Cuts, Scrapes and Stitches

You hear a loud thud and then screaming from the next room. You run in to find your three-year-old sitting on the floor, holding her forehead, while blood streams down her face. You look at the cut and blood seems to be pouring out. By the time you get her to the ER, her whole shirt and the back of your car looks like it's covered in blood, but your daughter actually appears well. You are confused, and perhaps embarrassed, when the ER nurse takes a look at the wound and says, "oh, she'll be alright. It's just a little cut."

This scenario happens to many parents. It is often difficult to assess cuts, especially when they are actively bleeding. Here is the Dr. Sears guide to what to do if your child is injured with a cut or scrape, how to decide if stitches are needed, and guidelines for proper wound care for scrapes and stitches.

For actively bleeding cuts:

• Step one is DON'T PANIC. If you stay calm, then your child may stay calm also.
• Step two is to cover the cut with whatever you can get your hands on the fastest. If you can cover the cut quickly, then your child will panic less.
• Step three is to look at the cut. Get an initial impression if it is minor or major.
• Step four is to stop the bleeding. Find a more appropriate item such as a clean towel or cloth and gently but firmly press it to the cut. Don't keep peeking underneath every 10 seconds. Hold it in place for at least two minutes (longer if necessary).
• For cuts that involve a large bump or bruise, such as on the head, you may also want to apply some ice wrapped in the towel.
• Once the bleeding has stopped or dramatically decreased, take a closer look at the wound to assess how severe it is. Proceed to the next step below.

Try to remain calm. It is virtually unheard of for any one to lose so much blood from a cut that it puts them in any danger. Cuts on the head and face bleed more than anywhere else on the body. This is because there are many more blood vessels in the skin here. Many parents worry that these cuts have caused a lot of blood loss. You can rest assured; the blood looks like a lot more than it really is.

Simple cuts that do not require stitches do not need to be seen by your doctor.If it is obvious that your child does need stitches, do not rush in to your doctor's office. Instead, call the office to find out what time would be best to come in. Since stitches usually take at least a half hour to do in the office, most offices would prefer to try to make some time later during the day, rather than squeezing you in immediately. Some offices may prefer to direct you to an ER or a plastic surgeon for the stitches, so calling ahead may save you a trip.

If you are not sure whether or not stitches are needed, here are some guidelines:

• Check to see if the cut is gaping open. If it is not, then gently tug on it to see if it gapes open. If it does, than it probably will need to be closed.
• Any cut that is gaping open with visible dark red muscle or yellowish fat should probably be closed, even if it is small.
• Any cut that is gaping and is larger than ½ cm (or 3/16 of an inch) should probably be closed. Get a ruler and measure it if you are not sure. Cuts smaller than this may not require closure, but if they are gaping, than it is best to have a doctor check out the cut.
• Small cuts that are not gaping may not require actual stitches, but may still benefit from steri-strips (see below)
• Any cut, even a small one, that is gaping open on the face should be seen by a doctor because of the risk of a scar.

There are two main reasons to get stitches:1. To stop active bleeding. If a cut is large and continues to bleed, then closing it is obviously beneficial. Most cuts, however, will stop bleeding after a while if pressure is applied with a towel or cloth.2. For cosmetic reasons. Cuts on the face obviously will have a better cosmetic outcome if they are closed. However, for a small cut on a body part where you are not concerned about a scar, then closing it is not as important. Decide if the trauma of doing stitches will be worth it.

Dr. Sears suggests: Stitches do not decrease the risk of infection in a cut if properly cared for.Most important – if you are not sure whether or not a cut should be closed, then see your doctor. It is much better to waste a trip than to have a big scar that was avoidable.

Most cuts can generally be closed as long as 24 hours after the accident. Some cuts should be closed sooner, but it is very safe to wait at least 8 hours to have a cut closed. Therefore, if the cut occurs at night, it is generally ok to wait until the next morning, as long as you can get the bleeding to stop. Very important – if you do decide to wait, wash the cut under the faucet to get out any dirt. Do not let the cut dry out. The best thing to do is to buy a bottle of sterile saline and some gauze. Wet the gauze and tape it over the cut. Change this every two hours to keep it moist. If you cannot do this, then put some antibiotic ointment on the cut and cover it with gauze or a band-aid. Repeat this every few hours to keep it moist. Stitches generally don't require urgent care.

There are four ways to close a cut. Your doctor will discuss these options with you:

1. Steri-strips. Also known as "butterfly" strips, these narrow strips are placed over the cut, with a bit of tension to keep it closed. A sticky liquid is placed on the skin to hold the strips on. These generally stay on for 2 to 5 days if kept dry and not accidentally pulled off. These are used for cuts that are small, not gaping open, not very deep and not over a joint or area of skin tension. If they stay in place for at least three days, the outcome can be just as good as stitches or even better because steri-strips avoid the "railroad track" appearance of some stitch lines. A big advantage is that they are quick and painless. A disadvantage is that they are not as strong and will not stay in place as long as stitches.

2. Stitches. These have the advantage of providing more strength and little to no risk of being pulled off too soon. An obvious disadvantage is the time and pain involved in putting them in.

3. Skin super glue. This is a skin glue that is applied by rubbing it over the cut while the cut is being held closed. It has the advantage of being quick and painless. It is a good choice for clean, straight cuts that are not gaping too much nor under tension. If you are hesitant to put your child through the trauma of stitches, but steri-strips are not enough, then this may be an option. If done well, the cosmetic outcome is the same as stitches.

4. Staples. These are often used in the scalp (within the hair). They are very fast, and close the cut almost as well as stitches.

No matter who does the stitches, there will be at least a slight scar. Even the best plastic surgeon in the world will leave a scar. It is, however, important to minimize the scar. Parents are naturally worried about this. Here are some suggestions on deciding where to have the stitches done.

• Plastic surgeon. The most common reason to use a plastic surgeon is for cuts on the face. An ER doctor or pediatrician could easily handle very small cuts on the face, but a plastic surgeon will be most able to minimize the scar. You can have the stitches done in the surgeon's office or in an ER by the surgeon.
• ER doctors have the advantage over pediatricians of doing stitches more often. They often put in stitches several times a day. This allows an ER physician to become quite skilled in stitches.
• Your pediatrician. For simple cuts anywhere besides the face, your pediatrician is probably the best place to go for the stitches, unless the office is very busy that day. Remember, there will be a scar no matter who does the stitches. Your pediatrician will do an excellent job in minimizing the scar.

Ask your doctor for some specific guidelines on proper wound care. Here are some general guidelines to follow:

• For 24 to 48 hours, do not allow it to get wet in the bath or shower.
• After 48 hours, it is ok to get the wound wet.
• Steri-strips are an exception. Keep them dry for at least 5 days. After that, they have been on long enough and you may get them wet to encourage them to come off. Do not pull them off unless they come off easily.
• Avoid the build-up of a scab. A thick scab within the wound can increase the scar and prevent the skin from growing together well. You can prevent scab build-up by dabbing diluted peroxide (½ water mixed with ½ peroxide) to the wound and then gently removing any loose scab. Do not pick away any scab that is still firmly stuck. Wait for it to loosen up from the peroxide. Do this twice a day.
• Apply antibiotic ointment twice a day.
• Keep the wound covered for at least 48 hours. You can continue to cover it if it is convenient to do so for several more days.

• Sun protection. Damaged skin is very susceptible to becoming permanently discolored by the sun for up to 6 months following an injury. It is very important to minimize sun exposure to the healing cut. Keep it covered with a hat or clothing as much as possible. When necessary (especially for long days at the park, beach, or swimming pool), apply a strong sunscreen or even a sun block (the white stuff that doesn't soak in). Do not apply sunscreen until two weeks after the cut.
• Flax seed oil. This is an oil you can buy in a nutrition store. It contains all the essential fats that are necessary for skin to grow and heal itself. It is not proven that this actually helps for sure, but theoretically it will. It is very healthy to take anyway, even without a wound. Give 1 tsp each day for infants, and 2 tsp for children mixed in a smoothie. Do not apply the oil to the skin; it needs to work internally.
• Vitamin E oil. You can rub this oil onto the cut after the stitches are removed. There is not a definite proven benefit, but it may help the healing.

• Face. These should be removed in 3 to 5 days. Why so soon? Because by five days the stitch thread starts to react with the skin and this can leave a mark for each stitch. If the stitches are not turning red where they enter the skin, then it is best to wait the full 5 days. If a stitch reaction is occurring sooner, then see your doctor before 5 days to consider having them removed. Your doctor may put steri-strips over the cut to provide a few more days of strength. Do not wait more than 5 days.
• Body and scalp. (within the hair) 7 to 10 days.
• Extremities. 10 to 14 days. If the stitches are done over a joint area that bends and stretches, then you should wait 14 days. If not, then 10 days is enough.
• Ask the doctor who puts in the stitches when they should be removed.

Over the first few days it is normal for the skin around cuts and scrapes to turn slightly red. If the redness continues to spread, your child develops a fever, or you see a foul- smelling greenish discharge from the wound, see or call your doctor. Your child may need an antibiotic by mouth. It is generally not necessary to page the doctor overnight for this. It can wait until morning.

Although scrapes are generally minor and do not warrant a trip to the doctor's office, large scrapes can leave a permanent discoloration to the skin if not properly cared for. Here are some guidelines to follow to help you properly care for scrapes.

• Wash off the scrape as soon as possible with soap and warm water. Rinse or gently wipe away any dirt.
• See your doctor if there is any dirt or gravel stuck in the scrape that you can't remove.
• Do not let the scrape dry out and form a scab. A thick scab may lead to permanent discoloration.
• Follow these steps twice a day until the scrape is healed:
  • Wash with warm water under a faucet to rinse away debris and germs. Dab it dry
  • Apply a diluted peroxide solution (½ water mixed with ½ peroxide) and let it sit for two minutes.
  • Dab or wipe away any scab what has accumulated.
  • Rinse away the peroxide.
  • Apply an antibiotic ointment. See antibiotic ointment
  • For large scrapes, instead of an antibiotic ointment, call your doctor for a prescription cream called Silvadene. It is used for burns, but also works well on large scrapes. Do not page your doctor after hours for this cream. You can use antibiotic ointment for a day until you can get the cream. This cream contains silver, so it may form a "tarnished" black color on the bandages.
  • Apply a non-stick gauze pad over the cream or ointment. One brand name is called Telfa, but you can use any non-stick gauze.
  • Tape or wrap gauze over this pad.
• For small scrapes, you do not need to meticulously follow all these steps. Simply use the peroxide and an antibiotic ointment, and try to prevent a scab from forming.
• Sun protection is very important. See the section above under long-term steps to minimize the scar.
• You can stop putting on the cream and dressing once the scrape has healed to a light pink color, with no more red, sore areas.
• Watch for infection according to the guidelines above.