Choosing Sutures

[230gr]

Choosing Sutures
Suture diameters most commonly used is measured in zeroes.  2-0 (00) suture, for example, is thicker than 5-0 (00000) suture. The more zeroes, the finer the “thread”. Finer sutures have less tissue reaction and heal faster, but are more difficult to handle for those without experience.

Sutures are classified as:
•   An absorbable suture is one that will break down spontaneously over time but not before the tissue has had sufficient time to heal.  This type of suture is commonly used in deep layers, such as muscle, fat, organs, etc.  A classic example of this is “catgut”, actually made from the intestines of sheep or cows. Synthetic absorbable suture include “Vicryl” (polyglycolic acid), “PDS” (polydiaxanone), and others.
•   Nonabsorbable sutures are those that retain their character for a very long time, and will stay in the body until removed. Nonabsorbable sutures are best used in skin closures and situations that require prolonged tensile strength. They include monofilaments (such as “Nylon” and “Prolene”) and braided multifilaments (such as ”Surgical Silk”).
 
I recommend Nylon in most survival situations, with 2-0 or 3-0 Nylon ideal for those new to the suturing skill.  This size “thread” is easy to handle and useful for aspiring medics to learn surgical knot-tying. The size of the “thread” you’ll use depends on the area of the body being repaired. Slowly healing tissues such as skin and tendons require nonabsorbable sutures; wounds in rapidly healing areas such as the inside of the cheek and vagina (childbirth) are best repaired with absorbables.
 
Skin sutures should be placed, in my opinion, about 1/2 inch or so apart in most instances. This will allow drainage while keeping the wound together.  Areas over joints or other moving parts should be closer together. In wounds not near joints, say, the forearm, the sutures may be further apart and could be interspersed with Steri-Strips or butterfly closures.

The type of needle is also an important factor in choosing suture material. Needles that are less traumatic to sensitive tissues, like the lining of the bowel and other deep structures, are round on cross-section. These are known as “atraumatic” or “tapered”. Needles that are best on tough areas like skin are triangular in shape on cross-section and are referred to as “cutting” needles. Most suture needles that are useful for skin form a 3/8 circle; needles for deep work are often ½ circle in shape.

suturing is more traumatic than using butterfly closures, Steri-Strips, surgical glue…  Each extra “hole” you create could allow the entry of bacteria into the wound.

There is also a video. “How to Suture with Dr Bones

See complete artical at: 
www.doomandbloom.net/choosing-sutures/

[WolfBrother]

One of the BIG things, especially in an Austere/PAW Medical environment, is knowing when NOT to suture.

[TWP]

One of the BIG things, especially in an Austere/PAW Medical environment, is knowing when NOT to suture.

Could you offer an example of this situation?  I understand small wounds might only need antiseptic and bandaging.

[230gr]

I am sure WolfBrother can answer this better than I but deep gaping wounds are are probably going to need to drain and, especially if contaminated, re cleaned periodically.

For anything fairly minor, I would look at butterfly closures, Steri-Strips, surgical glue or just plain binding as was done for thousands of years if you have nothing better.

Butterfly closures made with duct tape do work surprisingly well I have found. 

[TWP]

Ok, that makes sense and it points out something which should be in my larger medical kit, wound drainage tubes.  This is NOT an emergency kit, but rather a serious medical resource for home or BOL.

[WolfBrother]

 OK
4 sites that also can give info as to when not to.
The first, second, and the last are self doable.  The 3rd one will involve money and travel for a class
   http://thepreparedninja.com/xx-reasons-suture-wound/
Here are some of the most common reasons that a wound should not be sutured (contraindications):
1.      Any wound that is more than six hours old.

2.      A wound that is dirty with severe contamination that requires extensive cleaning or debridement.
3.      Some concave skin surfaces like the temple is best healed through secondary intention (natural healing).
4.      Complex structures like the eyelid require complicated repair and should not be closed.
5.      Damaged tissue, especially in severe wounds, crush injuries, and gunshot wounds.
6.      Any bite wounds whether from an animal or a human.
7.      All open fractures.
8.      Absorbable sutures should not be used where prolonged approximation (joining) of tissue under stress is required due to risk of potential tearing of the tissues.
9.      If the patient is set to go on a long journey/prolonged travel.
10.  All wounds that are a result of combat.
11.  Any wound that involves a tendon, nerve, or major blood vessel injury.
12.  Any wound that is so severe that anesthesia cannot be obtained without a toxic dose of local anesthesia or sedation.
13.  Silk sutures should not be used in any patient with an allergy to silk or silk products as well as in any location where permanent retention of tensile strength is required.
14.  Most open joint wounds.
15.  A wound should not be closed if antibiotics are not available to treat an infection if one becomes present.
16.  If the patient has a known allergy to collagen or chromium, neither plain or chromic gut sutures should be used to avoid potential allergic reaction.
17.  The wounds of a patient that is in severe shock should not be closed because of the risk that poor peripheral circulation could hinder proper wound repair and healing.
18.  Avoid suturing a wound that may have to be treated with skin grafting (degloving injuries, etc.)
--------------------------------------
With all of that being said, while the reasons listed above are all reasons to not suture a wound, many of these reasons are just indicators to delay closure of the same wound. You can take several of the reasons listed above to not suture a wound and change the circumstances by introducing the ability to clean the same wound or the availability of antibiotics and the reason to not suture the wound is gone. This may delay the closure but does not ultimately rule out sutures in the long run.
   
  Three page set of guidelines, with illustrations, from the World Health Organization.  They send people out into the Mud, Blood, and Beer.  A lot of their guidelines are based on Austere medicine
http://www.who.int/surgery/publications/WoundManagement.pdf
===========================================
A class from Dr. Bones and Nurse Amy
https://www.doomandbloom.net/medical-classes/
 
Description:
Complete Wound Care Class Description:
Learn how to provide complete wound care with hands-on suture training, as well as stapling with Dr. Bones and Nurse Amy, medical preparedness experts from DoomandBloom.Net. Using a pig’s foot, they’ll show you how to assess a wound, apply antiseptic, insert the sutures, tie a proper instrument knot, cut the extra sutures and learn how to space the sutures for proper wound closure.
Also, know how & when to use staples and, most importantly, learn when NOT to close a wound.
Wound care is also discussed in detail! This course is designed for the non-medical professional and those medical personnel without suturing knowledge.
   
Want to figgertit out yourself?
 
Wound closure manual – pdf, 80 out of the 120+ pages – useful – the rest – ads for suture.
http://www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Closure_Manual.pdf

[TWP]

WolfBrother,  thank you for the links.

Note, the last link has a font size formating problem.  It appears in 1 point font on my Firefox browser.  It works, and I could download the PDF, but it can't be read onscreen.

Good information and a respectable answer to my request for more detail.

[WolfBrother]

The WHO pdf is attached.

Here is another good pdf

http://depts.washington.edu/uwemig/media_files/EMIG%20Suture%20Handout.pdf

I generally do my reading/posting on my desktop - I've found not everyplace is phone/pad friendly.

[WolfBrother]

The last link in my original post was to Dr. Bones and Nurse Amy  almost any search for them will find their site

[TWP]

WB the last link on my browser, the one that is too small to read, is this:

http://www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Closure_Manual.pdf

I can click on it, even if I can't read the text... Isn't technology wonderful?

[WolfBrother]

WB the last link on my browser, the one that is too small to read, is this:

http://www.uphs.upenn.edu/surgery/Education/facilities/measey/Wound_Closure_Manual.pdf

I can click on it, even if I can't read the text... Isn't technology wonderful?

pdf attached

[TWP]

That works too, now it is on the NNPG server.

[TWP]

With respect to emergency sewing jobs, my anecdotal report is that sewing threat soaked in alcohol has worked twice for me.  I'm not recommending it, but you use what you have when the need arises.

These incidents occurred some time ago, before I began "prepping".  I have since upgraded my kit to better suture thread and real medical needles and Betadine.

ouch.

[WolfBrother]

Silk clothing thread and sewing needles were some of the original "sutures"


Monofilament fishing line works


You can order threadable suture needles from veterinary places

[230gr]

Monofilament fishing line works

My first suture material was very fine Monofilament used to tie fly fishing baits.