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How do you know when a nasty cut needs stitches?

Tuesday, January 25, 2000

By Gretchen McKay, Post-Gazette Staff Writer

The last place 6-year-old Amir Muhammad wanted to spend his Friday evening was flat on his back in the emergency room at Children's Hospital of Pittsburgh, under the harsh glare of a fluorescent light.

  Amir Muhammad of Shadyside gets stitches for a cut over his left eye. (Annie O'Neill, Post-Gazette)
But when the Shadyside first-grader tumbled off the jungle gym after school at Liberty Elementary earlier that afternoon, he'd landed on his face in the dirt and wood chips. The consequence: a fairly nasty cut above his left eyelid.

Fortunately, Amir's father, Malik, had just arrived at the school to pick him up and quickly rushed the bleeding child to the hospital. Unfortunately, there was no question the 3/4-inch gash would require sutures.

Amir is hardly alone: Emergency room staff sew up more then 11 million facial lacerations a year in the United States. Closing wounds with needle and thread, in fact, is one of the oldest known medical procedures, having been performed by the ancient Egyptians 4,000 years ago.

Still, it isn't always easy for parents to recognize when their child's cut necessitates a trip to the emergency room for treatment - or when just a Band-Aid, antibacterial cream and a kiss will suffice.

Whether a cut requires sutures depends largely on its size and how badly it is bleeding, experts say.

"Clearly, if the cut is gaping or the bleeding is difficult to control, it will need to be stitched," says Michael Decker, an emergency medicine physician at Children's and pediatrician in private practice with Pittsburgh Pediatrics. Sutures are also generally required for wounds in which the edges of the broken skin, once pulled together, separate again when the pressure is relaxed.

Sutures keep dirt from getting inside the cut, and just as important, they can reduce the amount of scarring, says Children's ER physician Bob Hickey.

"Stitches take the tension off the wound" so less scar tissue is made to bridge the gap, he says.

One of the toughest things about stitches is what Hickey calls the "anxiety factor."

"Holding the forceps and thread is the easy part - it doesn't require a whole lot of expertise," he says. What does take a certain amount of skill is keeping the child calm through what can be at times a painful procedure. Sometimes, younger children are strapped in a cloth "papoose" to minimize their squirming.

While many wounds can be numbed by applying a topical anesthetic gel, some require a shot of anesthetic into the wound. If the child is terrified of needles, the doctor may consciously sedate him with an anxiolytic drug like Versed (the child is still awake, just groggy) or block with a strong anesthetic the nerve that serves that part of the body.

"You have to be able to get in and clean the wound, which can be painful," says Hickey.

For fairly straight and uncomplicated cuts, doctors may close the skin with the relatively new adhesive, Dermabond. The doctor simply pulls the edges of the cut together, applies a thin coat of the Super Glue-like product on top and waits 50 seconds for the glue to dry.

The Dermabond procedure is about 75 percent quicker than stitches and is relatively pain-free, other than the child experiencing some "heat" while the adhesive sets. The main discomfort is in having the wound cleaned beforehand. Because the glue naturally sloughs off in five to 10 days, there is no need to return to the doctor to have stitches removed.

While Dermabond may sound revolutionary, it cannot be used over joints, on cuts that are under tension, or in cases where the torn skin has to be pieced back together. Nor can it be used in the mouth or other moist areas. Special care must be taken when the glue is used around the eyes.

Non-absorbable thread is stronger and less likely to promote infection than dissolvable thread. It is good for dirty wounds and animal bites, which get infected, as well as a cut under a lot of tension, such on knees, elbows and chins. For this type of thread, a child must return in three to five days (for facial cuts) or two to three weeks (those on the legs and feet) to have the stitches removed.

In Amir's case, the wound was too wide and gaping, and too close to the eye for Dermabond. Doctors used absorbable thread so the stitches would not have to be manually removed so close to the eye.

After applying the topical analgesic to the wound area and allowing about 20 minutes for it to take affect, intern Ericka Fink gently cleaned the wound by shooting sterile saline solution into it with a giant syringe. Attending physician Mananda Bhende then checked to see if the gash was totally numb by poking inside it with a syringe.

When Amir shrieked in pain, she administered a shot of lidocaine. "He still has a little sensation," she said.

A few minutes later, Bhende draped the cut with a piece of cloth and, continually dabbing the wound with a swatch of gauze, watched as Fink carefully closed it with a series of knots - tweezers-like forceps in one gloved hand and the tiny, curved needle in the other.

All the while, Dad held Amir's hand and whispered encouragement.

A half-hour later, Amir had eight stitches under a Bert and Ernie bandage, and some stickers and a red popsicle as his reward. The staff instructed his father to keep the area as dry as possible and watch for signs of infection: redness, tenderness, fever or drainage from the wound.

Amir was also instructed not to bump or stretch the wound during the next few days, and to wear sunblock on the area for the next six months or so; sunlight can make a scar more visible. Some doctors also advise their patients to rub vitamin E oil or cocoa butter onto the wound, or massage it a couple of times a day to reduce the scarring.

Whether the elementary student will have a noticeable scar depends largely on genetics. Stitches that are left in too long or get infected may result in railroad-like "tracks" on either side of the wound.

When should you call in a plastic surgeon? It depends on the complexity and location of the cut, not to mention the parents' anxiety level.

If the stitches are in a delicate spot - close to the eye, near the mouth or lips or on the ear lobe - a specialist is probably not a bad idea. Ditto if the suturing involves having to cut away pieces of skin or somehow change the wound's shape to improve mending.

When in doubt, parents should ask the examining physician if the wound is something he or she is comfortable stitching, said Decker, the ER physician at Children's.

"And if he or she gets upset, that would make me question the physician," he says.

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