Lacerations are trauma which result in cutting or tearing of skin and possibly underlying tissue. Please note that deep lacerations that are complicated by the involvement of injuries to major arteries, tendons, nerves or abdominal cavity contents are not usually treatable in primitive conditions.
Initial Care for Lacerations
Most bleeding is initially controlled with pressure. Wounds without deep involvement should be surgically repaired if possible to speed healing, reduce infection, and improve cosmetic and functional results. The approximation of the skin edges can be achieved with steri-strips, skin glue, staples, or sutures (stitches). Before any wound is repaired, a few simple rules should be understood.
- The longer a wound is left open to the environment, the more bacteria it will collect and therefore has a greater chance of infection, especially if the wound is closed by trapping these bacteria within the wound.
- Most wounds can be closed within 12 hours of the injury (since the bacteria count won’t be terribly high). Since the face and neck have increased blood flow compared to most other body parts this extra blood flow helps the wounds fight infection and promotes healing, therefore wounds to the face and neck may be closed up to 48 hours after the injury.
- Wounds that are to be closed must be thoroughly cleaned of any debris using forceps (tweezers) and using generous washings with clean or sterile water or saline. One source suggested using fresh urine from person without urinary infection since that should be sterile (I think I would rather use boiled water).
Creating Saline Solution for Laceration Washes
Saline solution can be made by adding one tablespoon of salt to 1 gallon of water or adding 1 teaspoon of salt to 1 L of water. Another irrigation solution can be made by adding 5 mils of household bleach to 1 L of clean water. Washing the area with Betadine or hibiclens before closure should be performed. Ragged wound edges and the tips of angularly cut tissue should be removed so that the wound edges to be approximated are smooth and will be likely to heal.
Steri-Strips, skin glue, and sutures may be the most useful ways to close a wound in a primitive environment. Staples may be used but require removal with a specialized removal tool which may not be readily available. Steri-Strips (tape) and skin glue can be applied to many wounds to hold the skin edges together until healing occurs. These are less secure than sutures (especially in larger deeper wounds) but maybe faster, require less technical skill, and may offer an improved cosmetic result.
For larger deeper wounds, sutures may be best for closure. Some wounds may have skin loss such that closure of the skin edges may be under some tension. The strength of sutures would be better for that closure, over glue or Steri-Strips. Sometimes tissue loss may be extensive enough that complete skin edge approximation may not be successful. Some gap in the skin edges may be allowed in these circumstances. Tissue loss with tension on the closure would require that the sutures be left for a longer period of time until the skin has stretched and relaxed enough so that there is no significant tension at the wound before removal of the sutures. In wounds without tension on the face, the sutures may usually be removed in about 3 to 5 days (this rapid removal is because of the high blood flow which speeds healing). The sutures on wounds of the trunk without tension may be removed in about 10 days. Sutures in the hands and feet are usually removed in about 10 to 14 days.
Suturing a Laceration
In primitive environments absorbable (dissolving) sutures are usually not available. Simple sewing thread may be used for closing wounds. Silk and polyester thread is strong and tough and will tolerate autoclaving or other sterilization techniques and therefore has been used extensively in the past for sutures. Braided suture like polyester or silk thread also ties easily and therefore is easier for a novice to use. Currently monofilament suture material (like fishing line) is more frequently used than braided thread/suture for wound closure because it is less of a skin irritant and being monofilament does not wick any fluid (possibly containing bacteria) into the wound. Fine monofilament fishing line may be considered for use as a suture if it is able to tolerate appropriate disinfection without losing its strength.
A sterile sheet with a hole to expose the wound is placed over the wound after the washing and prep with betadine or hibiclens. This allows suturing to be performed without the thread contacting dirty surfaces and therefore bringing bacteria into the wound. Sterile gloves should be used if available but non-sterile gloves which have been cleansed with betadine or hibilcens may be used. A common sewing needle may be used for the suturing, but most of these needles taper roundly to a point. In medical facilities, needles used for suturing the skin are of the cutting variety, where the tip of the needle is beveled thereby cutting through the skin. This is less traumatic to the skin, is less painful and requires less force to push the needle through the skin.
Suturing a wound may be achieved with interrupted sutures. Interrupted sutures are where each pass of the suture through both sides of the wound are tied. They may be helpful on irregular edges, and have the advantage that a few of the sutures may be removed to allow drainage from an infected area while allowing the rest of the wound sutures to remain closed. Wounds may also be closed using a running suture (a whip stitch for the more sewing experienced). This running suture is tied at one end of the wound and repeated passes of the suture material across the wound edges are performed and the suture is then tied at the end of this “whip” (or line of passes).
Sutures should simply bring tissue together without bunching or gathering up the skin. The thickness of each suture passage should be through the skin but not contain much of the underlying subcutaneous fat. The skin is very thin on the face but very thick on the back and bottom of the feet. Sutures should be cut leaving about 0.25-inch tag of suture beyond the knot. A square knot is often used to tie the suture. Try to pull most of the suture through the wound leaving a small amount left to tie. Thus results in less suture material being wastefully trimmed off beyond the knot. A frequently overlooked technique for closure of scalp lacerations is to tie the hair on each side of the wound together. Keep in mind that round wounds may require conversion to oval (with removal of a bit of tissue at the ends) since it is a more difficult to close a round wound.
Generally puncture wounds should not be closed with sutures because the depths of the wound cannot be thoroughly cleaned and closure would trap bacteria within the wound. Wounds that have extensive contamination and have been open for a longer time than about 12 hours (or 48 hours on face) should not be closed because doing so would trap bacteria within the wound. These wounds should be thoroughly cleaned and dressed with the wound open. Dressing changes and irrigations may be repeated in 48 hours. If there is no evidence of infection by five days, this wound may undergo delayed closure with sutures or steri-strips or glue.
Wounds closed with sutures should be kept dry for about 48 hours, after which time a water tight seal at the skin edges should be present to prevent water-carried bacteria from entering the wound.
Personal protective devices such as masks, eye protection and gowns are not usually not required for proper closure of a simple wound, as long as you don’t sneeze or cough into the wound and don’t touch non-sterile clothing to suture or wound. Personal protective material such as goggles ,mask and gowns are encouraged because they might protect the “surgeon” from any spraying fluid from small arterial bleeders or sprays of irrigation solutions which could infect the “surgeon.”
Lacerations from animal bites may be more contaminated due to the oral bacteria from the animal. More thorough washing may be needed before closing these wounds and a shorter interval of time would be tolerated before leaving the wound open. If there is any concern that the bite was from an animal with rabies, studies suggest vigorous scrubbing of the wound may help reduce the risk of transmission. The biting animal often dies within 5 to 7 days if it has rabies therefore observing the animal for one week should be performed. The wound should be left open if there is concern about rabies. The first symptoms of rabies usually occur within 3 to 7 weeks but may appear as quickly as 10 days or as late as two years after the bite. If there is any concern for rabies involvement, then treatment with anti-rabies injections would be needed. Treatment must begin before symptoms of the illness occur; once the sickness has begun there is no known treatment that can save the person’s life.
F250Doc is a board certified surgeon who seeks to help people prepare for a variety of situations.