WOUND CARE IN THE OUTDOORS
Shane Krogen
Site Admin
Joined: 15 Sep 2003
Posts: 197
Location: Fresno, Ca
Posted: Mon Oct 18, 2004 9:03 pm
Post subject: WOUND CARE IN THE OUTDOORS
WOUND CARE IN THE OUTDOORS by Ken Murray MD
There is no more common injury in the outdoors, than injuries
to the skin. These are usually easily managed with few
supplies, given some basic knowledge.
Basic concerns about wounds can be summarized as follows:
1. Blood loss.
2. Contamination.
3. Infection.
4. Wound closure
4. Pain
5. Scar formation.
BLOOD LOSS: Always the immediate consideration after a wound
is created.
Blood loss is the ONE thing that CANNOT be compensated or
corrected in the field. Many people believe that it is best to
let a wound bleed, to "wash out" the wound. If we are talking
about a slow ooze, I suppose that is all right. But if there
is significant bleeding, this qualifies as an EMERGENCY, that
requires immediate efforts to stop. The technique is simple:
Have the victim, if possible apply DIRECT PRESSURE using
anything available for a dressing, or if nothing is available,
bare fingers.
After safety precautions are instituted for the rescuer (latex
gloves), apply DIRECT PRESSURE, using anything as a dressing
(sterile gauze is nice, but not particularly important, if not
immediately available ), or gloved fingers if nothing is
available. DO NOT apply tourniquets, DO NOT worry about
pressure points. For virtually all wounds, direct pressure
works well. Most people apply pressure wrong: they apply
pressure, then after 20 seconds, take off the pressure to
look, re-starting the bleeding and ripping off any early blood
clots that may have formed. The way that direct pressure
works, is to stop the blood flow, which in the presence of
damage to tissue, causes blood clots to form. However, this
takes a couple of minutes to happen!
I advocate that you apply DIRECT PRESSURE, for five minutes BY
THE CLOCK.
This means that you have someone look at a watch and time for
five minutes.........it will seem like an hour! THEN, and ONLY
then, you can look to see if the bleeding has stopped. If not,
apply DIRECT PRESSURE for another 5 minutes, BY THE CLOCK.
Repeat as needed. It is extraordinarily uncommon to have to go
beyond 10 minutes. Once bleeding has stopped, one can proceed
to the next step.
CONTAMINATION. There are two kinds of wounds: Clean wounds and
dirty wounds. A clean wound is DEFINED as a wound created in a
sterile operating field. ALL WOUNDS ENCOUNTERED IN THE
OUTDOORS ARE CONTAMINATED.
The most important step to take to prevent infection and
reduce scar formation is to decontaminate the wound. This is
BEST done in the field.
The technique is simple: after stopping bleeding, one needs to
IRRIGATE the wound with large amounts of fluid. The fluid is
NOT important! Sterile saline solution would be great, but we
are talking about 1-2 gallons, OR MORE if possible, virtually
never available in the field.
Clean drinking water would be good, Gatorade would be good,
but even grossly contaminated water or urine would work! There
are already millions of bacteria in the wound, you don't need
to worry about introducing more. We kill them in the next
step. The most effective would probably be to immerse in a
good-flowing creek, preferably under a drop-off of 6-12
inches. If using fluid from a container, hold the container
2-3 feet above the wound, to create some force. The idea is to
have the force of the fluid blast the dirt and other
contaminants out of the wound. If bleeding restarts, apply
direct pressure to stop.
INFECTION. One of the most feared complications of a wound,
but almost always easily avoided. THE MOST IMPORTANT WAY TO
AVOID INFECTION IS TO DECONTAMINATE ADEQUATELY!! If a wound
has been adequately decontaminated, it takes 10,000 times more
bacteria to create an infection, than in a contaminated wound.
The technique is simple: Soap and water. It matters not, what
the soap is: bar soap, liquid soap, shampoo, dish washing
soap, Dr. Bonner's. Special solutions, such as Betadine,
iodine, merthiolate, alcohol, are SIGNIFICANTLY inferior,
cause wound damage, and INCREASE the incidence of infection!!
Apply a small amount of soap of choice and water, lather for a
minute or two, then flush liberally with a fluid.
WOUND CLOSURE. The concept of closing a wound is to prevent
contamination from getting in, and to hasten healing. THE BIG
MISTAKE is to tightly close a contaminated wound. Remember
that all wounds are contaminated!
So one would NEVER apply stitches to such wounds in the field.
In the ER, we have methods and gear to do advanced
decontamination, such as surgically removing the edges of the
wound, which are contaminated. If a wound is obviously still
contaminated, it is better to pack the wound with gauze,
cover, and change the gauze twice daily, decontaminating and
washing at each change. If the wound appears clean, it is
acceptable to LIGHTLY close with tape or band-aids, but
leaving an edge slightly open. If there is ANY contamination,
the body will reject it, IF we allow it a path. If not,
infection will occur. If there is any sign of infection, open
a wound and allow it to drain, use the packing technique for
further treatment. Apply antibiotic ointment to the surface of
a wound at each dressing change.
PAIN. Properly treated uncomplicated wounds should be nearly
pain-free.
If pain develops in a previously pain-free wound, there is
probably an infection. Otherwise, all OTC pain relievers are
safe to use.
SCARS. Properly cared-for wounds have minimal scarring. The
most important issues are decontamination, by far, and then
prevention of infection.
_________________
Shane Krogen
Director of Trail Crew