sound advice - If you don;t know what you're doing, you can make matters significantly worse by closing a wound. Benzoin & steri-strips can go a long way for minor wounds (this is pretty much all that I carry in my field first aid kits).

As for local anesthesia - applying anything directly to the needle is not going to work - lidocaine takes a few minutes to take effect under the best of circumstances. There have been reports of people using ice to numb the skin, or topicals such as oragel or hemmoroid cream -I have no experience w/ these. The only topical I've ever used is EMLA cream (a mix of prilocaine & lidocaine) - it takes a good while to take effect (around 30-60 minutes, IIRC), and it was not very good, in my opinion.

Again, the best advice - clean it as well as possible, remove any obvious debris, irrigate w/ the cleanest (potable) water you have, bandage & monitor. The human body can be incredibly forgiving (I often conclude that it heals inspite of what we do, rather than because of what we do). If you want to have extra tools in your toolbox - get some proper training. Unfortunately, this is not something easily picked up frm a book - it requires hands-on training & experience to become competent.

I don't carry water often, and when I do am often thinking more of its first aid uses than drinking it. One thing I've been wondering about recently: is water significantly dirtier if it comes out of a water bladder and/or drinking tube, like a Platypus, rather than a bottle?

I'm not disagreeing with you. I just didn't want people to think duct tape etc. is a suitable long term dressing. I have to admit to using electrical tape to close a nasty gash until I got to the doctor for stitches.

And you are right about learning to suture up a wound, it's not rocket science but practice is definitely the best way to learn to do well.

Really? Then how come it has been used with success by every culture going back to the Babylonians? If it made the wounds sour, there would have a lot more of them that didn't use it. In particular, the Romans used it, and they had the best medical system in the West until the mid-1800s.

Oh, and why is it still taught by military medical schools the world over? Maybe not to Navy corpsmen who would generally be on a vessel, but I KNOW that it's being taught to CSAR personnel and to people who might be a bit out of touch for a while. Flotsam, they told you about this, I'm willing to bet. It's isn't supposed to be your first choice, but it's far from the worst.

Water is a "very, very good medium" for bacteria, to. So is saline. Urine is basically warm saline with trace amounts of minerals, unless there is something wrong inside of you. Chemically, it's rather like sea water, only with less salt (usually, depends on your diet), a trace of ammonia (which kills things) and no microbes (unless you have an infection). Sure, if you leave a pocket of it in the wound, you're in trouble, but you have that with any irrigation fluid. Everything get's dirty once it's out of the bottle, and unless it will kill tissue, it will have bacteria growing in it 24 hours later. That's unavoidable in real world conditions. All you can do is minimize it.

Although, most people also spaz at the idea of using large ants as sutures. Show me a BIG honkin', tropical ant hill, and I'll show you more skin staples than you'll ever need. The folicle of a horse's tail strand is supposed to be sharp enough to stitch with (Chris, can you confirm?). Leach and maggot therapy makes most peoples skin crawl, and those are coming back to, in "convential" medicine. We aren't talking about something where you can be on a bunk in the ED in an hour. This is when something has gone very wrong. Given my choices, I'll irrigate with fresh water or saline. But giving a choice between leaving crud in a wound, and making someone a little queezy when I drop trou, guess what I'm picking?

Yeah, looking over my first post, I wasn't very clear on it. Sorry if I sounded like I was taking your head off- I've been told I'm doing that a lot lately, without meaning to.

Something about four days of torrential rain and arthritis. Makes everyone crabby.

No Problem, I can understand, except here in Arizona it's the number of days over 110 degrees that set you off.

I'd be looking for people with axe is hand. I don't mean the skunkspray they sell to teenagers. :P

At least with the rain, you have to be tied up have me outgimp you on a day like this.

Urine in the bladder is sterile to a certain extent, but once it comes out of the bladder, it passes thru the urethra and picks up the microorganisms therein and innoculates the wound with the said bacteria.
Primitive cultures had no concept of microorganisms and sterility hence they should be forgiven for treating wounds as such.
But like you said, if the choice was to have crud in the wound and nothing else, I would choose blood. Let the wound bleed to clear out the crud, then stop the bleeding. It would certainly be better than pissing on it.... <img src="/images/graemlins/blush.gif" alt="" /> But of course, if you really have no other choice, with no other irrigation fluids available, this would be better than dirt.....

In terms of preference:
Sterile saline
Non sterile saline
Sterile water
Non sterile water
Clean water
Blood

No arguement, blood is a good flush. You just need a lot of it.

The funny thing is, this is identical to a conversation I had with a buddy of mine a few years ago, but with the roles reversed. His background, he's a USAF PJ. I argueed the points on contamination with bacteria, pretty much the same about picking up cells during passage that Trus has made, he sent me about three pounds of documentation to back up it's use, both current and historical.

Emergency treatment, yes, but a valid one with relatively little side issues, is the summary.

And that is my last words on this sub-thread.

Irrigating with a diluted PI solution (10%) is proper proceedure when the water is not sterile. This is current proceedure according to the Wilderness Medical Society.