Sutures - Yay or Nay

[ptAltered]

In my lurking hours here I've seen many a kit that has sutures or a poster expressing their desire to obtain some sutures. I'd like to submit that the modern wilderness/austere medicine professionals recommend against suturing wounds in the back country and frequently even in the "front" country. I've seen wounds sutured, stapled, duct taped, DermaBonded, Krazy Glued and approximated using butterfly strips (or Steri Strips) and I've seen the best results with the Steri Strips.

The big myth here, I think, is that sutures are a life-saving intervention. In reality, physicians only use sutures on wounds that have stopped bleeding and are no longer life threats. If the patient is still bleeding the solution is pressure and absorbent dressings not a suture.

It's established then that we'd only even consider using sutures on a patient that was no longer bleeding. Our biggest concern now is prophylactic prevention of and monitoring for infection and following our first order, to do no further harm.

Each suture site (two per suture) is another open wound that can become infected. Each suture site is a puncture wound that could hit a nerve and cause permanent disability.

For these reasons I think that sutures should be excoriated from the austere/wilderness/backpacking medicine box. I've always had the best success in the backcountry with wound irrigation and approximation using Steri Strips and benzoin. These skills alone can be mastered in a few hours of practicing irrigation and wound closings on pigs feet from the butcher shop.


Looking forward to the community input...


Mo

[Kutter_0311]

My buddy just bought some vet sutures from Fleet Farm, and has been practicing on oranges. He's getting pretty good, and none of them have died. Also, the packaging is really beefy. Those things will store well.

As far as concerns over should one keep or use sutures, that's up to you. I'd rather have some (and be practiced at it), than not. You may be only 3-5 days from a surgeon, or they may have been wiped out by a biological incident. Train now, while you can, and have that tool in your toolbox...

[AKFTW]

I don't know, I think I'd rather have Steri-Strips or other adhesive would closures instead of sutures, cause just the idea of me having to literally sew myself or someone else up makes me a little queasy

[Kutter_0311]

I don't know, I think I'd rather have Steri-Strips or other adhesive would closures instead of sutures, cause just the idea of me having to literally sew myself or someone else up makes me a little queasy

I don't say only pack sutures, as the situation will dictate what you should use.

I would not limit myself to only one kind of anything.

[bonanacrom]

Interesting. But it could be said that most would apply pressure until the bleeding stopped, then suture. If far from medical assistance or when it is not known if any will even be found a decision must be made. With that in mind I ask about the in the back woods ? At home a butterfly bandage or equivalent may work fine, but in the back woods you will be moving a lot and that would not likely last, sutures are fine but, how many can do that by themselves ? Or even if they can what about in a not easily reached by yourself spot ? Napoleon Bonaparte had reports from his field surgeons that the use of the original staples healed wounds faster and with less infection than sutures. The complaint that staples result in puncture wounds that can get infected is amusing, the open wound is a giant infection waiting. Everyone has there opinions, I personally have been closed up with all mentioned techniques and the fasted healed was the glue,.

[Jamie]

I don't pack sutures in my FAKs...I have other wound closure stuff that I feel safer with in the backcountry...steri-strips, gorilla tape, crazy glue...all of these things have a place in my backcountry FAK, and are more multi-purpose in my mind.

Jamie

[abelru]

FWIW, staples can achieve adequate and often, equivocal wound closure in lieu of sutures. I've become a big fan of staples over the past few years for primary closure of superficial traumatic wounds to the scalp, and occasionally extremities.

My biggest barrier to using staples more frequently has been patient concern for cosmetic result, and occasionally wound characteristics.

One very tangible benefit to using staples is that they require very little training, and skill regression over time is favorable when compared to sutures. Additionally, the use of staples greatly reduces the amount of equipment needed to achieve closure. Just ensure that if you put 'em in, you are capable of taking 'em out.

Some fairly recent research has demonstrated increased rates of surgical wound infections with the use of staples for closure, primarily with orthopedic surgery of the hip. Anecdotally, I have not noticed a great difference in wound infections either way.

Steri-strips and dermabond are another closure technique to consider as an alternative to suturing for your bread-and-butter superficial lacerations (especially when treating kids). I've worked with a handful of cavalier practitioners who seemed inclined to dermabond nearly every lac that came through the door. I was, on more than a few occasions quite surprised at how well most patients fared with this technique. The key factor seemed to often boil down to the size of the steri-strip used. Apparently, bigger really is better.

So are sutures a worthy investment? Depends. No skill is not worth learning, but do you have the time, opportunities, and money to both learn to suture and maintain the skill over time? If yes (and not legally prevented from doing so), go for it. If not, consider your alternatives.

I would argue though, that your assertion that each pass of the needle potentially could result in permanent nerve damage and disability is overexagerated. Only in very extreme circumstances can I envision a scenario in which a suture needle causes lasting damage to a nerve of any consequence. Especially when closing superficial (subcutaneous layer and above) layer defects.

One last aspect to ponder is that most superficial wounds will heal with a favorable outcome with little more than basic first aid.

[IANMCDEVITT]

no sutures

[greenbeetle]

Nay.

For reason stated. Do you have lidocaine with your suture kit? Most people will not let you sew with their skin otherwise.

[stimpy321972]

Coming from someone who knows how to suture/staple, etc and does so on a routine basis. I can't think of a scenario, where as the OP stated that steri strips or duct tape would not achieve what you need. If something is bleeding that bad, you normally need at least two layers of sutures (deeps and surface) plus you need to suture or cauterize whatever is bleeding first before you close anything. If you don't stop the major bleeding, sutures will just help to create bigger problems.


In the field if you are not going to have professionial medical services within a reasonable amount of time, keep it as simple as possible.

[duodecima]

Unless you are specifically trained, nay. And even then, do you really need them in your circumstances?

Many small lacerations may heal more quickly and with less scarring with sutures - but will heal none the less without, and for the smaller ones, other ways to bring the wound edges closer together are frequently adequate - steristrips +/- dermabond. For the bigger ones, if you're not trained, you may not want to be suturing in those situations. Now, STERISTRIPS should absolutely be part of people's kits - simple, small, light, self-explanatory, and frequently very effective.

I DO have lidocaine, and means to inject it, but again, this is part of what I do for a living, and it's not in the kit I would usually carry. Things I would be thinking about - how dirty is this wound and can I clean it effectively with what I've got? How deep is it, and what other tissues may have been damaged? A lot of those injuries will be better served by getting the patient out of the woods to a hospital, if that's an option. The only thing I can think of that sutures might be really useful for is a regular lac that just happens to be over a joint, where there's a lot of stress across the lac, and sutures will be better at holding it closed. (This assumes I can get the wound as clean as it needs to be).

[majorhavoc]

Excellent early contribution, ptAltered.

This is really interesting to me because a suture kit has been one of those things I've been considering to expand my FA capabilities. But I've been viewing it with some trepidation because I lack the training to use them effectively. I've been worried I'd be doing more harm that good.

It's a huge to relief to hear that I can get most if not all of the wound closure benefits with alternatives like Steri strips and Derma bond. Now I just need to investigate those alternatives and figure out how to get competent at using them (I don't have ready access to pigs feet).

[duodecima]

It's a huge to relief to hear that I can get most if not all of the wound closure benefits with alternatives like Steri strips and Derma bond. Now I just need to investigate those alternatives and figure out how to get competent at using them (I don't have ready access to pigs feet).

Your grocery store doesn't have pigs feet (or the meat deparment can't get them)? That's where we always got ours.

I like using tinture of benzoin applied to the side of the lac, to help adhere the steristrips really well. (Don't get it IN the lac, stings like the devil.) Also, cut the steristrips to the length you will want them while still on the card, then use a tweezer/forcep to apply them with - they stick to your own skin and gloves while you're trying to put them on even more than bandaids do. I drop one end into the benzoin on one side of the wound, and then pull laterally to get the edges (hopefully) as close as I want them, then stick the other side down.

[KnightoftheRoc]

I'd rather have the option of sutures, than not. It wouldn't be my go-to approach, but for deep lacerations, and no medical help, they'd be useful. Tapes and such can only close the surface portion of a wound- what about the inside of it? Leaving it with a pocket of non-sterile air inside it is asking for problems, no matter how clean you got the wound before closing it. My understanding is that this is why they pack wounds, as well as bleed control. I'd rather have the hole in me packed with clean, sterile gauze than a possibly infected pocket of air that I cannot monitor for signs of trouble, and deal with it early on.

I am not trained with sutures, but have done a fair amount of hand sewing, including a few stitches in myself from time to time- and let me tell you, sewing yourself shut is no fun. I have also used superglue for wound closure. I find the glue to be preferable to me. It's fast, it's strong, and it was originally intended to bond human tissues together- cyanoacrylate (C5H5NO2, for you chemistry buffs) was invented by heart surgeons to quickly bond arteries and allow for stitching with minimal blood and time loss. I work small doses at a time, deep into the wound, and work my way outward in layers, to eliminate air as I go, with wound cleaning in between gluing applications. So far, I've had no infections happen with this approach- I may have just been lucky, or I may have just been doing it "right", I don't know. But when you're miles from help on a job site, and the time loss in the ER could mean the difference between eating or not, you do what you need to.

There's a reason the initials "MD" are NOT following my name- I'm a plumber by trade, not a physician, so don't take what I offer as medical advice.

[TacAir]

If I get to vote, no.

In my case, it's a matter of the law.

TITLE 09 CODE OF CIVIL PROCEDURE
CHAPTER 65 ACTIONS, IMMUNITIES, DEFENSES, AND DUTIES
SECTION 09.65.090

(d) This section does not preclude liability for civil damages as a result of gross negligence or reckless or intentional misconduct.

Since in Alaska, Registered nurse scope of practice does not include suturing, the case could be made that suturing is exceeding a level of practice, making the act 'reckless' - more or less. YMMV. Me? I carry SteriStrips and butterfly bandages.

[ptAltered]

Interesting. But it could be said that most would apply pressure until the bleeding stopped, then suture. If far from medical assistance or when it is not known if any will even be found a decision must be made. With that in mind I ask about the in the back woods ? At home a butterfly bandage or equivalent may work fine, but in the back woods you will be moving a lot and that would not likely last, sutures are fine but, how many can do that by themselves ? Or even if they can what about in a not easily reached by yourself spot ? Napoleon Bonaparte had reports from his field surgeons that the use of the original staples healed wounds faster and with less infection than sutures. The complaint that staples result in puncture wounds that can get infected is amusing, the open wound is a giant infection waiting. Everyone has there opinions, I personally have been closed up with all mentioned techniques and the fasted healed was the glue,.

After we've controlled the bleeding, which is the first step for any wound closure that isn't surgical (i.e. deep artery bleeds necessitating restructuring and suturing by a surgeon in an OR), we're primarily concerned with infection or as you mentioned, reinjury to the wound either in evacuation or further activities.

Tincture of benzoin, a sterile adhesive, should be used on the sides of the wound being approximated together with Steri Strips and after the strips are applied, a piece of tape running perpendicular to the strips is used on the edges to hold them down. If the wound becomes infected (due to a lack of proper irrigation), it's easy to remove the strips and open the wound to be cleaned effectively. If a deep lac that was sutured in the wild by untrained practitioners becomes infected then we've got to remove the sutures and clean the wound, who knows if any of the suture channels have infected material in them and deep, narrow gauge punctures are hard to irrigate.

I've found that Steri-Strips hold up fine to almost every condition except HEAVY sweating, and even then it's just a matter of reapplying more strips as necessary.

Thanks for the input! I'm off Wednesday, maybe I'll grab some pigs feet and do a video demonstration of wound irrigation and approximation.

[ptAltered]

I'd rather have the option of sutures, than not. It wouldn't be my go-to approach, but for deep lacerations, and no medical help, they'd be useful. Tapes and such can only close the surface portion of a wound- what about the inside of it? Leaving it with a pocket of non-sterile air inside it is asking for problems, no matter how clean you got the wound before closing it. My understanding is that this is why they pack wounds, as well as bleed control. I'd rather have the hole in me packed with clean, sterile gauze than a possibly infected pocket of air that I cannot monitor for signs of trouble, and deal with it early on.

You've hit the nail on the head! A DEEP laceration should NOT be closed in the field, by any means. Leave it open, pack with moist dressings and monitor for infection. Once the wound has begun to heal on the inside you can consider other methods of closure. Pack that wound, keep it covered with a semi-occlusive and monitor it daily for signs of infection. (Redness, tenderness, red streaks distal to the site, increased temperature, nasty smell, pus-y discharge)

I am not trained with sutures, but have done a fair amount of hand sewing, including a few stitches in myself from time to time- and let me tell you, sewing yourself shut is no fun. I have also used superglue for wound closure. I find the glue to be preferable to me. It's fast, it's strong, and it was originally intended to bond human tissues together- cyanoacrylate (C5H5NO2, for you chemistry buffs) was invented by heart surgeons to quickly bond arteries and allow for stitching with minimal blood and time loss. I work small doses at a time, deep into the wound, and work my way outward in layers, to eliminate air as I go, with wound cleaning in between gluing applications. So far, I've had no infections happen with this approach- I may have just been lucky, or I may have just been doing it "right", I don't know. But when you're miles from help on a job site, and the time loss in the ER could mean the difference between eating or not, you do what you need to.

I hear ya on that last part. Very few lacerations have much open space inside. If you can stop the bleeding totally, irrigate the wound with the best water you've got (or toss a Povodine-Iodine prep pad in a zip loc baggie with a few hundred mL of water), then you can easily close the wound with Dermabond. The only reason I like Steri Strips over DermaBond is that, if the wound becomes infected, you can remove the strips rather painlessly and deal with the infection.

Thanks for the input!


One PS. Super Glue has noted necroticity when used on live tissue, DermaBond is a special type of cyanoacrylate that is better tolerated by tissues.

Excellent video on DermaBond application and use;
http://www.youtube.com/watch?v=TAzPDIrrcfg

[ptAltered]

I would argue though, that your assertion that each pass of the needle potentially could result in permanent nerve damage and disability is overexagerated. Only in very extreme circumstances can I envision a scenario in which a suture needle causes lasting damage to a nerve of any consequence. Especially when closing superficial (subcutaneous layer and above) layer defects.

It's a risk and it depends on location. The wounds that are most frequently sutured are wounds to the fingers, how much sub-q tissue is present there and how do we weigh that against the ennervation and loss of function? We need to weigh the risk of not using sutures against the risk of using sutures and I feel the risk of puncturing a nerve or it's sheath is greater with a suture than with topical wound closures.

One last aspect to ponder is that most superficial wounds will heal with a favorable outcome with little more than basic first aid.

This is also VERY true. In urban settings the biggest issue is usually the cosmetic outcome. In wilderness or austere conditions, or in a Third World nation, the biggest issue is infection secondary to the laceration. Wound irrigation and proper closure can prevent a minor laceration turning into systemic infection and shock.

HTH!

[dallas]

The complaint that staples result in puncture wounds that can get infected is amusing, the open wound is a giant infection waiting.

This reminds me of a story I read as a kid. It was about the Doolittle raid. One of the planes ditched close to a beach. The navigator or bombadier was thrwn throught the nose and compound fractured his leg along with a big gash on it. Every thing was going fine until the Chinese resued him days later and pulled him into a junk.

When they pulled him in, he got a small scratch on his ankle that got infected. He had to have his leg amputated over that not the big compound fracture. Go figure. The main problem with suturing is sewing bacteria into the wound. It is easier to keep it clean and uninfected if it is open.

[dallas]

You've hit the nail on the head! A DEEP laceration should NOT be closed in the field, by any means. Leave it open, pack with moist dressings and monitor for infection. Once the wound has begun to heal on the inside you can consider other methods of closure. Pack that wound, keep it covered with a semi-occlusive and monitor it daily for signs of infection. (Redness, tenderness, red streaks distal to the site, increased temperature, nasty smell, pus-y discharge)

+1

[KnightoftheRoc]

I would argue though, that your assertion that each pass of the needle potentially could result in permanent nerve damage and disability is overexagerated. Only in very extreme circumstances can I envision a scenario in which a suture needle causes lasting damage to a nerve of any consequence. Especially when closing superficial (subcutaneous layer and above) layer defects.

It's a risk and it depends on location. The wounds that are most frequently sutured are wounds to the fingers, how much sub-q tissue is present there and how do we weigh that against the ennervation and loss of function? We need to weigh the risk of not using sutures against the risk of using sutures and I feel the risk of puncturing a nerve or it's sheath is greater with a suture than with topical wound closures.

[quote][quote]

I'll argue this one a bit from the POV of the patient. Sure, the risk of SOME nerve damage is present- it's there in an ER, too. But, I've already injured the area, possibly some nerves with it, and faced with a choice of some nerve damage, or losing limb, possibly my life, from an unclosed, infected wound, SEW ME UP!!! That's a rather minor risk IMO, compared to what the alternatives could be. I'm not failing to see your point, and I actually agree wit it to a point. If sutures or something else can do the job equally well, sutures shouldn't be the choice. But if sutures are called for, the tiny amount of damage a suture needle can do, vs the major damage otherwise, sutures wins, hands down, to me.

[PotatoMuncher]

If you're experienced, yay. If not, either learn from someone who's certified or nay. It's nothing I'd really be willing to teach a civilian with next to no medical experience. But to an EMT-I or even an advanced Basic (like myself) sure.

Personally, I keep a suture set in my trauma bag and a couple extra stored away in my closet.

[ptAltered]

If you're experienced, yay. If not, either learn from someone who's certified or nay. It's nothing I'd really be willing to teach a civilian with next to no medical experience. But to an EMT-I or even an advanced Basic (like myself) sure.

Personally, I keep a suture set in my trauma bag and a couple extra stored away in my closet.

I'm strongly in disagreement here. Definitive wound care isn't something a street practitioner needs to worry about. I think all of the commotion about sutures is because of the incorrect assumption that sutures are a life saving intervention applied to severe bleeding. No protocols or medical professionals in the civilized world indicate the non surgical use of sutures to stop bleeding. Direct pressure with hemostatic agent if indicated, pressure dressing with absorbent gauze, tourniquet. That's how bleeding is controlled and that's what a trauma kit should focus on, in my opinion and according to both my urban and wilderness protocols.

After bleeding has stopped the decision regarding closure comes up. I'm going to assume austere, wilderness or apocalyptic setting here; almost all soft tissue injuries should be irrigated with clean water and the highest pressure that a 60mL syringe and soft plastic catheter tip can generate. Deep lacerations and punctures have a much higher risk of infection and should not be closed. Smaller and shallower lacerations can BEST be closed by wound approximation using strips.

When you're looking at some wound always ask yourself what the worst case scenario could be and think up ways to avoid it. When I see a wound that isn't bleeding and isn't, of itself, a life threat I always consider infection. A shallow laceration that isn't bleeding doesn't need invasive procedures performed by laymen, it needs to be sealed in a manner that allows it to heal naturally and enables quick access for irrigation should infection occur.

Everyone thinking about invasive medical procedures instead of simple, effective techniques needs to have a plan for dealing with the deep set infection that could occur. And for what, really? Using sutures doesn't guarantee a better outcome. More risk for no real benefit. Think of your loved one in front of you with a horribly infected wound that's sutured up. You're in a remote setting and you've got no IV antibiotics, no medical professionals nearby and just whatever kit you've brought that contained the sutures. Action plan? You've got to access the infected tissue so the sutures come out. Then you've got to irrigate the area again, and what about debriding the area? Perform another medical procedure without training and hope for the best?

I'm adamantly opposed to sutures. I've got access to them at work and I'm sure a physician would provide some training with the understanding it's out of intellectual curiosity and that I'm not authorized to perform the procedure. I've seen doctors opt for approximation with strips, DermaBond or staples before sutures.

If you're planning on bringing something or performing medical procedures be prepared for side effects or consequences. I feel confident in my ability to clean and close a wound with topical devices and to monitor that wound afterwards.

be safe!

[PotatoMuncher]

While I do agree with your logic (that's exactly what I was taught in medic school), I also do believe it's a skill worth learning much like inserting chest tubes, or performing venous cut downs. I'd rather know how to do it and not need to do it, than need to do it and not know how.