We've previously covered stopping the bleeding, cleaning wounds, and various non-suture options for closing wounds, and the different options in actual suture materials. Now it's time to address wound closing with sutures.
Let's begin by going in a bit of reverse order by listing the wounds that do not get sutured/closed until later. These wounds may be too contaminated, even after thorough cleansing and irrigation, and the risk for infection is too high. These wounds are not closed until usually five days later, and the terms doctors use to refer to them are secondary intention and delayed closure.
- Puncture wounds have penetrated deeper into the tissue. They probably carried a lot of bacteria and contaminants in with them. They must be irrigated and cleaned out as well as possible. However, it can be incredibly challenging to clean them out. Puncture wounds do not get sutured because the risk of trapping bacteria and contaminants is too high. If there is no sign of infection after the fifth day, then the wound may be sutured.
- Bites, animal or human, carry too, too many bacteria. Even if the bite isn't very deep, the wound does not get closed until the fifth day, and that is only if there are no signs of infection.
- Wounds open longer than 12 hours (24 hours on face) do not get closed. This is because bacteria have had the opportunity to establish a good foothold, and closing may trap bacteria within the wound. Just thoroughly clean and dress, leaving the wound open. Change the dressings every 48 hours. If there are no signs of infection by the fifth day, the wound may be closed.
- Wounds to the hands and feet, due to the numerous tendons and ligaments, have way too many opportunities for something to go wrong and infection to set in.
All other wounds get closed. When it happens right after the injury, within the acceptable time frame for safe closure, it's called primary intention.
Ideally, you've got some sterile gloves to use for doing your work. But if those need to be saved for a more intense situation, non-sterile gloves washed with Hibiclens or Betadine will suffice. As far as the patient is concerned, the care provider doesn't need to don a mask, goggles, or gown, as long as the provider isn't coughing or sneezing into the wound or allowing the wound or suture to come into contact with non-sterile clothing. However, these personal protection items are recommended for the care provider's safety, to protect from accidental sprays of fluid from the patient.
After cleaning out a wound by irrigating with clean water and then cleaning around a wound with disinfectant, a fenestrated drape (sterile sheet with a hole to expose the wound) is placed over the wound. This prevents the suture material from coming into contact with contaminated clothing or other objects and dragging bacteria into the wound.
The goal of the suture is to approximate the skin tissue. (Doctor speak for fitting the skin edges together like you put a puzzle together.) Jagged edges or flaps of skin will not heal well and may actually cause more scarring, so these need to be trimmed with a scalpel or tissue scissors. For the best healing result with minimal scarring and risk of infection, the sutures should bring the skin tissue together without any puckering or gathering up of the skin. Each passage of the suture needle should be through the skin, but not into underlying subcutaneous fat or other tissues. As skin is not of a uniform thickness over the body, the depth of the sutures will vary by location on the body. For example, skin on the face and the back of the hands is quite thin. It is much thicker on the back and soles of the feet.
There are numerous types of suture stitches, and it would be a good idea to learn a few of the most common. Interrupted sutures are single stitches that pass through each side of the wound and are then knotted and cut. They are good for irregular edges, and if the wound happens to get infected, one or two may be removed to allow the infection to drain while leaving the others in place. A running suture (whip stitch) can be quickly put in place, with knots only at the beginning and end. Square knots with an additional throw or two are the most commonly used for suturing. Do not use a granny knot. It will slip, and then you're back at square one.
Keep the wound dry and protected from contamination.
Suturing is a skill that needs to be seen repeatedly and practiced even more repeatedly, with real instruments and suture materials. That's the only way. Here are some excellent Youtubes:
Most instructional videos feature suture boards or pigs' feet, which is a bit of an unnecessary expense, especially in the beginning. Banana skins are great for beginners. They have a bit of depth to them and clearly show the spacing of your stitches so you can improve your technique.Links to related posts:
Stopping the Bleeding
Wound Closure Options
For more information:
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