Wilderness and Rescue Medicine 7th Edition Jeffrey Isaac, PA-C and David E. Johnson, MD

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Wilderness and Rescue Medicine

instrument or gloved finger may reveal a pre- viously unnoticed laceration of the fascia that exposes muscle or joint space to contamination. Treatment and evacuation for high-risk wound care would then be a priority.

object remains imbedded in the tissue, infection is inevitable. In most cases, impaled objects should be removed in the field and the wounds cleaned like any other.

General Principles

Wound Treatment WILDERNESS PROTOCOL

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General Principles

Wound Treatment

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Remove Impaled Objects Unless: • Impaled in the globe of the eye • Removal will cause significant problems: • tissue destruction • severe bleeding • unmanageable pain

Dressing and Bandaging: • Prevent contamination. • Allow for drainage. • Avoid causing ischemia. • Allow for wound inspection. • Keep warm and moist • Preserve and enhance perfusion. “It should not come as a surprise that products developed for use on livestock, or in nursing homes and home health, are particularly useful in wilderness medicine.”

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©2018WMA

©2018WMA

Having said that, we must acknowledge the other reality; sometimes removing an impaled object is impossible, impractical, or dangerous. If you are going to do significant damage trying to remove the object, or be unable to control the bleeding that results, you must stabilize it in place and evacuate as quickly and carefully as you can. Consider prophylactic antibiotics enroute. Finally, we hope to never have to remove an impaled object from the globe of the eye. The fluid inside the eye cannot be replaced, and any amount lost will doom the patient’s vision. Cover both eyes if possible and evacuate urgently to medical care. Pain control and patient care and protection will be challenging. Bandages and Dressings for a Hostile Environment The combination of bandage and dressing should allow for wound drainage while preventing con- tamination. The goal of long-term wound care is to preserve and enhance oxygenation and perfusion of the tissue, and to prevent infection. Prolonged shell/core effect or local vasoconstric- tion of the hands and feet in wet and cold condi- tions are typical impediments to healing. Altitude is also a problem. Wound healing is significantly delayed at 3000 meters and is almost impossible above 6000 meters.

In most cases, the wound is then covered with a sterile dressing to prevent outside contamina- tion and to absorb wound drainage. Allowing for drainage is important to normal healing. Wound closure with tape, sutures, staples, or glue can cre- ate an obstructed hollow space prone to infection. In the backcountry or offshore setting, the risk in wound closure usually outweighs the benefit. Early wound cleaning is essential; early wound closure is not. Wound repair or scar revision can be safely delayed for days or weeks if necessary. The exception would be simple wounds that do not penetrate the full thickness of the dermis. These may safely be closed after cleaning. This is mostly a matter of convenience. Steri-strips, butterflies, and wound closure glue are equally effective but will require protection frommoisture and contamination. Temporary wound closure with tape might also be indicated for functional reasons, such as taping wounds on the hand to allow paddling or on the feet for hiking. This type of functional taping should be removed at the end of the day. Impaled Objects Ideally, any significant impaled object is best removed by a surgeon in a hospital but evacuat- ing a patient with an impaled object will often risk more tissue damage than will pulling it out. If the