Cut my head open...

[TF Kilo]

Originally Posted by Doczilla

Absorbable suture:
- To close deep layers of a wound when doing a multi-layer repair (ex: laceration to the forehead all the way to the skull). I usually use Vicryl for strength.
-Running subcuticular stitches to minimize stitch scar. Usually done with complex plastic repairs or closing surgical wounds. With the complex plastic repair, I'll revise the wound edges, close deep, do a running subcutic, and then a running 7-0 or 8-0 skin layer of absorbable sutures really close together to minimize tension on the individual sutures. Less tension = less stitch scar. Current dogma discourages subcuticular stitches in "dirty" wounds, since they may prevent draining of the wound.
- I'll use chromic gut on lips and face because there is less granulation around the suture material, leading to less stitch scar.
- If follow-up is a problem, and you don't think the patient can make it in to have their stitches removed, or if it's a child and you think they'll pitch a fit about suture removal because of where the stitches are or how they reacted to having them put in, I'll use absorbable.

Virtually everything else that is accessible: regular nonabsorbable suture, staples, "hair sutures", or superglue.


'zilla

Ok... next question to ask, what's the average time before an absorbable becomes absorbed?

My wife did a number to her finger, and after an hour and a half in the ER with no other patients IN the ER, she had only been seen by any staff once for a betadine finger bath, when she was brought in back... She was fed up, I was fed up, so we signed the AMA and left. I superglued it back together, and it's doing rather well, although when I get back from work on wed. I get to clip her fingernail off to help relieve some pressure it seems to be causing...

The ER nurse said it would need stitches, but when I got home all we had were absorbable. I didn't know if they would make the grade, as well as without pulling the remainder of her fingernail I didn't think I could go the full circumference of the laceration... so I decided the next best thing was to superglue it.

Although I cleaned it extensively prior to the superglue, it still ended up looking rather nasty...

Diagram of injury caused by a nice sharp AXE

That was 3 weeks ago, and now she's healing up rather nicely and able to generally, although gingerly, use the finger.

I've since found out that level of care from the ER there is the norm regardless of injury type or severity, and will subsequently be taking care of things myself, or making a 30 minute dash into anchorage to Providence hospital for any severe trauma from now on.


And no, I don't let her split kindling anymore.

[The Reaper]

ss:

Would you care to explain the procedure and cautions (especially for females or male models) of home repairs of lacerations, especially along the vermillion borders? The surface closure is also not the only concern, there may be damage to underlying tissue as well. This could cause significant post-op problems as the vessel or nerve is left disconnected.

The fact that I would use Superglue or 100mph tape to close my own wounds does not mean that I would do that on my spouse or my kids. Especially if they are girls and you expect them to marry well some day. I am given to understand that the Frankenstein scars do not help with that process, regardless of the great story that goes along with them.

I might also point out, as an uneducated layman that to minimize scarring, the sutures need to be put in as quickly as possible, after a period of time (six hours, I seem to recall) the wound edges have retracted and granulation is going to be the primary closure mechanism.

For the uninitiated and new people here, swatsurgeon (along with selected others, like Doc T and RockyFarr) is a real trauma doc, he does not play one on weekends, on TV, nor did he stay in a Holiday Inn Express last night. I would take his advice and write it in my book when he gives it. (Eagle5US is a PA, and is in a similar category).

Thanks for the info.

TR

[swatsurgeon]

Thanks TR...very good points you bring up.
Lips and eyelids are very delicate areas and when repaired MUST be re-aligned just right, with the correct amount of tension across them, the correct number of layers closed and with the correct material....when all of the stars align, a nice repair occurs. If any of the factors including absolute debridement and cleaning of tissue isn't perfect, the end result is usually less than satisfactory.
As for the 6 hr rule, hit it right. After 6-8 hours we re-excise the laceration and fix it primarily. If not we let it heal 'on its own' which doesn't necessarily give the best looking scar....and YES, ALL LACERATIONS/INCISIONS LEAVE A SCAR.
Field cleaning and closure buy you time to reduce the incidence of infection and maintain function. Once back at an ED, aid station, hospital, etc, the knowledge of appropriate wound management...NOT really wound care, is paramount. Our training in wound mangement is , in my opinion, more important than just wound care. I have seen alot of wounds mismanaged that require alot more wound care and future management because of the poor care given at the first point of contact.

Never rub anything into a wound as your mother's recipe or grandma's home recipe for improved wounds. No powders, creams, salves, lotions...good old soap and water, NO hydrogen peroxide, some antibiotic ointment is fine and dress/cover it to prevent further contamination. 100mph tape, superglue all work very well as the definitive closure IF the wound is clean, doesn't need debriding and the wound gods are smiling on you.
ss

[The Reaper]

Doc:

As a final point, and to expound on your "wound management" statement, I would mention that MRSA, CA MRSA, and PVL are becoming more and more serious concerns.

I would be very concerned about any wound, especially one home treated, that did not appear to be healing properly or going infected and would seek professional treatment immediately.

Any danger signs that are particularly significant?

Don't forget your tetanus shot while you are at it.

TR

[JGarcia]

Two questions.
1. Tetanus shot. I just had a medical SRP last month where they go over your shot records and give you whatever shot you are short of. When I went to have this head stitched up yesterday they asked me when my last tetanus shot was, since I routinely get shots, I can't recall what each and every shot is and when I got what, but I went with the assumption that last having deployed in 05, that I got one then so I told the Dr. I was good, should I have gotten another tetanus shot yesterday? I can always go and get one this morning.

2. Hydrogen Peroxide. Why don't you use that to clean out a wound anymore?

Head, neck, shoulder sore today; no dizziness, blurred vis, headache, naseau, etc.

[swatsurgeon]

Wound infection is a real concern....hence, clean all wounds. Any increased redness, tenderness, drainage, seek medical attention for likely wound infection. Most times a retained foreign body is the culprit.

Peroxide KILLS fibroblasts, the cells that make you heal...as does straight betadine.

Field injuries are especially 'dirty' and if occur around a farm or pond, MUST use a penicillin type med either pill or IV...this is another area that IED/vests with bolts, rivets, nails, BBs, etc get coated in feces or pond scum and cause delayed death by infection. We carry PCN like meds and some for PCN allergic patients for these types of injuries in the locations mentioned.
***When in doubt, leave the wound open.........just cover, use antibiotic ointment, we can always re-excise and close later, safely.

ss

[Kyobanim]

Everytime I think we're done a new question pops up.

Peroxide KILLS fibroblasts, the cells that make you heal...as does straight betadine.

Now that I've been using peroxide my entire life I find out I've been wrong. What should you use for the cleaning of generic type cuts and scrapes?

[swatsurgeon]

ivory soap, baby shampoo, hibiclens......

[Eagle5US]

Originally Posted by swatsurgeon

ivory soap, baby shampoo, hibiclens......

I tell people this and, no kidding, I get:
But none of that stuff is prescription

Eagle

[x SF med]

And after cleaning it out with Ivory soap, Witch Hazel makes a great astringent and antispetic. Sorry, no prescription needed here either.

[JMI]

Originally Posted by Kyobanim

Now that I've been using peroxide my entire life I find out I've been wrong. What should you use for the cleaning of generic type cuts and scrapes?

Originally Posted by Answer from swatsurgeon

ivory soap, baby shampoo, hibiclens......

Huh, no kidding. Learn something new everyday here.

[x SF med]

Hey Shooter -
Forgot to ask - how much damage did your head do to the poor branch?

[JGarcia]

He, he he...

Once I collected myself, I promptly started the chain saw back up and reduced the branch to 18" sections, vanquishing my opponent at my feet. I've sentenced it to rot in the sun for 12 months, and then I will burn it as my family gathers round to watch.

Seriously, that was one heavy muther... full of water. What happend is that after I made my cuts, I got down anticipating it to snap free... but it just stared at me. So, I walked around to the end of it, and grabbed hold, I gave it one tug, nothing. The second tug, "snap" it came at me and I started to jump back. There are ornamental grasses about 18" high around my feet, the grasses concealed a sprinkler, as I stepped off to get out of the way I tripped on the sprinkler, I was donefor, I ducked my head down and tried to get my arms up as I fell, but the branch struck a glancing blow from the top of my head down to my ear, and then walloping my right shoulder pretty good. This was a very, very large branch, more like a second trunk of the oak, more like a vertical growth than a lateral one. If I had let it go, well it might have split the tree some day, or so I thought. I wouldn't be talking to you if it had landed square on me. Its a good looking tree now.

My little girl, she is three, was watching all of this from the safety of the dining room. When I put her to bed last night she began her AAR by asking me why I pulled on the branches, and then proceeded to admonish me.

I have no other plans to trim anymore of my oaks any time soon.

[The Reaper]

I'd leave the logging up to professionals.

I am sure that for the appropriate amount of liquid refreshment, Mr,. Harsey could be tempted to come out of retirement and safely cut your oaks for you.

TR

[JGarcia]

Yes Sir.