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  • Emergency Wound Care and Management

    Thank you FLA_MEDIC at PlanforPandemic for permission to re-post this information.

    EMERGENCY WOUND CARE AND MANAGEMENT

    Note: The following is a description of how I, personally, would opt to treat wounds such as abrasions, avulsions, and lacerations during a period of time when no doctor or medical facility is available. I am a long retired paramedic, and am not a doctor, and offer this information for education and discussion purposes only. Nothing contained within should be construed as medical advice.



    Trauma


    Victims of trauma are likely to have one or more insults to their body. Often, the most obvious ones are not the most life threatening. When you treat a patient, your goal is to treat the whole patient, not just the apparent wound.

    The first step whenever dealing with a patient is to ensure, to the best of your ability, your own safety. Scan the scene for dangers. Downed electrical wires, hazards from falling objects, chemicals, etc. You will do your patient absolutely no good if you get yourself killed or injured trying to help them.

    When I approach a patient who has been injured, I remember my ABC?s. A is for Airway, B is for breathing, and C is for circulation. It does no good to properly bandage someone who is non-breathing, or who is in cardiac arrest. If you have not learned to do CPR, take a course now!

    When dealing with a trauma patient, it is very important to understand, if possible, the mechanism of the accident or insult. Did the patient fall? How far? Onto a hard or soft surface? Has the patient moved, or been moved? Do you suspect a back or neck injury?

    Sometimes, it will be obvious what happened. A knife slips, someone misses with an axe and slices their leg, or even a gunshot wound. Other times you may be dealing with someone who has rolled their car, and that nasty head gash may be the least of their problems.


    Bleeding


    It is axiomatic that tablespoon of blood looks like a cup full. And a cupful of blood looks like a quart. Everybody tends to overestimate blood loss. Some areas of the body are very vascular, and even a small cut or laceration, say to the scalp, can drench a patient in blood. Arterial bleeding (the most serious) will spurt with each beat of the heart. Venous bleeding will ooze out, although it can do so at a remarkable rate.

    Unless you know the person you are dealing with, and know with certainty that they are HIV, Hepatitis, and H5N1 free, you need to avoid contact with their blood. Latex gloves are your first line of defense. Was a time, when we?d stick an ungloved finger into a deep laceration to stop a pumping artery. Today, I?d recommend gloving up before you approach any patient. Glasses, or eye protection are also highly recommended.

    Before you start worrying about fancy bandaging, your first step with any bleeding wound (other than a slight oozing of blood) is to slap 4 or 5 gauze pads on top of the injury. If the patient has multiple wounds, deal with the most serious first. Don?t worry about abrasions or `road rash? if there are deep lacerations or avulsions (an avulsion is a flap of skin).

    For 90% of patients, bleeding can be controlled by firm pressure. Rarely does this fail to stop the bleeding. Even traumatic amputations of arms and legs generally respond to this treatment. Therefore, a pressure bandage, or simply placing your hand on top of the gauze pads, is your first line of treatment. If the gauze soaks thru with blood, put more on top. Don?t pull the old, blood-soaked gauze off, as it will restart any bleeding that might have ceased due to coagulation.

    Elevating the wound, above the heart, can also assist in halting the bleeding. This should not be done if you suspect a fracture, however.

    Duct tape is a surprisingly good bandaging material (with gauze underneath). If you?ve got a major trauma, and need to move the victim, it can quickly close nasty wounds. It is also excellent for ad hoc splits. Of course, closing a wound with duct tape in the field is a temporary measure. Useful if you need to stop bleeding, or evac a patient. It should not be considered a permanent solution.

    A word about tourniquets. We?ve all seen the movies where the hero takes off his belt, cinches it tight around his leg, and saves himself from bleeding to death. In the real world, after about 20 to 30 minutes with a tourniquet, tissue death will begin and his leg will be lost. The simple rule is, use a tourniquet, and expect to lose the limb. It should be a last resort.

    There are products out there that will stop bleeding. You can buy packets of QUICK CLOT, which reportedly does a terrific job at stopping bleeding. It is, however, fairly expensive, running about $28 for a packet. When sprinkled over a wound, and covered with a pressure dressing, it will stop just about any bleeding. Highly recommended.

    Without recommendation, I can tell you that potato starch flour, or even finely ground instant mashed potato flakes, will reportedly do the same thing. I have not tried this `remedy?, and would much prefer to have the sterile, commercial version of Quick Clot in my bag. However, if QUICK CLOT is unavailable, and I had no other recourse, I?d be tempted to try it.

    If after all other measures fail, you are unable to control bleeding, then, and only then, should you consider using a tourniquet.

    Don?t worry about getting fancy with your bandaging. It will all be cut away once the patient is stabilized, and is ready for wound management. A stack of 4 x 4 pads, with several wraps of kling bandage are all that is generally required. A pressure dressing, such as the combat trauma dressing can be used for large wounds. If you find yourself without one, a sanitary napkin held in place by an ace bandage does a remarkably good job.


    Shock

    Patients may experience hypovolemic shock, if they have lost more than a pint of blood.

    While you should be mindful of shock, your first task is to stop the hemorrhaging. Once that is controlled, think about a blanket, and elevating the feet. In severe cases of hemorrhage, IV replacement fluids such as plasma, whole blood, or blood expanders are used in hospital emergency rooms. Unless you can type and cross match blood, it is playing Russian roulette to do a blood transfusion from one person to another. If you have a compound, with a number of members, it would be worthwhile to have everyone?s blood typed, and dog tags made reflecting their types.

    Once you?ve stopped the bleeding, it is important to take a set of vital signs, and record them. Blood pressure, pulse, and respirations. While there are normal ranges, there are wide variances between people. You should then repeat vital signs every 10 to 15 minutes, and monitor changes. A sudden drop in blood pressure could indicate internal injuries.



    Clamping arteries


    A truly desperate measure. Arteries supply blood to broad areas of the body. Clamp an artery, and you deprive that area of oxygenated blood. Without a vascular surgeon, and an arterial graft, the odds are not good long term. When an artery is severed, it usually retracts into the muscle. Finding it, and clamping it are difficult at best. The good news is, often the artery will seal itself. Personally, I?d be very hesitant to try to clamp an artery, and would regard it as a last ditch effort.



    Infection

    Wounds are rarely clean, and never sterile. The probability of infection is high, particularly if dirt or contaminated water has been introduced into the wound. Open fractures are particularly susceptible to infections. In a hospital, Ancef and Gentamyacin are routine administered IV when such contamination is suspected.

    In all likelihood, the best you will be able to do is irrigate a wound, clean it the best you can, and hope the body?s defenses can handle any bacteria introduced. Debriding a wound may be necessary over the course of wound treatment to remove any dead or dying tissue, and to remove any pus that forms.

    Only after the wound has stopped bleeding should you consider cleaning the wound. Oozing blood is fine. But if it is more than that, reapply the pressure dressing.

    Irrigation with sterile water (boiled) or saline, using a bulb syringe or hypodermic syringe, is the easiest way to clean a wound. Once you have thoroughly irrigated the wound, you can use sterilized tweezers to remove any debris.

    A more detailed explanation of how to deal with an infected wound may be found at

    http://www.ehow.com/how_5403_treat-infected-wound.html




    Suturing


    A difficult subject. Not exactly an open and shut case. Many wounds will do just fine left unsutured. They will fill in, from the bottom up, and will heal nicely. There will be more scarring, and the healing process will take longer, but it can be the right choice in a number of circumstances.


    For many minor cuts, steri-strips can be used instead of stitches. They are cheap, and painless. Even superglue can be used to `weld? the skin together for a few days, but care should be taken not to get it inside the wound.

    But the subject of suturing always comes up, and so I will address it.


    You can buy a suturing kit, with an assortment of sutures, needle holder, forceps, scalpel, and even lidocaine for under $50 on the net. No Rx needed. Really cheap kits can be had for under $15, but generally don?t include the lidocaine.

    Closing a wound is more complicated than just sewing it up. Different areas of the body require different types of suture material. Different shapes and sizes of wounds require different suturing techniques. And for deep wounds, knowing how to suture muscles, ligaments, and blood vessels together is beyond the scope of most of us. Even with my field experience, I?d be very hesitant to suture anything more than a minor laceration. And those, I figure I can handle with steri-strips.

    That said, I have a suture kit in my medical bag. Why? Because, if push came to shove, I?d rather have it than not. If I can?t use it, I might find a doctor who can.

    But when you suture a wound, you run the risk of closing in contaminants. Dirt, bacteria, foreign matter. All can (and likely will) lead to infection. If that happens, you will likely be pulling stitches out, opening the wound, and draining it. You would have been better off leaving it open (and covered), debriding it daily, and letting it heal naturally. A lot of things can happen when you suture a wound, and quite frankly, most of them are bad.

    You should also never attempt to suture a wound that has been open for more than 12 hours. If the wound is older, then let it heal as an open wound.


    Open wound Treatment

    Open wounds often heal faster if kept slightly moist. Large wounds can be packed with sterile gauze, moistened with a disinfectant solution. Clean, boiled water should be used, with either salt, or a small amount (1 ounce) of povidone-iodine in 1 liter of water, or both added. This packing should be removed once or twice a day, and replaced. A dry bandage can be placed over this packing material. But should not come in contact with the wound itself.




    Debriding an Open Wound


    Debriding is the removal of dead tissue, and frequently pus, which often indicates infection. You are looking to save pink tissue. White, yellow and green are colors of decomposition. You can frequently catch a whiff of bacterial infection when you open a wound, and the odor is unmistakable.

    An open wound is easier to debride if it is first softened by freshly moistened gauze, soaked in salted warm sterile water. Allow the gauze to remain in contact with the wound for 15 minutes before starting.

    Using tweezers, forceps, scissors, and even a scalpel, your goal is to remove anything that is dead or dying from within the wound. Care must be taken not to remove living tissue, and sometimes you will have to go back day after day, taking a little more dead tissue out each time. Pus can be expressed, and drained from the wound, and wiped away with cotton balls or gauze pads.

    Once a wound becomes infected, you may find yourself opening and debriding the wound several times a day.

    Signs of infection, beyond pus in the wound, include fever, swollen lymph nodes (groin, armpits, neck), and red streaks emanating from the wound.

    At that point, if I had any oral antibiotics, I?d use them. The choice of an antibiotic is normally predicated on the type of infection. You won?t be able to culture bacteria, and check for drug resistance. My first choice would probably be a cephalosporin, although in a pinch, I?d probably use any broad-spectrum antibiotic I could lay my hands on. You are, however, gambling that the antibiotic you have will be effective.


    More details on how to debride a wound can be found at

    http://www.healthatoz.com/healthatoz...ebridement.jsp




    Closed wound treatment


    If you close a wound, with steri-strips or with sutures (or staples), a little neosporin can be smeared over the stitches, and a light dressing applied. Keep the wound dry. Stitches, depending on the type, and location, should stay in between 1 and 2 weeks.


    For those that are interested, a pretty good tutorial on suturing is available at:

    http://www.bumc.bu.edu/Dept/Content....69&PageID=6067


    Once again, I am not advocating home suturing. But if you must, please take the time to learn how. Practicing in advance is highly recommended.
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