Wilderness and Rescue Medicine 8th Edition

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Section IV: Trauma

be high risk, whereas a wound on the buttocks several centimeters deep is considered low risk. Puncture wounds often appear very benign on the surface but carry a substantial risk of infec- tion to deep structures. Avulsion flaps should be lifted, inspected for debris, and probed for deep structure involvement. Wounds to the chest or abdomen may enter the organ cavities. In such cases, there is some- times an obvious hollow space, visible or probed. These carry a very high risk of life-threatening infection and often involve critical system injury. Early administration of antibiotics and emergency evacuation to surgical care can be lifesaving.

may be used temporarily to slow major bleeding while you find and dress the bleeding site, or in cases in which you are too busy managing other critical system problems. A proper tourniquet is composed of a wide (4–5 cm), soft band applied 5–10 cm proximal to the injury. Enough pressure must be applied to stop arterial blood flow, or else venous congestion and edema will develop. A tourniquet can be left in place for up to 6 hours before it causes significant damage from ischemia and infarction. Be sure to note the time of application. Conversion to a pressure dressing should be accomplished as soon as practical. With unmanageable bleeding, however, there may be no choice but to leave a tourniquet in place. After 6 hours, a tourniquet should be left in place until definitive care is reached. Long-termmanagement of any wound requires early wound cleaning to help prevent infection. The use of prophylactic antibiotics is limited in the civilized setting but should be considered for the wilderness context due to the greater difficulties involved in wound care. The initial dose should be administered as soon as possible after the injury has occurred. Cleansing a wound usually restarts some bleed- ing by disturbing the clot, so you should not attempt to clean wounds that are associated with life-threatening bleeding. In less serious wounds, a tourniquet can be used for short periods to allow for adequate visualization for assessment and cleaning. Wash the skin around the wound with soap and water and/or a disinfectant like povidone iodine. Clean a wide area of skin, being careful not to allow soap or disinfectant into the wound itself. Irrigate the wound with copious amounts of clean water. Tap water is fine at home. In the field, water filtered or disinfected for drinking is suitable for wound irrigation. When water supplies are limited, using a 1% solution of povidone iodine may reduce the incidence of infection. There is no significant advantage to using sterile saline or specialty wound irrigation solutions.

General Principles

“Avulsion flaps should be lifted, inspected, and probed for deep structure involvement.”

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Remember that wounds also present risk to the examiner. Don’t forget to protect your eyes, skin, and mucous membranes from contact with blood and exudates. Wear gloves and eye protection, and keep your mouth shut or wear a mask. Field Treatment of Wounds The initial field treatment of both low- and high-risk wounds is the same: Stop the bleed- ing, inspect, clean, dress, and monitor for infec- tion. Evacuation should be initiated for high-risk wounds. Bleeding is best controlled with direct pres- sure and will usually stop within 15 minutes as the clotting mechanism is activated. If bleeding persists, it is usually because the pressure is not firm enough, is applied in the wrong place, or is not being applied for enough time. A tourniquet