Depending upon who you talk to, a severe wound or lasceration should always be sutured close. Or should it?
When faced with an austere survival situation, the decision you make to close an open wound could spell the difference between proper healing and an infected mess. Personally, I vote for proper healing but getting to the correct decision when under pressure may not be easy.
Help is on the way.
Dr. Joe Alton, known to those of us in the survival community as Dr. Bones, is launching the first of a series of exclusive articles for Backdoor Survival readers in this article, “To Close or Not to Close”. This article began life as a question from a reader, making it particularly relevant.
To Close or Not to Close (A Wound)
By Joe Alton, MD
When a laceration occurs, our body’s natural armor is breached and bacteria, even species that are normal inhabitants of our skin, get a free ticket into the rest of our body. Microbes that are harmless outside the body could be life-threatening inside the body.
It only makes common sense that we want to close a cut (also known as a “laceration”) to speed healing and lock out infection. There is controversy, however, as to whether or not a wound should be closed. When and why would you choose to close a wound, and what method should you use?
A laceration may be closed either by sutures, tapes, staples or medical “superglues” such as Derma-Bond or even industrial “Super-Glue”. After rendering first aid, which includes controlling the bleeding, removing any debris, irrigation the wound, and applying antiseptic, you will have to make a decision.
What are you trying to accomplish by closing a wound? Your goals are simple. You close wounds to repair the defect in your body’s armor, to eliminate “dead space”, and to promote healing. A well-approximated wound also has less scarring.
It sounds as if all wounds should be closed. Unfortunately, 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 some years ago in a “zip line” 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 from this an important lesson: Namely, that the decision to close a wound is not automatic but involves several considerations. The most important consideration is whether you are dealing with a clean or a dirty wound.
Most wounds you will encounter in an off-grid setting will be dirty. If you try to close a dirty wound, such as a gunshot, you have sequestered bacteria, bits of clothing, and dirt into your body. Within a short period of time, the wound will become infected. An infected wound appears red, swollen, and hot. In extreme cases, an abscess may form, and pus will accumulate inside. The infection may spread to the bloodstream, a condition known as “septicemia”, and become life-threatening.
It may be difficult to fight the urge to close a wound. Leaving the wound open, however, will allow you to clean the inside frequently and directly observe the healing process. It also allows inflammatory fluid to drain out of the body. The scar isn’t as pretty, but it’s the safest option in most cases. In addition, if you’re truly in a long-term survival scenario, the suture material or staples you have aren’t going to be replaced. It’s important to know when closure is absolutely necessary and when it’s not.
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 or 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.
Another reason the wound should be left open if it has been open for more than 8 hours. Why? Even the air has bacteria, and there’s a good chance that they have already colonized the injury by that time.
Let’s say that you’re certain the wound is clean. It’s less than 8 hours old. Here are some other factors that would suggest that closure is appropriate:
• The laceration is long or deep. The exception would be a puncture wound from an animal bite. These bites are loaded with bacteria and should be kept open in austere settings.
• The wound is located over a joint. A moving part, such as the knee, will constantly stress a wound and prevent it from closing in by itself.
• The wound gapes open loosely, suggesting that it can be closed without undue pressure on the skin.
t’s important to realize that you will only have a limited supply of staples and sutures. Feel free to mix different closure methods like alternating sutures and steri-strips, or even adding duct tape when you’ve run out of medical supplies. You’d be surprised what qualifies as medical supplies when the chips are down.
If you are unsure, you can choose to wait 48 to 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 avoid the accumulation of inflammatory fluid.
Drains, consisting of thin lengths of latex, nitrile, or even gauze, might be placed into the wound for this purpose. “Penrose” drains are a version of these that are still used in some operating rooms. Drains have a tendency to leak, so place a dressing over the exposed area
Many injuries that require closure (and some that don’t) also should be treated with antibiotics in oral or topical form to decrease the chance of infection. Natural substances with antibiotic properties, such as garlic or raw, unprocessed honey, may be useful in survival scenarios.
More on antibiotic use in future articles.
The Final Word
I am over the moon thrilled that Joe has agreed to bring exclusive new content to Backdoor Survival readers. You will begin to see his articles monthly, as I carry out my initiative to present survival and prepping information from some of the best and the most experienced minds available.
Last month I sent Joe and his wife, Nurse Amy, a long list of survival medicine related questions you have been asking. As with his upcoming article on antibiotic use, you can bet that we will be getting to your requests a bit at a time.
Stay tuned, and, as always, keep your questions coming.
Enjoy your next adventure through common sense and thoughtful preparation!