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..."