The Open Wound

Years ago, we held the first suture class for non-medical people in the preparedness community. Our purpose in doing this was to provide education that might be useful in a post-apocalyptic setting. We felt that teaching people medical skills may save some lives in long-term survival scenarios. To us, any unnecessary death in times of trouble is one too many.

Nowadays there are a lot of folks that put on these classes.  The main goal, however, is not simply to learn the mechanics of throwing a stitch but to develop the judgment necessary to understand when a wound should be closed and, more importantly, when it should be left open.

When the medically-responsible person evaluates a wound, the following question must be asked:  What am I trying to accomplish by stitching this wound closed?  Your goals when performing wound closure are simple.  You close wounds to:

• Repair the defect in the body’s armor
• Eliminate “dead space” that can lead to infection
• Promote healing.
• Provide a pleasing cosmetic result (less scarring).

Sounds like every wound should be closed, doesn’t it? Unfortunately, it’s more complicated than that.  Closing a wound that should be left open can do a lot more harm than good, and could possibly put your patient’s life at risk.

Take the case of a young woman injured in a “zipline” accident.  She was taken to the local emergency room, where 22 staples were needed to close a large laceration.  Unfortunately, the wound had dangerous bacteria in it, causing a serious infection which spread throughout her body.  She eventually required multiple amputations. We learn an important lesson from this tragic case: Namely, that the decision to close a wound is not automatic but involves serious considerations.

The most important of these is whether you are dealing with a clean or a dirty wound.  Most wounds you will encounter in a wilderness or collapse setting will be dirty.  If you try to close a dirty wound, you sequester bacteria and dirt into your body.  Within a short period of time, the infected wound will become red, swollen, and hot.  An abscess may form, and pus will accumulate inside.

Here’s an article I wrote about infected wounds:

 http://www.doomandbloom.net/wound-infections/

The infection may spread to the bloodstream and, when it does, you have caused a life-threatening situation.  Leaving the wound open will allow you to clean the inside frequently and observe the healing process.  It also allows inflammatory fluid to drain out of the body.  Wounds that are left open heal by a process called “granulation”; that is, from the inside out. The scar isn’t as pretty, but it’s the safest option in most cases.

Other considerations when deciding whether or not to close a wound are whether it is a simple laceration (straight thin cut on the skin) or whether it is an avulsion (areas of skin torn out, hanging flaps).  If the edges of the skin are so far apart that they cannot be stitched together without undue pressure, the wound should be left open.  If the wound has been open for more than, say, 6-8 hours, it should be left open; Even the air has bacteria, and the injury may already be colonized.

IF you’re certain the wound is clean, you should close it if it is long, deep or gapes open loosely. Also, cuts over moving parts, such as the knee joint, will be more likely to require stitches.   Remember that you should close deep wounds in layers, to prevent any un-approximated “dead space” from occurring.  Dead spaces are pockets of bacteria-laden air or inflammatory fluid in a closed wound that may lead to a major infection.  An exception to this is a puncture wound from an animal bite.  These are loaded with germs and should never be sutured.

If you are unsure, you can choose to wait 72 hours before closing a wound to make sure that no signs of infection develop.  This is referred to as “delayed closure”.  Some wounds can be partially closed, allowing a small open space to allow the drainage of inflammatory fluid.  Drains, consisting of thin lengths of latex, nitrile, or even gauze, should be placed into the wound for this purpose.  Of course, you should place a dressing over the exposed area as it can get messy.

If you must close a wound, use the least invasive method. If you can approximate the cut edges of skin with butterfly closures, it is better than puncturing the skin again and again with sutures or staples. Use an adhesive such as tincture of benzoin to hold the tapes in place. Even Super-Glue may be a better option in certain cases, and is used routinely in underdeveloped countries like Cuba with good effectiveness.

The safest method, though, is to leave that questionable wound open. Using a 60-100cc irrigation syringe, flush the area aggressively with a dilute solution of Betadine (Povidone-Iodine) or sterilized saline solution. If you don’t have commercial sterile solutions, studies show that clean drinking water can keep a wound clean in an austere environment. Place a sterile moist (not soaking wet) dressing in the wound and then cover with a dry sterile gauze dressing. Replace the dressing at least daily, more often if possible.

If you have antibiotics, this may be a good time to use them. Check out the link in this article about infected wounds to see which are most useful.

About hydrogen peroxide, undiluted Betadine, or Alcohol as a cleaning agent for open wounds:  If it’s all you have, it’s ok for the first cleaning before you place the dressing.  These substances, however, tend to dry out newly forming cells and may actual hinder healing.  As such, stick with milder solutions or clean drinking water for long -term wound care.

Learning how to suture is a useful skill. Knowing when to suture, however, is much more important.