A Stitch In Time

This week’s guest columnist is Dr. Blake McDonald, a Family Practice resident at the University Hospital and Clinics here in Lafayette.

One night while I was on duty at the hospital, a surprise call came not from the wards, but from my sister!  Her 6 year-old son, Finn, had been playing by the fireplace, tripped, and hit his forehead on the brick mantel.  My sister was panicked: He’s bleeding and does he need stitches!!??

Sometimes it’s difficult for parents to tell if a cut needs stitches, and sometimes a judgment call the parents and doctor make together.  So what lacerations need stitches?  The goals of wound care are to stop bleeding, avoid infection, minimize pain, and minimize scarring.  With these in mind, here’s some guidelines.

First, stop bleeding.  Apply pressure to the wound for several minutes with a clean cloth or gauze.  Keep pressure on the whole time; if you keep lifting the cloth to see if the bleeding’s stopped, you won’t give enough time for a clot to form.  Once bleeding has stopped, then clean the wound. Dirty wounds are at greater risk for infection, which worsens pain and scarring.

Gently scrub with plain soap and water, and rinse plenty.  If there is lots of imbedded dirt, peroxide can be used to foam out debris.  But just once- too much peroxide poisons tissue and slows healing.  If there’s just too much junk and it hurts too much to clean, that’s a reason to get seen.  We can anesthetize the wound to decrease pain and get the cleaning done.  In kids this is often achieved with an anesthetic ointment we place in the wound and after 45 minutes it’s numb- no shots necessary!

Other reasons that kids need to get seen: full thickness lacerations on faces, particularly eyelids, lips, and ears.  These can have worse scars without stitches.  Deep wounds of joints, hands, or feet are at risk for infection and loss of function if not cared for properly.  Crush injuries, or other lacerations that could involve bones need attention too, for the same reasons.  Animal bites also can get infected and transmit rabies.

Finn got three stitches (a.k.a sutures) that night, and it was an uneventful experience.  He wasn’t too scared, but many kids freak out when they hear “stitches,” because they think “needles.”  But like we discussed above, the anesthetic gel we put in the wound often numbs the cut completely and injections aren’t needed.

Three days later I got another “consult” call from my sister.  She had been instructed to bring Finn back in 3 to 5 days to get the sutures out.  ”Really,” she asked, “is that long enough?”  She also was told to wash the stitches with plain soap and water. Surely there’s more to it than that?

Timing of suture removal depends on where the cut is.  Places with great blood supply, like the face and scalp, heal quicker than places with less, like hands and feet.  Blood brings oxygen and nutrients that skin uses to build new tissue.  Blood also brings blood cells that fight infection.  Therefore, cuts on faces and scalps don’t need antibiotics because the blood keeps things clean.  But cuts on hand and feet should get antibiotics because of less blood supply, and hands and feet tend to be dirtier than faces and scalps. Also, animal bites always get antibiotics, no matter where the bite is, to prevent infection.

Face sutures can be removed after 3-5 days, scalps 7 days, arms and legs 10 days, and hands and feet 14 days.  If we leave the sutures in longer than that, the suture material can irritate and make worse scars.  We’ve all seen scars with the row of white dots lining the sides of the scar- don’t want that on a face!

It’s also important to wash the cut once daily, and yes, plain soap and water is enough. But a brief wash: no long tub soaks or swimming with stitches.  After washing, apply antibiotic ointment and a bandage.  If the skin gets red and itchy from the bandaid, you can use paper tape.  Or if it’s only a few days before suture removal, leave the bandage off.

Kids like Finn play and get cuts, and sometimes need stitches.  But you needn’t freak out about pain and having to care for sutures.  It’s as easy as the adage, “A stitch in time…”

Hey…Stitch This!

This week’s guest columnist is Dr. Frank Betanski, a Family Practice resident at the University Health Center here in Lafayette.

“OUCH!!” (ou-ch); exclamation; a four-letter word indicating urgency and anxiety when children get a cut.  It raises questions with parents that are often confusing and overwhelming: “Does this need stitches?”  ”Should I go to the ER?”  ”Oh Lord, what is THAT??!!”  My mother faced these questions when I returned home from the movie “Edward Scissorhands.”  I grabbed the cutlery and literally started running with scissors.  So let’s discuss the how-to’s (and don’ts) of skin injuries.

First, some terminology:

-Laceration: tear into the skin with blunt force.

-Avulsion: A chunk of skin is removed, exposing a hole in the tissue.

-Puncture: stab through the skin

-Incision: laceration made with a sharp-edged object (knife, glass, scalpel, etc)

You’re thinking: “Thanks for the vocab lesson, doc, but what to do right now with all this bleeding?”  FIrst, apply pressure to the wound with a clean cloth or bandage.  Pressing for several minutes will stop most bleeding.  Remember, constantly lifting pressure to check if the bleeding has stopped will just prolong the bleeding.  Be patient, hold that wound for a good five minutes before checking.  If the cloth becomes soaked with blood, put a new cloth on top of the old one.  Should the bleeding not stop, head to the ER.

Once bleeding has stopped, wash your hands and remove dirt by running water over the wound.  Don¨t scrub the wound yet.  The old faithful hydrogen peroxide can help clean. Peroxide kills germs and can “bubble up” dirt and dead skin.  Only use peroxide once. Multiple uses can poison good tissue and delay healing.  Soaking open wounds in a mix of water and betadine also kills germs. If there is no more bleeding for áwhile, then you can gently scrub the wound with a washcloth if ít has embedded debris.

We see a variety of lacerations in the Emergency Department, and a variety of parental questions about management.  Sometimes the child has a tiny scrape the size of an eyelash, with Dad asking if we should call plastic surgery.  At the other extreme, the kid comes in with a mangled hand that looks like it was attacked by a bulldozer, with Mom wondering if it needs a bandaid.

So when should you bring your child in?  Here are some examples: heavy bleeding that doesn´t stop after 5 to 10 minutes of direct pressure.  Deep (down to fat or muscle layers) and/or longer than one inch.  Large, gaping cuts on the face.  Animal or human bites that break the skin.  Dirty wounds that you can’t get all the debris out. Signs of infection like increased pain, spreading redness, swelling, or drainage.

Many wounds heal themselves without stitches, and sometimes doctors prefer to leave wounds open to heal “from the bottom up.”  For example, we don´t stitch most animal bites, so that the stitches don’t trap infection inside the wound.  We stitch cuts mainly to minimize scarring and improve how the scar will look. Stitching wounds also can stop bleeding, increase scar strength, heal cuts faster, and decrease pain.  Face and forehead wounds can particularly need stitches for the best cosmetic result.  On the other hand, cuts inside the mouth and on the tongue, even deep ones, rarely need stitches. The inside of the mouth heals miraculously, closing big wounds in a few days.

We have many methods to close wounds: stitches (a.k.a. sutures), medical glue, staples, steri-strips (sterile tape).  Glue is good for clean, no-tension incisions.  If the wound cannot be easily closed by gently pushing the edges together, or has shaggy edges, then stitches are better.  Staples are best for areas where scarring is not an issue (inside hair lines). By the way, don’t remove medical staples yourself with an office staple remover.  Paper and medical staples are different animals.  Been there, saw that, saw the scar….

When in doubt, call your doctor, or maybe even send a picture from your phone.  Doctors can often tell you over the phone if a wound needs stitches, but sometimes we just gotta see it for ourselves, to know if we need to…Stitch This!

Needing Stitches?

In most of my blog entries, I discuss how to stay out of the Emergency Department.  However, getting a deep cut that needs stitches is one of those times that it is probably best to bring your kid to the ED.  Here are some good things to know.

What cuts need stitches?  These are cuts that are through the skin where you can see fat inside, cuts that are gaping open, cuts that will leave as wide a scar as the cut itself.  One old wives tale is that if you wait too long, the cut can not be stitched.  This is not true- if you are out fishing, get a cut, and can’t get in before four hours, you can still get stitches and minimize infection and scarring.

Do I need a plastic surgeon?  Many parents wonder about this since so many of kid’s cuts are on their faces.  Kids meet the world with their big and heavy heads, and parents worry that cuts on foreheads, eyebrows, lips, and chins will leave noticeable scars.  It is an old wives tale again that plastic surgeons do some magic with these cuts that ED doctors don’t.  For the vast majority of those cuts, the plastic surgeon would do nothing different than the ED doc- sew it up!  All cuts leave some scar, but most kid scars on faces fade after six months to a year and are barely noticeable.  If the scar ends up looking bad, then it is time to see the plastic surgeon for a “scar revision.”  But again, the plastic surgeon would do nothing different for the first closure.

Will it hurt?  If your ED is really with the times, they will numb the cut with an anesthetic gel- no shots needed!  It takes about three applications over 30-40 minutes.  The gel works great for faces, scalps,  and most limb cuts.  It can not be used for fingers and toes.  Then the cleaning and stitching are painless.   However, fidgety babies and toddlers will still need to hold still for their stitches and may need to be on the velcro “papoose” board.  Then there will often be plenty of screaming because no toddler likes to be trapped.  At least they won’t feel the stitches themselves!  Also, there are no reports of toddlers needing psychotherapy later in life because they were traumatized by the papoose experience.

How do I take care of the stitches?  After stitches are put in, keeping them clean and covered is important to lessen scarring.  Yet another old wives tale (that many doctors believe!) is that stitches should be left out in the open.  In fact, stitches heal faster and with smaller scars if they are cleaned gently once per day with plain soap and water, then covered with over-the-counter antibiotic ointment and a bandage.  No swimming, no long soaks, no peroxide.  Peroxide is best for a one-time, first cleaning of a cut, but after that too much peroxide poisons tissue and slows down healing.

Finally, few cuts with stitches need antibiotics.  If they are cleaned well and on a body place with good blood circulation (faces, scalps), infections are very rare.  The cuts that need antibiotics are those from animal bites, or dirty wounds on limbs.

If you have any questions about the stitching experience, or have a stitching story to share, please comment!