Wilderness and Rescue Medicine 8th Edition

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Wilderness and Rescue Medicine

General Principles

Wound Treatment WILDERNESS PROTOCOL

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Low-Risk Wounds:

• Clean surrounding skin surface. • Irrigate with copious amounts of clean water or 1% PI solution. • Explore wound and remove foreign bodies.

• Cut away dead tissue. • Dress and monitor daily.

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“Proper wound cleaning can take quite a bit of time. Make yourself and your patient comfortable and do a thorough job.”

© 2018 WMA

Only a few lightweight and inexpensive instru- ments are required for wound cleaning in the field. For irrigation, use only clean water or saline, a 1% povidone iodine solution, or a product specifi- cally formulated for use in open wounds.

General Principles

Wound Treatment WILDERNESS PROTOCOL

12

High-Risk Wound:

• Clean per protocol except punctures and wounds at risk for life-threatening bleeding • Early evacuation • Consider antibiotics if authorized • Contact local health department about rabies risk in mammal bites “Gentle probing…may reveal a previously unnoticed laceration of the fascia exposing muscle or joint space to contamination.”

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© 2018 WMA

There is an advantage, however, to applying a little pressure to the irrigation stream. Studies demonstrate that the ideal irrigation pressure is generated by a steady stream from a 30–60 cc syringe and an 18-gauge catheter. You are not try- ing to sterilize the wound, just flush out debris and reduce the bacteria count to levels that can be managed by the body’s immune system. Be sure that the irrigation fluid can easily flow out of the wound; otherwise, the pressure will only drive contaminants deeper into the tissues. It is usually impossible to irrigate puncture wounds effectively without this happening. It is harmful to irrigate a wound with full- strength iodine preparations (typically 10%) or hydrogen peroxide. Iodine and peroxide kill both bacteria and body cells, leaving a partially steril- ized wound lined with dead tissue. This can actu- ally increase the risk of infection, as does soaking a wound in a basin of saline or iodine as is still practiced in some clinics and hospitals.

The ideal wound irrigation device is a syringe with an 18-gauge catheter. Continue cleaning by removing any imbedded debris that was not flushed out by irrigation. A soft toothbrush, forceps, scissors, and a head-lamp are useful tools for this. Cut away any dead tissue or loose fat. These are likely to become a site for bacterial growth. Proper wound cleaning can take quite a bit of time. Make yourself and your patient comfortable and do a thorough job. It may be inconvenient, but it will save you a lot of time and trouble by preventing an infection. Once cleaned, the wound should be carefully inspected to determine the extent and depth of the defect. Gentle probing with a sterilized instrument