December 25, 2006
A Stitch in Time?
Nestled within my field medical pack is a small blue zippercase containing two syringes, three 25 gauge needles, a small bottle of Xylocaine, gauze, gloves, a sterile drape, suture forceps, scissors, and various sutures. This bag goes where I go, and for no real reason.
I do not think I have ever come across a situation where suturing had to be done in the field. I know, a lot of people will be now saying “what about deep lacerations?” or “yeah, well you can’t have ever dealt with a bullet wound!”. Well, the simple truth is that without a guaranteed clean wound, stitching or rather suturing is not the treatment of choice.
When closing a wound by the use of sutures the main goal is to align surface tissue to prevent the influx of infection, and to minimize scarring. Pressure, rest, and the body’s incredible ability to clot blood and begin repairs minimizes the need for the so-called “stop the bleeding” stitches. Sure, they help but they can also kill.
Consider the following examples:
A)
John “Rambo” Testosteroni is power hiking the hills when he steps onto a crumbling portion of an embankment. Upon waking up, he notices he is now at the bottom of the ridge he had been on. Thanking his stars that his fall was broken by the swamp he landed in, it takes a while for him to realize he has a two inch gash along the proximal aspect of his left forearm. It is a three hour walk back to civilization, so pulling out his genuine “First Blood 1AB Survivor” knife, he coolly spins open the hollow compartment in the handle, avoiding the hideous glob created by the merger of his wire saw and the Mars bar he put in there last year, and fishes out his trusty suture set. Quickly tearing open the sterile packet with his teeth, John deftly starts pushing the cutting needle through his arm.
Five curses to the very gods and seven minutes later, all bleeding has stopped and John prepares to carry on home. Thanks to proper preparation, another disaster has been averted.
B)
Dave Donegettum has succesfully bagged another Muley! After gutting the beast, he is hard at work caping it in the crisp autumn air. Without at first feeling it, he has unwittingly sliced into his left palm with his drop point skinner. Noticing the newer blood, Dave figures this isn’t too good! Sitting down to collect his thoughts, he pulls out a wad of cloth from the depths of his jacket and applies direct pressure to the injury. After a few minutes he checks the extent of the damge. Yep, it be a gooder. Clenching his wounded hand in a fist around the cloth, Dave realizes he is going to have to get stiches in that puppy, and pretty soon. Pulling out his hunter medical kit, Dave selects some tincture of benzoin, a packet of ¼” wound closure strips, and some povidone.
Liberally applying the povidone to the injury, Dave then applies the benzoin to the skin around the laceration. Once this has set, he places the closure strips across the injury. After wrapping it all up nicely with a conforming gauze bandage, Dave puts his gloves on and prepares to get the attention of his hunting partners…maybe they won’t mind packing out his bag while he heads to town to sober up the doctor.
Now, I know these sound like pretty sad examples, but if I were to bet on who ends up with a bad scar and even worse infection, it would be John. Self suturing works great on film. All field suturing causes additional entry points for infection. Poorly done suturing results in tented skin, crushed subcutaneous tissue, isolated pockets of infection, and airspaces where aerobic pathogens hold wild parties.
Application of povidone minimizes the presence of pathogens without increasing pain, wound closure strips do not damage underlying structures, and they do not introduce more pathogens. Covering the site with a loose yet secure layer minimizes chances of contamination.
Consider the following excerpt from a study on suturing versus taping from the Department of Surgery, University of the West Indies, General Hospital, Port-of-Spain, Trinidad, West Indies.
Background: In less than ideal situations wounds have to be closed without extensive cleaning using sterile adhesive strips (Steristrips). This prospective analyses the efficiency of this technique and compares it to the more conventional approach.
Methods: Altogether 147 lacerations were closed with sterile strips with no wound cleaning. Patients were subsequently followed up for a minimum of three months.
Results: The sepsis rate in compliant patients was 1.4% with a total complication rate of 2.7%.
Conclusion: This technique, while contradicting the "sacred tenets" of wound closure, is a cheap, quick, and effective alternative to routine closure of traumatic wounds in a casualty department.
The most practised method of skin closure is suturing the skin edges together. This process requires expensive suture material, sterile instruments, a minor operating theatre, cleaning solution, local anaesthesia, and an assistant. In the third world accident and emergency setting, such facilities are sometimes not readily available but even when they are, cleaning and suturing involves increased cost, longer waiting time, and a longer procedure—cleaning, draping, giving local anaesthesia, suturing, and dressing the laceration. On occasion we have had, in apprehensive children, to resort to tape closure of wounds without injecting anaesthetic and without cleaning or suturing. We have also had to do this in adults admitted to the ward when it was not possible to get into the theatre within six hours. We noticed, however, that these wounds healed quite well, with a low incidence of infection, and decided to study tape closed wounds prospectively. All the wounds in our study were a result of trauma outside hospital in a non-sterile environment, with non-sterile objects, and therefore were considered contaminated.
A total of 117 patients with 147 wounds were studied. Their ages ranged from 2–65 years (mean 29 years); 61% (89) were male. Wounds were inflicted by assorted instruments, the most common being knives 40 (27%). Fifty two (35%) were due to blunt trauma.
Forty one per cent of the wounds were on the face, 21% on the trunk, and 38% on the limbs. The length of the wounds varied from 2–17 cm (mean 8 cm). The depth varied from 0.25–2.0 cm (mean 1.0 cm).
There were three infected wounds. One wound became infected in a patient who removed both the dressing and the strip on day 2 and refused further treatment. The other two cases were detected on day 5 and were treated with antibiotics. Steristrips were reapplied on day 7 and healing followed an uneventful course.
One case of dehiscence was seen in a patient who removed the strips on day 3. The wound was restripped on day 5 and healed uneventfully thereafter.
The overall sepsis rate in compliant patients was thus 1.4%. Dehiscence occurred in 0.7%. The total complication rate was 2.7%.
Ten per cent of the patients had previous suturing of wounds. Subjective assessment of patients' experience with tape and suture closure revealed that all expressed a preference for tape closure, claiming that it was far less painful than the conventional technique. They have so far all been pleased with the surgical scar.
Sutureless closure of wounds gives a lower rate of infection than those sutured. The number of organisms needed to cause an infection is reduced by a factor of 10 000 in the presence of a silk suture. Further, tape closure decreased sepsis and it has been shown that survival of Staphylococcus pyogenes is reduced under micropore tape. Regardless of how meticulously a wound is cleaned, repeated puncture of the suture needle will inoculate the subcutaneous tissues with organisms. The suture material itself is a potential source for foreign body reaction, and in addition may cause strangulation of the tissues leading to ischaemia and necrosis and create the ideal milieu for infection. Tape closure thus leads to a lower infection rate when compared with thread closure especially in contaminated wounds.
Traumatic wounds produced in a non-sterile environment are already contaminated both with micro-organisms and microscopic inorganic debris. Surgical convention dictates that such wounds should be meticulously cleaned, chemically and/or mechanically, by irrigation and scrubbing. Our study disputes this dogma. Using tape closure in wounds with no microscopic signs of contamination and without formal chemical or mechanical cleaning, we were able to obtain an overall infection rate of 1.4%. This compares well with previous studies where overall incidence of infection for tape closure of cleaned abdominal surgical incisions was 1.1%. We excluded all wounds with obvious gross contamination: those with particulate matter and necrotic tissue. Such cases are better treated in the conventional manner, with copious irrigation and debridement of soiled or necrotic edges.
The technique of tape closure without cleaning may be performed far quicker than the conventional approach with no need for a formal operating room. This technique is also far cheaper as there is no need for expensive sutures, sterilised equipment, sterile gauze, sterile gloves, cleaning solution, or local anaesthesia. Because of the technical ease of the procedure, no assistant is required to cut sutures or administer local anaesthesia. Furthermore, the patient does not have to return for removal of sutures and can be discharged with advice on infection. The patient is not subjected to the pain or discomfort of anaesthesia injection, suturing and removal of sutures, and therefore finds this treatment more acceptable. Cosmetically, tape closure is not associated with needle puncture marks and crosshatch scarring, features which make suture closure relatively unacceptable, especially in patients with keloids or hypertrophic scarring.
Similar findings have been described by other medical professionals worldwide. Why do I even mention a subject such as suturing on a Wilderness Medicine website? Simply because I receive numerous requests from individuals for suturing supplies. Now, as a capitalist I could just sell them some suture kits, but the medical side of me cannot give a person the tools without first informing them of the pitfalls.
I would also raise these points:
If you are going to suture someone, is the wound clean? Has it been irrigated?
If you are going to use Xylocaine, are you aware it hurts too?
Do you know, and I mean really know, how to inject Xylocaine?
Are you aware of the different types and sizes of sutures, and their uses?
Do you practice? Try suturing a pig’s foot from the butcher…nothing like a hobby.
Will you follow as sterile a technique as possible?
There are numerous alternatives to field suturing which do not prevent delayed suturing later (even days) at a hospital. In this day and age of toys and nifty gear, we have to remember that the patient is always the priority, and hearken to Hippocrates when he said “First do no harm.”
In coming thoughts, I will cover different types of suture alternatives. Remember this is what I say and think, if you differ in opinion please feel free to disbelieve or even better email me with your experiences.
Stay safe, play even safer…
Until next time,
Brian
Article cited was:
Department of Surgery, University of the West Indies, General Hospital, Port-of-Spain, Trinidad, West Indies
Correspondence to:
Dr Dale Maharaj, Department of Surgery, General Hospital, Port-of-Spain,
Trinidad, West Indies;
dalemaharaj@hotmail.com
Submitted 30 October 2001
Accepted 30 January 2002
Available in the RAEMS download section as closureofwounds.pdf