Thursday, February 14, 2013

Lesson Thirteen: Wound Care

Lesson Thirteen: All Bites Are Dirty – Wound Care & Considerations

Following on to why closing wounds and performing field surgery is both unnecessary and ill-advised, some basics and beyond on wound care.

Wounds come in all types:

abrasions - scraping of the skin, or scraping off the skin
punctures - everything from stepping on nails to gunshots
avulsions - removal or near-removal of large pieces
incisions - sharp, clean cuts
lacerations - jagged, rough tears
contusions - minor to moderate impact injuries
crush injuries - major impact injuries

Going back a step, these all start at the skin. Your skin and mine provides three fundamental benefits:

It keeps the insides where they belong - structural support
It helps maintain body temperature - thermal regulation
It keeps germs on the outside - infection barrier

It's largely this last one that concerns us. Any break in the skin, and most wounds result in one, can be fatal precisely because it provides a new way for crap from the outside world, even on our own skin, to get inside and make a home -- killing us in the process.

Before the early 1900s, lack of understanding of germ theory and lack of antibiotics to treat it meant that a staggeringly large number of minor wounds became septic and the patient/vicitm simply died. This included during childbirth.

Bear in mind that in a SHTF scenario, even though you know about germ theory, you're still probably going to be lacking in antibiotics for short- or long-term response. With similar outcomes.

What you can do to change this is to do your best to limit infection entry. How?
1. Clean all wounds.
Benzylkonium chloride is a quaternary disinfecting agent, biocidal to a host of bacteria and viruses. You and I know it best by its trade name, Bactine. As such, it also contains a small amount of lidocaine, which like anything ending in -caine, is a local anesthetic. Bactine really does make boo-boos hurt less.

Povidone iodine generically, or Betadine commercially, is also fabulous, for people (most of us, but not all) who aren't allergic to iodine or shellfish. Use the Solution not the Scrub formulation. Solution is for topical (skin) use. Scrub is for cleaning surgical instruments and tables -- far stronger. The solution can also be cut with clean (ideally sterile) water, for a disinfecting soak.

Plain old clean water (warm, not boiling hot, but cold if it's all you have) and some mild soap is your third choice. Most city tap water is highly chlorinated enough to qualify. Water in the wilderness must be purified, ideally by boiling first, then allowing to cool to body temperature.

But the key is to CLEAN. Pour, hose squirt, scrub gently with clean or sterile gauze, use a soft toothbrush soaked in betadine to scrub out deeply embedded material/crud. Look as deep inside as possible to make sure anything and everything that got injected into the wound has been removed. Then repeat. Then repeat. Then repeat. Then repeat. I hope I'm getting this across. Oh, then repeat. And for good measure, repeat.

2. Clean AROUND all wounds.
Whip out your trauma shears, and cut up a seam to lay open a pant-leg or sleeve. If it's a torso, remove what you have to. Remember, clothes are dirty, unless they came out of a surgical sterilizer; get them away from the wound.

Clean around the wound with those things everyone wants to put IN wounds (Don't -- See Lesson One) rubbing alcohol, hydrogen peroxide. Purell hand sanitizer (kept OUTSIDE of the wound) is mostly jellied alcohol, great stuff to kill nearby cooties on the intact surrounding skin. Hydrogen peroxide is great for dissolving clotted blood (OUTSIDE the wound), which is a petri dish for growing bacteria, and must be cleaned away.

3. Protect the wound.
That means clean, dry, sterile gauze. Cover the site, and around the site, with at least one clean layer. Don't pack wounds, let them drain. Note I said drain, not gush blood. If bleeding is a problem, direct pressure, an ACE wrap, and pressure points will generally suffice in 99.9999% of injuries. Thus in many cases, a tourniquet is best saved for putting around the hands of anyone trying to place one on your patient. (Penetrating gunshot and shrapnel wounds are an exception, which is what TCCC is for). But if you absolutely can’t stop the bleeding any other way, the CAT tourniquet has been applied and left in place on extremities for 4 hours with no long-term adverse affects. If you apply a tourniquet, make sure anyone you pass the patient along to knows where it is, and when you applied it. (And yes, you hard chargers can even mark it in blood on the casualty’s forehead, it that’s all you’ve got. But a Sharpie is usually a better choice, along with a lapel patient tag.)

The only exception to dry, sterile gauze are large, painful (2nd degree) burns, and eviscerations, where internal organs have become external organs. In that case, large abdominal (5x9 and larger) dressings should be applied soaked in sterile saline, and everything wrapped/draped and packaged for transport as best as you can.

4. Protect the dressing.
This is where bandaging comes in. Dressings MUST be sterile, bandages need only be CLEAN. Roller gauze or ACE wraps are bandaging. Wrap them around the wound dressing securely, but not tightly. The provide support, keep dressings in place, and provide pressure to limit bleeding. In long-term settings, they can be washed when dirty, and re-used once new sterile dressing material has been replaced. Bandaging should never be so tight that circulation or sensation is compromised. Fingernails and toenails beyond the injury should still turn white, and return to pink in less than 2 seconds when pressed and released. There shouldn't be any "pins and needles" sensation either. If this isn't so, loosen your bandages somewhat, and rewrap.
Alternatively, for smaller areas, any number of adhesive tape varieties can also be used, with the same concerns about circulation. Unlike bandaging, tape is generally a single-use proposition, and repeated application can damage skin around the wound. And some people are allergic or extremely sensitive to the adhesives. Use cautiously, and monitor well. Which leads to:

5. Monitor the wound.
Done properly, the first dressing can be left on for 48 hours, unless it's soaked through. After that, daily dressing changes are indicated. Sooner if the dressing is soiled or soaked. A little sunlight UV can also help disinfect the wound; leave it briefly uncovered and exposed to direct sunlight each day. (Not in blowing sandstorms, but you should get the concept.)

During dressing changes, observe the wound.

Is it draining small amounts blood or clear fluid? Scabbing over somewhat? Excellent.
Swelling up? Hot? Aching? Red? Draining pus? Foul-smelling? Road-map of streaks up veins?
You've got major problems. These are all signs of local (and growing) sepsis (infection). The body isn't going to "get better" with this. It's going to fight valiantly, and lose.

Hopefully, long before that first 48 hours, you got your patient to medical help.
If you did or didn't, and you see these signs, NOW IS THE TIME, whether it's been one day or ten.
Or they're going to die, left untreated.

First side note: no hospital or doctor is going to stitch things closed after 12 hours. It only increases the risk of abscess and infection. Again, if you think stitches are indicated, and you can get there, get to definitive care and repair as soon as practicable.

Second side note: People with crappy peripheral circulation, like the elderly, diabetics, or people in cold environments not properly kept warm, are at much greater risk for infection. So are people with poor immune systems, because of being already sick, under chemo/radiation therapy, or having long-term immune system issues. Know your patient.

Ideally, you want the wound to heal from the deepest part in, towards the outside. This prevents pockets of infection (abscesses) from forming, and generally makes the wound heal up prettier and more effectively, with minimal scars, pains, and problems.

Thus wounds that go deeper, like punctures from gunshot wounds or bites, or large area wounds, like burns and abrasions, are more likely to become infected than the other types. Clean them and monitor them even more closely than other types.

And no bite, from anything, is "antiseptic". Dog saliva is just less dirty than human saliva. That's like saying cow poop is cleaner than pig poop. In fact, since dogs, cats, spider, snakes, and other insects, not to mention a lot of humans, don't brush between meals, all our fangs are veritable bacterial paradises, so treat any bite, or any open wound, as a sewer, and clean accordingly.

For very minor superficial wounds, use of generic triple antibiotic ointment, commercially known as Neosporin (or, as I call it, "The Magic Spackle") can be a good thing. It's about 95% inert Vaseline, and 5% or less actual antibiotics (three of them). The vaseline base sticks the antibiotics where they'll do the most good. There are three main ways to attack bacteria -- the shell, the innards, and their method of reproducing. By no strange coincidence, the three antibiotics in Neosporin contain one that uses each method.

Know also that double antibiotic ointment, commercially known as Polysporin, contains two. It's generally preferred by hospitals because the third antibiotic in Neosporin is the one with the highest incidence of allergic reaction in patients. Always ask about allergies before you consider applying anything in or on someone in a first aid situation, and consider all medico-legal ramifications, label instructions, doctor's advice, and standard boilerplate warnings. Really.

Final word: Tetanus prophylaxis.

Tetanus boosters actually protect against diphtheria and tetanus (dT). They're generally given at 4-6 years, and again at 14-16 years, in the US. After that, you're on your own for getting boosters.
Lately, due to a huge influx of folks who never got immunized, pertussis is making a comeback as well, so in many cases the shot is TDaP (tetanus, diphtheria, and pertussis). Ask what you’re getting.
Tetanus spores don't live on rusty nails. They live on EVERYTHING. Any wound is also a pathway to tetanus.

When you come to my ER, I ask two questions to those with open wounds:
"When was your last tetanus shot?"

If you don't know, my next question is, "Do you know when your next one's gonna be?"
The correct answer is, in the next hour or so.
You have approximately a 72-hour window to get the booster in an emergency.
The booster is considered effective for ten years for minor stuff (stepping on a nail) and five years for major wounds (gnawed on by crocodiles, flung through a windshield, etc.).
If you don't know when your last dT booster was, FIND OUT. If it's been more than 10 years, or if you're going anywhere, from backwoods camping and hunting to safari in some third world paradise, get your booster before you go!

Tetanus leads to lockjaw (byproduct toxin from the spores) which leads to dead. Very, untreatably, irreversibly dead. With every muscle in your body stretched as tight as a bowstring, and your head and heels on the bed, while your torso is arched up, until you die, wide awake, when the paralysis hits your respiratory muscles, and you suffocate looking at the wall behind your bed.(From an early 1900s medical text description of a patient who died of tetanus. Quite a pretty visual, huh?) Dead is more serious than being a wussy about a needle at the doctor's office.

Get your booster, and write the date on a Post-It you stick on the back of your driver's license.
Then, when I ask you when your last booster shot was, you'll know.

If you aren't up to date, you aren't prepared.

No comments: