Suture Experience: Face Off [suture pad, stapler, face flap]

A 70 year old female walks into a bar...and then walked into the edge of a staircase, slicing her face from mid forehead to her ear, nearly 8 inches long down to the skull. The EMS report in triage was "she was scalped". 

The patient came wrapped up in blood soaked abdominal pads and cling wrap. Normally I take down wounds and look, then get supplies to match the wound; but this time I went to get supplies in advance. Specifically, water, gauze and a stapler.

This is why: closing the wound is less important than the neuro exam & head CT this patient needs; and in general massive bleeding laceration on the face or scalp is a distraction to staff and delays evaluation of ABCs and getting to imaging. Just staple it and move along! Plus you can remove the staples later, piecewise as you close a long or complex lac; especially when the wound naturally wants to open up. 

I took the bandages down, and the patient's face fell down in front of her eyes. i was ready, as the nurses shrieked and family members moaned and stumbled into their chairs. I had wrapped her shoulders in a towel in advance; so I quickly held up the flap with pickups, poured a bottle of saline into the wound; letting it down down to the ear; and then quickly placed 6 staples. I stepped back; and the patient actually looked normal. I dabbed the blood off her face and moved onto my exam, and then left to place orders. After the song and dance of evaluating a head wound was done, I was able to return to the wound; closing the midpoints between staples carefully, removing the staplers after the sutures were in place; and finally replace the staples at the end. 

Take away points:

1) learn to identify complex or large wounds, listen to EMS!

2) prepare for bad wounds before you unwrap them, towels, gauze, saline, and a rapid method to close, and more bandages

3) complex lacerations are often easier to break into smaller pieces and close piece meal

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To simulate this experience you'll need:

Setup:

  • make a long incision along the length of the suture pad, leaving 1/2" on each side (and 1/2" from the top or bottom of the pad); through to the red layer; then go 90 degrees from the wound; forming a shallow and wide U
  • undermine the edge of the wound, at least 1" if not 2" 
  • the goal is to make a long and large flap that falls over on itself
  • prop the pad up on a vertical surface (a book works well)

Practice rapidly closing the wound at 4-6 points and then going back to close the wound more carefully. 

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Don't be distracted by bad wounds; focus on what's important, airway, breathing, circulation...and permanent disability!

 

suture pad


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