Laceration Repair in the Wilderness

I'm delighted to present another guest post from Jeremy Joslin, M.D., entitled "Laceration Repair in the Wilderness":

The Scenario

It always happens by accident. You're using your new, lightweight pack saw to collect downed wood for an evening fire when the saw slips and slices into the back of your left thumb. Blood flows immediately, and you feel a rush of pain up your hand. You're four days' hike from civilization and the cut looks like it needs stitches.

Let the first aid begin. You apply pressure and the bleeding stops. After irrigating the wound with clean water, you reach into your pack to find your sewing kit and sutures. But should you really be stiching up this cut?

The answer doesn't necessarily hinge solely on your training. I've discussed this subject with emergency physicians who repair lacerations daily, as well as with first responders who learned from their grandmothers that if they could sew cloth, they could sew skin. My personal opinion is that people should take great pause before sewing a laceration outside of a medical exam room. In my mind, the decision about whether or not to sew a wound in the field is related to the issue of "wound appropriateness."

Wound appropriateness takes both wound size and cleanliness into account. A small wound that remains contaminated with dirt and debris shouldn't be closed because the closure would trap all the necessary ingredients for an infection. On the other hand, a small wound that's fairly clean probably doesn't need stitches anyway - perhaps not even in the Emergency Department! An article (1) reviewed this particular topic and came to the conclusion that uncomplicated lacerations less than 2 cm (just under an inch) didn't heal better or ultimately appear better when sutured (stitched) compared to when they were left unsutured. A small, debris-filled wound should be cleaned with water that is disinfected enough to drink, and then left open to heal or closed (e.g., skin edges brought together) with an adhesive bandage (strips).

My preferred technique for caring for small wounds is to clean them thoroughly, then use skin (tissue) glue to make the initial closure, after which I cover the entire wound with a piece of gauze and duct tape or with Tegaderm (a thin, clear, plastic adhesive covering) for protection. Some people have used "super glue" to close wounds, but this is not recommended for several reasons. Any laceration can be sutured by a physician in a delayed fashion upon your return, if such a repair is necessary for cosmetic or other reasons.

Any large wound needs to be examined with three things in mind:

How contaminated is the wound?
How much will the wound bleed?
Are there any other structures involved?

Every large wound will have different answers to these questions, which is where clinical acumen comes into play. Always prioritize control of blood loss, and consider closing the wound(s) loosely with stitches if this is the only way to staunch the bleeding. If the wound is deep, there may be damage to structures beneath the skin, such as tendons, ligaments, and/or nerves, any of which may require formal wound care not possible in the outdoors. Therefore, consider evacuation for all large wounds. While evacuating, the wound should be covered and compressed with a clean bandage.

(1) Emergency Medicine Journal 2007;24:217-218; doi:10.1136/emj.2007.046813

image courtesy of St. David's Healthcare

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Tags: laceration, cut, wilderness medicine, outdoor medicine, healthline

Labels: cut, laceration, wilderness

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Tissue Glue, Fingers, and Float Tubes

When you are in the wilderness, it's good to carry supplies that can be used for multiple purposes. Duct tape is important for it's usual purposes, such as fixing a rip in a tent, but it can also be used as a wound closure strip or, in a pinch, to fashion a pair of emergency "sunglasses" for someone with a scratched cornea. We usually think of how non-medical supplies can used improvisationally for medical purposes, but the opposite holds true: there are occasions where the first aid kit comes in handy for non-medical purposes.

Here's how I killed two birds with one stone on a recent fishing trip. After instructing all the kids on the trip to be careful around the campfire, when chopping wood, and using sharp knives, I proceeded to stab myself deeply into the pad of my thumb when cleaning a fish. The wound bled freely, but wasn't spurting or gushing (e.g., no major blood vessel was involved), so I decided the finish the task at hand, then attend to my wound. After I was done with my chore, I washed the wound out vigorously with camp soap and disinfected water, because I am familiar with the sorts of infections one can acquire from bacteria that reside in the freshwater environment. Rather than achieve immediate closure tight closure with tape, I elected to pull the wound edges together only enough to stop the bleeding, and then applied bacitracin ointment and a bandage, so that I could give the cut a day to begin its healing process before attempting a more definitive closure.

The next morning, the cut looked clean, but after a day of fishing and repeated immersion in lake water, it was open and would clearly be a nagging nuisance for the remainder of my vacation, so I wanted to close it. Tape and bandages would work on dry land, but I had observed that even my super-sticky Coverlet® bandages worked themselves loose after a few hours of fishing and repeated immersion of my hand in the water to retrieve fish, handle them, and set them free after they were caught. So, I needed a better solution.

I always carry a few DERMABOND® ProPen (Ethicon, Inc.) applicators with me when I am traveling, so I carefully washed and rinsed my cut again, allowed it to air dry, and then glued it shut with the tissue glue. That worked like a charm, and the cut not only healed without incident, but the pliable and semi-transparent wound repair easily withstood three days of nearly constant soaking in the water. When I returned home, I easily peeled the remaining purple tissue glue off my finger.

While I was gluing my cut, one of my fishing buddies noticed me working on my hand, and asked for an explanation. His eyes lit up and he said, "I think you have a solution for me. The valve on my float tube has come loose. I got it to fit back together but I need something to keep it in place, and I can't find any epoxy cement. Do you think your stuff (the tissue glue) might work?" I had no idea, because I had never used DERMABOND® on anything other than people, but it was worth a try. Using the applicator, he applied a ring of the 2-octyl cyanoacrylate compound to the reassembled valve, taking care to avoid occluding the opening. It was the perfect viscosity to penetrate the connection. We let it dry, then applied one more coating for good measure.

It worked! So, my cut was fixed, and so was my friend's float tube. Of course, I'n not advocating that you consume precious medical supplies to fix your fishing gear, since a tube of Super Glue would be much less expensive, but it's nice to know what works. Furthermore, once you break the seal on a vial of DERMABOND®, it's a one-time use situation, because the vial that is now exposed to air will harden and need to be discarded, so you might as well figure out if you have anything else that needs to be glued before you throw the applicator in the garbage. After observing our success with the float tube, I touched up a few pinholes in my tent and one fraying tent seam, for good measure.

Tags: tissue glue,DERMABOND, cut, fishing, first aid, wilderness medicine, outdoor medicine, healthline

Labels: cut, DERMABOND, first aid, supplies, tissue glue, wound, wound closure

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