Sutures

Should you ever be so misguided, or insuch a dire emergency, that you must stitch yourself or others, read this first. Pretty well done: just hit the 'next button' 'til done.

http://cal.vet.upenn.edu/surgery/index.htm

[Sorry: original link failed. I hope this one is better.]

Link?
I have sutured actual people, and don't relish the idea of doing it in the woods somewhere.
And no way could I suture myself!

This is my answer to the dangers of self-stitching.

I have used these many times on cuts for which any doctor would have recommended stitches assuming you could get to a doctor while the wound was still fresh. I have had great experiences with these. After cleaning the wound and stopping the bleeding then I pinch the wound closed and apply the strips then cover with a gauze or something similar to protect from dirt, debris, etc. They hold amazingly well and tend to do just a well as sutures for minimizing scarring... at least in my experience. Pretty easy to apply one-handed as well, which is helpfull for me since I seem to often be treating cuts to my hands and arms.

I'm having a hard time imagining a situation where you should suture an injury. The combination of original wound contamination plus the high probability of further contamination due to improper material handling and lack of hygenic facilities makes me shudder.

I would prefer to clean the wound as best I could, then bandage it to prevent further contamination, and get the victim to a medical facility, even if it was several days away.

Sue

That is the best plan, Sue.
You are more likely to close some infectious material in the wound, and cause more problems in the short and long term.
Steri strips are great as noted above, and we use them in the hospital for the same thing.

Some hypotheticals:

You fall on your knife, tearing a 3" gash in your thigh. You are two miles away from your vehicle. Your cell phone has no signal. You are bleeding badly and are starting to get light-headed.

Same scenario, except you have just fired your 30.06 hunting rifle into your calf after dropping it crossing a fence, hitting the bone. (yea-it could never happen to you, except it has, and now you have to get your ass out of this nightmare and survive.)

You are alone in both cases. How do you seal up the wounds long enough to get out?

If you are bleeding that badly, you will need a tourniquet. Especially in your 30.06 situation. Or, even better, I would try the QuickClot first if you had it available.

Sutures are for closing wounds, not stopping massive bleeding. If you are all ready lightheaded from bloodloss, it's a little late to be thinking about preforming minor surgery on yourself. Sealing up the wounds won't help, the bleeding will continue. So anyone that carries a knife or firearm, needs to carry FAK stuff to deal with any potential wound. But it does happen, a few years ago my buddies came upon a lone hunter. He'd shot his foot with a 7mm rifle and laid down to die. They managed to save him, and it took a LOT of gauze to get the bleeding stopped. He was flown out and lost half of his foot, but lived.

Dave

Anyone that has had lots of sutures will tell you (as would any doctor) that you can only suture a wound within about 8 hours after the bleeding stops. The only way around this is for the doctor (and I have only had this done once out of many many trips to the doctor for sutures) to reopen the wound intentionally, then suture it. So if your doctor is more than 8 hours away, visiting him may still be a good idea for getting some antibiotics to prevent infection, but he/she won't be doing any suturing. <img src="/images/graemlins/smile.gif" alt="" />

Exactly... If the wound is clean and the bleeding has stopped then your work is done. Closing the would via tape, glue, sutures, staples or whatever else only serves two purposes that I can think of. 1) It makes the wound less likely to repopen. 2) It minimizes scarring. Reason 1 (preventing the wound from reopening) is my primary reason for carrying the butteryfly strips (and sometimes glue) with me in my kits, though the secondary effect of reducing scarring is nice too.

A tourniquet is the absolute DEAD LAST option to stop bleeding. When you decide to use a tourniquet, you have decided to sacrifice that arm or leg. When you get to medical assistance, it WILL BE amputated.

Most bleeding can be stopped with pressure. If the bleeding is from an artery or large vein, that person isn't going anywhere except on a stretcher or travois. Help will generally have to be brought to him.

It would be a good idea to read up on how to stop bleeding, as 98% of what you've see in movies & TV is garbage.

Sue

Not entirely true regarding the tourniquet - it's time dependent. If you can get to help in a few hours, the limb can possibly be saved (ischemia times greater than about 4-6 hours tend to greatly reduce this chance). That's why it's important to note the time the tourniquet was placed.

As to suturing wounds - easy enough skill to learn, but it takes a while to get good at it & to develop the clinical judgement to know when to close & when not to. In a field environment, my opinion is to clean the wound as best as possible (cleanest water you have available - the solution to pollution is dilution <img src="/images/graemlins/smile.gif" alt="" /> ), apply the cleanest dressing you can, and get to help. Most wounds, even big ones, don't necessarily need sutures to heal - sutures do a few things: speed healing time by holding tissues in approximation, improve cosmetic outcome, and contain maintain anatomical integrity (in the case of tendons/fascia/etc... The risk of infection is pretty high in a contaminated wound, which includes essentially all of wounds acquired in the boonies.

Good luck, stay safe!

Sam

If someone's life depended on me threading 'em up, they're past tense. I can't even sew a button worth a darn.

But back to a tourniquet ... a tourniquet applied long enough to pack and bandage the wound is not a good idea?

And, to open another can o' worms ... anyone here of the Crazy Glue school?

I generally carry both a tube of Crazy Glue and a tube of EMT Gel (for the dogs) in the FAK i carry pheasant hunting.

And there's always wound strips and duct tape.

Perhaps. Orthopedic surgeons routinely use tourniquets to control bleeding during surgery. In the above hypothetical situation, you are alone with a massive gunshot wound to a long bone and are symptomatic from blood loss. Time to use a tourniquet if direct pressure will not stop the bleeding. A GSW to the femur (in this case a high powered rifle), good chance are you are going to lose the limb anyway. The decision to amputate is based on whether or not the extremity is viable.

I've used Dermabond which is basically the same thing as crazy glue. It's the same glue they use in hospitals IIRC. Pretty expensive stuff. I got lucky and happened upon a small bottle of the stuff for free. From what I understand the only problem with using Crazy Glue or Super Glue is that some people are allergic to it. I have never had the guts to find out if I'm one of those people.. <img src="/images/graemlins/smile.gif" alt="" />

I must admit to using superglue, quite recently, in fact, when I managed to slice the pad of my thumb, and really could not spare the dexderity that would be sacrificed by a big bandage. So, I approximated the edges well, glued it -- two coats -- let it dry and put heavy clothsurgical tape over it. It worked great. It hurt some, but not really more than the dilute providone iodine I irrigated with.

I don't recommend it on sensitive areas of skin.

Well, yes and no. 'Clamp time' must be monitored quite closely, and in the event that a major vesel is not totally severed the tournquiet must be loosened periodically to restore some blood flow to oxigenate the tissues. Different tissues are tolerant to different degrees of ischemia, and there is a degree of temperature dependency. If you can get tissue temp down with ice, it can tolerate ischemia longer.

I spent a very long, very cold trip in the back of a horse trailer once loosening the torniquet on a horse's leg for five minutes out of every 30. Three hour trip in. He did OK.

The use of a tourniquet in the shaking hands of a inexperienced person who doesn't really know what they're doing is virtually guaranteed to be a disaster.

If you're in a situation with a doctor or veterinarian tending to you, they probably know what to do, and how to do it with the minimal amount of damage. But under most conditions, performed by an untrained, frightened, shaky Good Samaritan, the limb will start to die in about 20 minutes.

Yes, if the arm or leg has been mostly ripped off or blown off (or the arm is stuck under a boulder & you have to cut it off), get the tourniquet on, as your choices are non-existent. But some (most?) people are so upset at the sight of a goodly amount of blood that they don't consider the consequences of their first and only thought: stop the bleeding with a tourniquet. It's simple and easy. They've seen John Wayne do it.

Tourniquets: Create-A-Cripple in one easy step.

Sue

Deja vu all over again. This thread comes around a lot.
I've been on two backcountry trips in which someone got a severe laceration. Both times, there were two surgeons present on the trip (and enough medical supplies to stock a MASH unit!). NEITHER time did the surgeon(s) want to suture. Asked recently, both agree that they'd never suture in the field. NEVER. They may use a suture to ligate a bleeder, but would never, never, never suture a wound closed.

So... I suggest a poll of forumite who are actually MDs, or EMS/EMTs.

1) Would you use a suture to ligate or tie-off a bleeder... in the field.. if you had no hemostat?

2) Would you suture a wound closed in the field. (Assuming all the "sterility" you can muster in the field)

During one year of rotations in the actual ER as a Paramedic I got to learn how to suture pretty well (way out of my scope of practice) but young docs always find pleasure in showing off and teaching others. I would not atempt to stich a face or a child since my threads are not the pretiest and I rather have somebody who does it every day and not once a week do it. But with rest anything goes. I would drop off my patient from a cardiac call than walk thru the er and doc would yell "hey Matt finish up for me" and there I go stiching somebodys arm. I know how to do it, I know the proper way of cleaning the wound but I would never stich anyone in the field . I would use direct pressure, elevation and pressure point and tk if had to, I even throw in up to 3000 cc of fluid in there to maintain you. Infection risk is to great as oposed to benefit. Plus sutures give false sense of secuirty. Yeah you stiched my leg it's not bleeding anymore I can go further.

Now to ligate a bleeder... I saw it being done but never did it my self. So this is plain simple no unless it is a case book scenario procedure I watched being done. Anything complicated (and it always is) would have to be controlled using bls stuff.

And some wounds are really tempting to stich too. They look easy and are not deep enough to be hard to clean. Still it's a no go. I will cover it, clean it, make buterflies out of tape but will not stich it.

Okay, first: I am a Registered Nurse (not MD, EMT, or Paramedic)
I was certified to work under an MD's direction, either directly or indirectly.
1. Nope, don't know how, wouldn't attempt to try it.
2. No, because it just doesn't make sense. You won't get a sterile environment, I probably wouldn't have antibiotics to give, and a good bandaging job will give better results "in the field".
I can place arterial and venous catheters in premature babies, in the hospital, with sterile equipment and sedation if needed. No way does this translate into the experience necessary to suture someone outside the hospital setting.

Would I ligate a bleeding vessel - yes. I've done it hundreds (if not thousands) of times - if the choice is bleeding or ligating, I'll ligate. If I can control the bleeding in other ways(pressure/wound packing, etc...), that would be my first choice.

Would I close a wound, probably not - again,as stated before, the risk of infection is too great. I've closed more wounds than I can recall (I'm a PA, working in surgery), from operative wounds to traumatic wounds. I've also treated more wound infections than I can recall (some from operatiions, some from trauma, some just localized infections from folliculitis, etc..). The open wound will more than likely not kill you, overwhelming sepsis can. Control the bleeding, apply a dressing, get to a higher echelon of care.

Sam

My first post here <img src="/images/graemlins/smile.gif" alt="" />

Short presentation: Scandinanvian MD with some ER practice and who recently did the (American) AdvancedTraumaLifeSupport course (the most used and probably best course in this field for MDs and Surgeons currently available)

Over to your questions:

1. If practically possible the absolutely best way to stop bleeding is manual pressure. Just look in the wound where the bleeding comes from and press there just hard enough to make it stop. This way no further harm is caused and the bleeding is stopped. Tie-off and suture damages tissue and complicates definitive surgery later on.
Suture is the most efficient of these two alternatives in some cases but also more technically difficult and might cause more damage.

2. Not sure I understand your question correctly. In the field the only wounds I would suture are scalp wounds without cranial fractures, if it bleeds profusely and the bleeding cannot be stopped in any other way. The suture in this case is a very efficient way of stopping the bleeding and infections are not as dangerous as in other parts of the body.
If a patient arrives to the hospital with a wound closed in the field I would suture it after rigorous flushing with saline if:
* The wound is caused by a clean object.
* It is no more than 8 hours old.
* Pulse,skin temperature, sensitivity and motor function "below" the wound all are ok. (Otherwise surgery might be required.)

The above answers are based on my personal competence and experience and might differ from what is the best solutions for other people in other places.

So ladies & gents,
can I assume that unless you have a decent level of competency/skill/practice/knowledge that comes with working in the 'hands on' medical profession, then for us luddites its best to stop the bleeding using direct pressure & elevation of the area affected and if that doesnt work, use indirect pressure on the arterial points before the wound..... clean up and cover to prevent further contamination and then hightail it to medical assistance.
Bear in mind, the UK is not that big so a day is the furthest from contact in a worst cas scenario. AND I never travel alone so if 1 goes down others can cover.

Reddave, you said what I believe... except the part about skilled individuals going ahead and suturing in the field. Even IF YOU ARE a trauma surgeon or some other similarly skilled practitioner, I disagree with suturing to close a wound in the field. This thread seems to always come up, and I guess there are always going to be forumites who still would suture.

So.. fair WARNING TO ANYONE who goes into the back country WITH ME:
1) Expect to get lost, and/or injured. Usually it's me who does so, but once (just once) it was the other guy.
2) If you get cut enough so bleeding is a problem, I promise to do my best to stop it with direct pressure or as a last ditch step with clamps or ligatures.
3) I promise I will not suture or staple to close the wound. I'll steri-strip, butterfly, ..even duct tape.
4) And if I'm the wounded party, I promise I'll cut or shoot you if you try to suture me! Then we can do it your way..on you!

Many have pointed out that you shoud clean the wound....having seen many things used, I would like to point out that the best is still soap and water. Don't use the peroxide or alcohol or much of anything else. KISS. Soap and water.

Thanks for the confirmation of my thoughts. With reference to the suturing, I just accept that I'm not medically proficient so that would be their call, as opposed to giving it the ok.
As for comment 4... yes you are absolutely right, because if I'm in big pain from bleeding cut, there's also the embarrassment of it. AND then you think I will willingly let someone hurt me by stickin' a big ole needle n thread through somewhere that's REALLY hurtin..... I take the same stance as you on that.
As for the duct tape.... have you tried pulling that stuff off after its been on for more than twenty mins?? Now changed over to using electricians tape for skin contact. Duct tape could be used instead for the grlfriends leg waxing, or substitute for your cars tow rope to pull it home. Its adhesion is lethal ( made more mess of my thumb than the cut it covered)
Anyway, thanks for putting my mind at ease

Re the duct tape. Actually, when we use it to butterfly an eyebrow and eyelid lac. it was because it was handy and waterproof. It was no problem to remove: we just instructed our buddy to leave it alone untill the hunting trip was over and he got back home. Then.. let his doctor look at it and possibly remove it. So you see.. no problem to remove (for me!).

Q1: If there was no other way to stop the bleeding and the vessel was critical yes. I would ligate the vessel leaving plenty of remnant suture for the attending surgeons to locate the vessel ligated later. This situation would most likely apply to limb injuries and the collateral flow in the limbs are sufficient even if you ligate one major bleeder.

Q2. As I have stated many times before in this forum, NOT if I had a choice. The best option would be for it to be cleaned and dressed and secondary suture done in the ER/MD office where things are more controlled. That being said, if I had to insert a chest tube for a soldier with a tension pneumothorax in the field, I would.