Wound care. The Close.
The part that everyone has been waiting for! How to close that would. So first before we get to the actual close, let’s talk about the type of closing material and the should and should knots.
Last week’s news letter we talked about the types of injuries and the cleaning. I’m not going to re hash that. Other than being absolutely positively sure the wound is clean before closing. If not then you are sealing in bacteria in the perfect environment. And possibly sentencing your patient to at the minimum a really cleaning of the wound AFTER YOU READ OPEN IT. To a full on infection, to them losing their limb and or life. Okay, clear?
Types of closure devices.
There are multiple methods to close with. Glue, tape, suture, Staples and there are some herbal methods that can be used on their own or in conjunction. So in no particular order:
Suture. Sutures are basically string. That string is broken down by construction of the string. Monofiliamnet or Multifiliament( Braided). Also type of material. Synthetic or Natural. And the duration of the material. Permanent or absorbable. The list is bewildering since each type has a specific area to be used on, strength and duration.
Suture sizes. Think of suture numbering like shotgun bores. The bigger the number the smaller the diameter of the suture. O is bigger than 2-O. 4 is smaller than 1.
Natural vs synthetic
Natural sutures can cause localized inflammation in the area where the suture contacts.
Synthetic. Rarely causes any reaction of the suture sites
Braided vs Monofiliamnet.
Braided suture is easier to handle knots much more easily. But braided used in skin closure can cause “wicking “. Think of a kerosene lamp. The cotton wick combined with the heat of the flame causes a capillary action and draws the oil to the flame. The same happens to braided sutures. That is why we say keep sutures dry. The heat of the body and any wetness is sucked into the wound.
Absorbable vs Non absorbable.
Absorbable are perfect for internal closure but have a lot lower tensile strength and can cause inflammation due to the absorption of the suture. Non absorbable have a lot higher strength and are perfect of supporting structures. When used for skin they need to be removed
We are going to limit then sutures to just a few.
Monofiliamnet. This comes in two types. Absorbable and non absorbable. Think of monofiliamnet as fishing line.
Braided. This is also divided but more so than monofiliamnets. These are separated by absorbable and non. Also on natural or or synthetic. And then add in the absorbable and non absorbable.
Sutures are my LAST resort for closing in the field. Unless you have control over your shoulder environment and the resources and ability to ensure a wound is clean then use another method. Also remember unless you are very skilled in suturing and do a internal running mattress or its equal, every time you place one stitch you are making at least 2 new holes in skin. If you cleaning job isn’t up to snuff you add 2 new holes for each stitch . You are begging for an infection. That being said on a large wound, say over 2 inches long and past the dermal layer then I would and have put in one or two to hold it together and then pulled them and did a good cleaning with an antibiotic wash.
Natural Absorbable Synthetic Absorbable Braided
Absorbable monofiliamnet Synthetic Monofilament
Synthetic Braided Natural Braided
Staples are pretty new compared to sutures. They are very expensive compared to sutures. But require a lot less skill to use. Suturing is a learned art. Everyone can learn to suture but not everyone is an artist at using them. Staples on the other hand take a short class and that is about it. There is no special technique nor skills oppose the skin, center the staple guys and deploy. Their biggest disadvantage of staples to sutures are cost, they SHOULD have a special tool to remove them and if SHTF your can’t easily refill a staple gun. Suture on the other hand as long as you have fishing line and a needle you have sutures.
The new Super glues are a godsend on disaster/emergency medicine little skill is needed. There are 2 types that are common. The normal super glues found at the local department store and the medical grade skin glues. Super glues are normally Ethyl cyanoacrylate and the medical glues are 2-Octyl cyanoacrylate. The same base chemical but world’s of difference in the finished product. Super glues dry hard and brittle and medical glues are rubbery. Also skin glues cost about 10 times that of super glues. Both of the glues should be only used on the epidermal, or outer layer of the skin. If the glues are allowed into the depth of the wound then intense itching and irritation will occur. For months. They should not be used where strength is needed they offer no support to the skin or structure. They generally wear off in 7 to 14 days. One big advantage is that when properly applied it makes a water proof bandage over the wound, but that is also disadvantage. If the wound is not perfectly clean and sealed and an infection sets in it will be bad unless the Medic can recognize the infection and stop it.
However with all those disadvantages it is my first choice for field dressing. Stop the bleeding. Start at one edge and seal. Done and done! By having some nail Polish remover the wound can be painlessly re opened and cleaning done. If you do not have, or wish to buy the medical grades glue, get the best super glue. In my OPINION the best I have found is Locktite (c) control tip Gel. Stay away from the runny liquid glues.
Tape has been with us for centuries. Tape has bound more wounds than all the suture staples and super glue ever used. The key to using tape is to have the wound and surrounding ding area perfectly dry. To increase the “stickiness ” a spray adhesive called Benzoin is applied. Benzoin is a type of pine sap dissolved in alcohol. In a SHTF situation pine sap can be used. Here in the SW. we use Pinion sap for its stickiness and it’s antibacterial properties. The best way to minimize scaring and infection is to cut the taped into Strips about 1/4 inch wide buy about 1 to 2 inches long. Start at on edge, lay the tape and pull over the wound and stick the other. The Strips should cover the entire wound and they should be left on until the fall off on their own. Steri Strips (c) are a commercial version that are great for temporary and permanent wound closing.
What if you are out of commercial suture and super glue?
If you have none or run out there are alternatives to buying your suture from Johnson and Johnson (c) Basic fishing line in weights 1 lb to 10 pound correspond to 4-0 to @O monofiliamnet suture. Un dyed and unflavored dental floss is a close match to 0 nylon suture. Yes Horse tail is an excellent monofiliamnet. Now all these lines need to be sterilized before use. None can stand the heat of steam sterilization so your best bet is to wash the suture in soap and water rinse completely the tie the suture to your needle and then place in 190 proof Ethyl alcohol. To tie the suture to the needle just pull it though once and then tie one half hitch slide it down to the needle eye and then tie one more on top. Be sure not to make your knot bigger in diameter than the needle.
There is not one part of the wound care process that is more important than any other. All must have equal attention to detail for good results to happen. Also it is impossible to give every detail and nuance of wound closure in a news letter. That is what we have classes for. So keep an eye out for a suture class in your location or if in New Mexico please consider the Medic Shack for you Ditch Medicine education
Current Training Schedule
These are the classes for The Medic Shack. For local central NM classes they will be held at Lovelace Medical Center. (LMC)
601 Dr. Martin Luther King Jr. Ave NE Albuquerque, NM 87102
July 8-10t 2016 POSTPONED TO AUGUST 11-13 DUE TO RANGE SCHEDULING CONFLICT. Personal Defense Handgun II and III (TMS is just helping sponsor. I’m taking the class also!!) Sign up here!!!
Herbal First Aid Course July 23rd and 24th Albuquerque NM
Early Bird Special! Type in EARLYBIRD in the coupon code area for a 20% discount!
Wilderness/Disaster Medic Class.
August 12th to Monday August 15 At the Eagles Lodge in Bethany Missouri
Arrrgh My wife told me to wait til the end of the month for the drawing for the Tactical Hot pack. Sign up for the news letter and get entered into the drawing!
********* DISCLAIMER **********
Use of the information on this newletter is AT YOUR OWN RISK, intended solely for self-help, in times of emergency, when medical help is not available, or expected to BE available The information on this site is meant to be used only during times when improvisational, last-ditch efforts are all that is possible. The hosts of The Medic Shack assume that if you are using this information that TSHTF and no help other than what YOU have is forth coming. DO NOT USE THIS INFORMATION WHEN YOU CAN GET MORE TRADITIONAL OR PROFESSIONAL CARE.