Principles And Techniques Of Advanced Wound Care

NOTE:  The following are not designed as instructional guidelines for First Aiders. They are presented mainly for those on expeditions, in remote areas for extended periods, and for Advanced Wilderness Medicine practitioners

 SCENE SAFETY – PROTECT YOURSELF – Body Substance Isolation (BSI)

Any discussion regarding soft tissue injuries and bleeding has to include the techniques of protecting yourself and Body Substance Isolation (BSI). This is to minimize the risk of spreading or contracting an infectious disease from the casualty being treated. The concept is simple – every effort should be made to avoid getting blood or other body fluids on your skin, in your eyes, in or on your mouth or other mucous membranes.

When providing casualty care there are three primary modes for the transmission of infectious disease: direct contact, indirect contact, and airborne.

 Direct Contact:

This occurs when blood, saliva, vomitus, or other body substances come into direct contact with your skin or the mucous membranes of the eyes or mouth. Wearing gloves and eye protection or establishing some sort of waterproof barrier between you and the casualty prevents direct contact. If a bodily fluid does get on to your skin, thoroughly wash the area with soap and water and clear or rinse the eyes clean, if necessary, as soon as possible.

  • Indirect Contact:

Indirect contact refers to coming into contact with infectious disease microbes that are on a contaminated surface, such as medical equipment, a door knob, or a countertop before they have been properly cleaned. The microbes are transferred to the face or mouth by hand-to-mouth transmission. It almost sounds too easy, but this is exactly how most common colds, flu’s, and many other viruses are spread. Simple hand-washing and properly decontaminating medical equipment and surfaces minimizes this source of contamination.

  • Airborne Contact:

Airborne contact is the most obvious and familiar mode of transmission. Someone with a cold, TB, flu, or other infectious respiratory tract infection sneezes or coughs. In the process they spray infectious particles all over the place. If you are in the same area and simply take a breath, as you do every 5 seconds or so, you will inhale the infectious droplets into your airway and lungs. The spread of airborne disease is prevented by covering the casualty’s and your mouths with surgical masks to filter out the infectious particles. to filter out the infectious particles.

 DETERMINE CAUSE – WHAT HAPPENED? – Mechanism of Injury

A very important part of the assessment of any injury is to establish the mechanism of injury – exactly what happened and when. For example, how you manage someone who stubbed their toe 10 minutes ago is very different from how you manage someone who was trapped in rubble with their foot caught between two concrete slabs for the past 24 hours. The external appearance of the injury may be very similar, but how you manage them is very different. This may sound like common sense, but it is the mechanism of injury that allows you to be suspicious and discover other potentially major problems that would not be otherwise obvious.

CONTROL THE BLEEDING – Hemostasis

Soft tissue injuries will almost always involve some degree of bleeding, internal and external, ranging from minor blood seeping from an abrasion to a life-threatening bleed spurting from a major wound involving a large vein or artery. The vast majority of time bleeding can be controlled by applying direct pressure to the wound, and, if necessary, the application of a pressure dressing.

Control of Bleeding: dirty laceration

  • Direct Pressure
  • Rest
  • Elevation
  • Pressure Dressing
  • Tourniquet

 Direct Pressure:

There are several steps to controlling bleeding. The first is to apply direct pressure: putting pressure directly on the wound with your gloved hand. If possible, place some absorbent material, such as gauze pads, on top of the wound before applying the direct pressure to the wound site. These pads will act like sponges to absorb and hold the blood in place, helping clots to form. Because the vast majority of bleeding is venous, which is the low pressure side of the systemic circulation, gentle external pressure on the wound should control the bleeding.

 Rest:

Having the casualty in a resting position will slightly reduce the heart rate, reducing the pressure at which the blood is trying to escape. This will also minimize muscular contractions which may stimulate a “pumping” action, increasing blood flow.

 Elevation:

If the bleeding wound is on an extremity, elevation of the extremity can be added to the direct pressure to help lower the blood pressure at the site of bleeding. Simply raise the bleeding wound above the level of the heart. This will allow gravity to help lower the blood pressure in that extremity making it easier to control the bleeding.

Elevation is not being taught in first aid classes nowadays, and the reasons given by various instructors do not mention the actual rationale which, according to the AHA Guideline is:

Pressure Points and Elevation

Elevation and use of pressure points are not recommended to control bleeding (Class III, LOE C). This new recommendation is made because there is evidence that other ways of controlling bleeding (Direct Pressure)are more effective. The hemostatic effect of elevation has not been studied. No effect on distal pulses was found in volunteers when pressure points were used.

 Therefore if elevation is used, it should be as an adjunct, and not a primary method of bleeding control. (Direct pressure, rest, dressing, and then position slightly elevated, as for a sprained wrist or ankle)

 Pressure Dressing:

Manually applying direct pressure to a serious wound will occupy your hands for the next 10 – 20 minutes. A pressure dressing can be applied to the wound temporarily to maintain the direct pressure, freeing you up to continue to evaluate and treat your casualty. This can be accomplished by placing a bulky dressing over the wound and then wrapping the wound with an elastic bandage to maintain the pressure. Once bleeding has been controlled for 20 – 30 minutes, the bandage and bulky dressings can be removed for further wound evaluation and cleaning.

NOW FOR THE “WHAT IFS”:

 What if you apply the absorbent dressings and direct pressure to the wound, but the bleeding continues and bleeds all the way through the dressings?

If this occurs, then obviously you have not controlled the bleeding. Most textbooks will tell you to add more absorbent layers to the wound; however, this does not help to control the bleeding. Instead, remove the dressings that are all ready on the wound and take a look at the wound. You may have been applying pressure to the wrong area, or there may be a small, spurting arterial bleed. You will know that an artery has been cut open by the spurting of blood. To control arterial bleeding, apply digital pressure – take a gloved finger and put it directly into the wound, compressing the bleeding artery. Once the bleeding has stopped, you have to maintain digital pressure for 10 minutes, by the clock, allowing time for the blood clot to form in the artery and plug the leak.

 Tourniquets: When are tourniquets necessary?

A tourniquet is a device used to control extreme life-threatening arterial bleeding in an extremity that cannot be controlled any other way. In the non-military setting, tourniquets are very rarely needed. Virtually all bleeding can be controlled with direct pressure and, if needed, digital pressure. Remember, if the decision is made that a tourniquet is necessary, you may have to sacrifice a limb to save a life. Tourniquets are used on extremities only, and they must be placed on the upper part of the arm or leg. The tourniquet has to compress the tissues overlying the artery with enough force to shut off that artery. This will produce ischemia in the tissues distal to the tourniquet. These affected tissues will become very painful over time, and these tissues may die. The TECC course offered by RAEMS covers tourniquet use in depth.

How do you control internal bleeding?

Internal bleeding occurs when there is damage to the vascular system inside the body. Quite often internal bleeding is a surgical problem, but internal bleeding can be controlled by applying gentle direct pressure to the tissues overlying the area of bleeding. Blunt trauma to the abdomen can cause in damage to any of the internal organs resulting in internal bleeding. In this case, once internal bleeding is recognized, gentle pressure can be applied by wrapping the abdomen with an elastic compression bandage, accomplished by using two six-inch elastic wraps or other material to gently compress the abdominal cavity. This procedure will decrease the potential space for the blood to accumulate and will apply counter pressure to the torn vessels, slowing the loss of blood and allowing the blood clots to form within the damaged organs.

 ASSESS THE DAMAGE – Explore and Examine the Wound

inspectionSuperficial damage is obvious, but what you see is not necessarily what you’ve got.

You also have to know what has happened beneath the surface. You need to take the time to examine and explore the wound, to see how deep and extensive the wound is, and check to see if the muscles, tendons, and nerves are intact and functioning properly. Initial evaluation of the wound should be performed prior to injecting or applying any anaesthetics into or around the wound as this might interfere with the evaluation.

 Sensory – Nerve Function:

Test the area distal to the site of the injury for loss of sensation indicating nerve damage. You are not going to do anything about an injured nerve, but you do need to document any loss of sensation or function.

 Motor – Muscles and Tendons:

Motor function is tested by having the casualty flex and extend the muscle groups distal to the site of the injury. There should by normal, active, full range of motion (ROM), and strength. Strength should be tested and compared bilaterally. Any loss of movement or strength should be documented. Loss of the ability to flex or extend a finger or toe most likely indicates a severed tendon requiring surgical repair. It is possible to repair a lacerated tendon in the field, but it requires experience and training. Most often lacerated tendons are best splinted and left for an orthopedic surgeon to repair. DO NOT perform range of motion tests below an impaled object, as this may cause further damage to internal structures.

 Examine the Wound:

The wound itself needs to be gently pried open and explored to see how deep and extensive the wound is and what structures were lacerated, damaged, or crushed. This is usually done after the wound has been anaesthetized, to keep the casualty comfortable which then allows you to perform your exam.

 CLEAN THE WOUND – Debride and Rinsemuddywound

The primary reason for taking the time to properly clean a wound is to minimize the risk of infection, cellulitis, or abscess formation. This involves removing any foreign material, dirt, grass, sticks, glass, etc. as well as any devitalized (dead) tissue.

 Local Anaesthesia: If not already done, you should take the time to properly infiltrate the wound area with an anaesthetic for casualty comfort. Once the area is well anaesthetized, it is easier to thoroughly explore, debride, and clean the wound site.

There are many ways to anaesthetize a wound, from nerve blocks to locals, and there are several different agents to use. But, if you had to choose one way to accomplish this, the easiest would be to use Lidocaine 1% or 2%, without epinephrine, injected into the soft tissues surrounding the wound. The anaesthetic agent will temporarily shut off the pain receptors in that area making the wound numb. This local anaesthesia should last 30 – 45 minutes.

 What about epinephrine?

Local anaesthetic agents come with and without epinephrine. Epinephrine is a powerful vasoconstrictor that will help to control bleeding and keep the anaesthetic in the area longer. But, you cannot use epinephrine in areas where vasoconstriction will cause problems by decreasing circulation distal to the area of infiltration. These are the finger, toes, ears, nose, and genitalia. When in doubt, don’t use it.

 Prevention of Infection – Wound Cleaning:

To properly clean a wound, you will need lots of clean, preferably sterile water, soap, a surfactant solution, and/or an iodine solution (Betadine, Povidone, Iodine). It is also very helpful to have available forceps, tweezers, or some sort of tool to aid in the removal of debris from the wound.

While the bleeding is being controlled, and the wound is resting, blood clots are forming in the damaged blood vessels. Clot formation will maintain hemostasis while the wound is being cleaned. During this 20 – 30 minute period, sterile water can be made by adding Betadine, Povidone, or iodine (any iodine solution) to the water and allowing it to stand for 30 minutes. For thorough wound cleaning you will need 2 – 3 litres (quarts) of sterile water solution for irrigation.

Wound irrigation is best accomplished if you can create a directed stream of the sterile water under force, such as can be produced by squirting water out of a syringe (18 gauge is ideal). This can done by using a syringe or it can be improvised by putting a small hole in the top of a flexible water bottle or cutting a pinhole in the corner of a Ziploc bag. If all else fails, simply pouring the sterile water into the wound is better than nothing.

 Procedure

Once bleeding has been controlled, for at least 20 minutes, blood clots will have formed in the vasculature, and the wound is ready to be closely examined and cleaned. Remove the dressings and take a close look at the wound. If possible, apply anaesthetic to the wound before debriding it. Gently explore the wound, looking for anything that belongs outside of the body – grass, sticks, twigs, dirt, stones, or any debris. All foreign material must be removed by gently lifting it out with forceps or by rinsing it out with the sterile water.

As you examine the wound and remove the debris, evaluate the tissues in and around the wound to see if they have been damaged beyond repair. If they have been, they will appear pale, numb, and lifeless. Sharply remove these devitalized tissues with scissors or a scalpel, as any dead tissue left behind in the wound will become necrotic and increase the risk of a wound infection.

 The Rinsing Process:

Once the visible debris in the wound has been removed, begin the rinsing process. First rinse with a dilute soap solution or dilute iodine solution, 5 – 6 times, and then perform a final rinse with clear sterile water or with the dilute iodine solution. The iodine solution has to be less than 2% iodine; if the iodine concentration is too high, >5%, it can be toxic to the healthy tissues.

 What are these compounds – Iodine, Betadine, Povidone?

 Iodine:

Iodine is a non-metallic chemical element, atomic #53. It is an essential element used by the thyroid gland to produce the hormone, thyroxine (T4). Thyroxine establishes and maintains our basal metabolic rate. Caution: some people are very sensitive to iodine on the skin, and it will cause a chemical burn. Iodine in low concentrations is lethal to germs, but harmless to human tissues, therefore making it an excellent wound disinfectant.

 Betadine:

Betadine is a commercially available 10% solution of iodine in water that is used as a skin and wound disinfectant. It is never used in its 10% concentrated form, as a solution of greater than 5% iodine can be harmful to human tissue. Since iodine is very effective in dilute solution, Betadine is usually diluted – 10 parts water and 1 part Betadine, which makes a 1% solution of iodine in water, a very effective disinfectant.

 Povidone iodine:

Povidone iodine is a water-soluble complex of iodine and polyvinylpyrrolidone. As it is water-soluble, it can be applied directly to a wound as an antiseptic. Commercially available, it contains a 2% concentration of iodine, so it can be used directly on a wound or diluted with water to make an iodine solution for rinsing. Once applied to the wound, it slowly releases iodine into the wound, helping to keep the area sterile or to actively treat infected tissue.

 When to Close and When Not to Close the Wound

The real question regarding wound closure is when is it best to close the wound and when is it best to leave it open. There are several points to consider when making this decision.

There are basically two reasons to close a wound: cosmetics and functionality.  The vast majority of wounds that are sutured closed are strictly for cosmetic reasons, to minimize scarring. The other valid reason is to promote and maintain function. When the wound is over an area with frequent flexion and extension such as a joint or in an area where the skin is under a lot of tension, if not sutured, the wound will continue to break open and not heal properly.

 Considerations:

 The age of the wound:

If a wound is more than 12 hours old, it is better not to close it tightly. Properly clean and debride the wound as thoroughly as possible. You may want to approximate the edges, but do not close the wound tightly with sutures, skin glue (Dermabond), or butterfly bandages (Steri-Strips). The problem with closing the wound is the risk of infection. During the time that the wound was untreated, bacteria have had the opportunity to settle into the wound and multiply. After 12 hours the risk of infection, even with proper sterile wound cleaning techniques, goes up dramatically. Take the time to manage the wound as usual, but do not suture or close it tightly.

Approximating the edges of a wound refers to the technique of shrinking the gap in an open wound to a few millimetres wide. This still leaves the wound partially open, so, if the wound does get infected, the pus can drain out of the wound. Approximating the edges will allow the wound to fill in with connective tissue, minimizing the size of the scar.

 Location of the Wound:

As mentioned above, wounds that are over joints and in areas where the skin is tense have a tendency to continue to break open as they try to heal. Suturing these areas to help support the skin during the healing process will minimize the risk that the wound will dehisce (split open).

The other aspect of location is cosmetic, especially the face. Proper suturing techniques or the use of skin glues and Steri-Strips will help to minimize wound scars on a person’s face. A simple example is a laceration through the upper or lower lips. There is a border called the vermillion border where the color of the lips meets the skin of the face. When a laceration involves this border, a cosmetic defect can by prevented by making sure that there is a stitch at this border pulling it into alignment. As the wound heals, if the two edges of this border are lined up, any cosmetic defect will be minimal.

 How dirty is the Wound, and Bite Wounds:

If a wound is very dirty, or if the wound was caused by an object that was rusty, covered with filth, associated with animal dung, or a bite wound, then it is best not to close it. Some wounds are very hard to clean out well, especially bite wounds. It is therefore, better to properly clean the wound, considering iodine wet-to-dry dressings, approximate the edges, and leave it open.

Once the wound has healed, if the individual does not like the remaining scar, the area of scar tissue can be removed under sterile conditions and the skin sutured closed. This is referred to as wound closure by secondary intention.

Steri-Strips and Butterfly Bandages:

There are commercially available bandages, called Steri-Strips that are designed to hold the wound edges together. These can be used in the place of sutures, where there is minimal wound tension. These strips can also be improvised by making butterfly bandages.

In either case, the idea is to control bleeding, clean and debride the wound, and then approximate the edges and hold them in place with a Steri-Strip or butterfly. This technique works best if the skin is painted first with Tincture of Benzoin and allowed to dry. The application of the Tincture will make the skin very sticky allowing the bandage to better adhere to the skin. The Steri-Strips are left in place and allowed to fall off on their own in about 4 – 5 days.

 Skin Glues and Adhesives:

Like the Steri-Strips, the glues work best in areas where the wound is not under tension with little or no movement.  Skin glues or adhesives can be applied directly over a wound to create a bandage that will hold the edges of the wound together. Non-skin glues, such as SuperGlue and Krazy Glue contain methyl 2-cyanoacrylate. The human skin glues contain a less skin-toxic 2-octyl cyanoacrylate.

Before glue application, the wound is cleaned properly and then dried well. The area that the glue is going to be applied to has to be dry. The edges of the wound are placed and held exactly where you want them, and then the glue is painted over the wound. Several layers of the glue are applied. This will build up an adhesive dressing that should hold the edges together. The adhesive is left in place and allowed to fall off on its own in 5 – 7 days.

 Different Brand Names of Skin Glues:

  • Dermaflex QS
  • SurgiSeal
  • Octylseal
  • FloraSeal
  • Dermabond
  • Surgi-Lock
  • Nexabond

 Suturing:suture

There are several different suturing techniques that can be used to close wounds of various types. But, the easiest technique to perform and the most universal to use are interrupted sutures.

Learning techniques of suturing is not difficult, but the devil is in the details. If you have decided that the best way to manage a wound is to suture it closed, the suturing may prove to be the easy part. The trick is that suturing a wound closed has to be done under sterile conditions. Otherwise, the wound is going to become infected, resulting in cellulitis and possible abscess formation that will require you to open and drain the wound, oral or IV antibiotics, and possibly the use of non-scalding hot water with Epsom salt soaks. Sterile techniques start at the very beginning. Once the wound has been examined and infiltrated with an anaesthetic medication, a sterile field is established around the wound area.

 The steps in a sterile procedure:

  • Wash and dry your hands and then put on sterile gloves using proper sterile technique.
  • A sterile field is created by placing your sterile equipment on a sterile towel.
  • The wound area is prepped by painting it with a dilute iodine or Betadine solution, using sterile technique, being extra careful not to spray or splash body fluids into your own face and eyes.
  • The wound is explored and debrided using sterile technique.
  • Once thoroughly cleaned and debrided, with all devitalized tissue being removed,
  • the wound may be closed using interrupted suturing.

 Interrupted sutures:

The idea is to place a suture into one side of the wound and then out the other. As you tie the knot on top of the wound, you can adjust the tightness to approximate the edges. These interrupted sutures can then be placed 5 – 10mm apart to align and support the laceration.

 PROTECT THE WOUND – Dressing and Bandaging

Once cleaned, debrided, and closed, the wound site should be covered with a sterile dressing and bandaged to hold the dressing in place. Dressings should be changed every 12 hours, and the wound inspected for signs of infection. Proper dressing and bandaging techniques will support and protect the wound during the healing process.

 WOUND FOLLOW-UP – Monitor for Signs of Infection

Any wound, even in the best of circumstances, is at risk of becoming infected. No article on advanced wound care would be complete without a review of the infectious process, and what to do about it.

 THE INFECTIOUS PROCESS – What if a wound does get infected?

If there are bacteria in the wound site, they will begin to multiply rapidly causing a local skin infection, cellulitis, which can progress to a more serious abscess formation. Bacteria that are in a wound are exactly where they want to be. They like their environs to be dark, warm, moist, with minimal oxygen, and lots of nutrients. At 37°C bacteria multiply once every 26 minutes, so what starts out as 2 after ½ hour becomes 256 trillion hungry mouths to feed after 24 hours. This is why wound infection is a very big deal. Little, dirty wounds can develop life-threatening sepsis in 24 – 48 hours.

 What is Cellulitis?

As bacteria multiply, they produce waste products called pyrogens. These pyrogens are recognized by our immune system as coming from a foreign invading germ that is out to destroy us. Although bad, these pyrogens start the chain of events that stimulates our immune system and defensive mechanisms. The response of our immune system to the infection causes the signs and symptoms of the localized infection.

The bacterial waste products cause white blood cells (WBCs) called mast cells to degranulate and release histamines into the immediate area. These histamines cause localized vasodilation, which increases circulation to the area. The increase in circulation will increase the number of bacteria devouring WBCs known as granulocytes or neutrophils. Attracting granulocytes to the site of the infection is called chemotaxis. As the granulocytes gather in increasing numbers, their accumulation is recognized as pus, or purulent material.

As the pyrogens get into the blood stream and make their way to the brain, they stimulate the thermoregulatory system to raise our core temperature, producing a fever. The reason for a fever is that, as our core temperature increases, the rate at which the bacteria are multiplying slows. So, a fever is a good thing up to a point. A fever up to 39C helps to control the rate at which the bacteria multiply. But as a fever approaches 40C, it needs to be controlled or even lowered with a warm sponge bath – the evaporation of water will lower the core temperature – and the use of acetaminophen (Tylenol).

The vasodilation at the wound site increases the circulation to that area. This brings in more nutrients, antibodies, and white blood cells (WBCs) which are all needed to help battle the invaders. When peripheral blood vessels dilate, small gaps between the endothelial cells that make up the vessels open up allowing WBCs to escape into the surrounding tissue and sera or fluid in the blood to also leak out. This process will cause an increase in the redness and warmth of the skin, mild swelling, and tenderness – which explains the classic signs of a skin infection:

  • Rubor (redness),
  • Tumor (swelling),
  • Dolor (pain),
  • Calor (warmth)

In a process known as chemotaxis, the WBCs are attracted to the waste products produced by the bacteria. It is the collection of WBCs at the infection site that produces the pus or purulent material that can be seen draining from an infected wound.

As the pyrogens get into the systemic circulation, they are detected by the thermoregulatory center in the brain, causing the brain to now increase systemic body temperature, creating a good old-fashioned fever. Bacteria multiply every 26 minutes at 37°C, but, as the core temperature goes up, the rate of reproduction of the bacteria goes down, giving our WBCs a better opportunity to destroy the bacteria.

If the wound infection goes unattended and untreated, the bacteria may overwhelm the immune system and get into the lymphatic drainage from the wound site. The lymphatics then become infected (signaled by a red streak, lymphangina), moving centrally up the extremity. If it reaches the lymph nodes, the nodes will become warm, swollen, and tender, (lymphadenopathy).

If the progress of the infection is not slowed or halted, it will eventually reach the central circulation and the heart. Once in the circulation, it is quickly distributed throughout the body causing septic shock, high fevers, shaking chills (rigors), tachycardia, hypotension, and death. Thus, simple wound cleaning becomes very important.

 Recognition and Management of Cellulitis:

Monitor the wound site for the initial immune response to the multiplying bacteria.

  • Rubor: The redness of the skin caused by the vasodilation.
  • Tumor: Swelling of the soft tissue by the fluids that are escaping the dilated vasculature.
  • Dolor: Pain caused by the swelling in the tissues.
  • Calor: Warmth in the tissues from the vasodilation.

Treatment:

As soon as cellulitis is suspected, examine the wound closely for any foreign material retained in the wound. Remove any that is found. Heat soak the area of cellulitis in non-scalding hot water with Epsom salts or table salt in the water. This is an old, tried and true technique for treating infections. Heating up the area will slow the rate of reproduction of the bacteria and increase circulation to the area by further vasodilation. The reason for salt in the water is that fluid flows to the areas of greatest salt concentration. This osmosis will help to draw the infectious material out. Epsom salt is used because it is harmless to the human tissues and lethal to bacteria. The area of cellulitis should by heat-soaked every 4 hours for at least 30 minutes until the infection has resolved.

 Evacuate:

As soon as possible, organize and evacuate the casualty to advanced medical care for further evaluation and treatment as they may need IV antibiotics or surgical management of the infected wound.

 Abscess formation:

In cellulitis the war that is being waged by the multiplying bacteria and the WBCs occurs in the layers of the skin. As the WBCs begin to gather at the site of the infection (chemotaxis), forming in a space within the wound, this collection of WBCs and bacteria are referred to as an abscess.

An abscess is more dramatic then cellulitis. While cellulitis is red, warm to the touch, slightly swollen, but not normally tender, an abscess has a definite area of swelling with induration (a distinct palpable margin around the abscess), redness, warmth, and tenderness to the touch. In the case of abscess formation, cells called fibroblasts surround the infection site and build a wall of very tough, fibrous cells to prevent the bacteria from escaping into the body. If the bacteria do breach the wall of induration, just like with cellulitis, the infectious material will get into the lymphatics causing lymphangina, lymphadenopathy, and eventually septic shock. As long as the abscess remains sealed and pressurized, it is very dangerous to one’s health. The immune system will have a very hard time winning the battle. The abscess should be treated the same as a cellulitis with non-scalding hot water salt soaks. But, in addition, the abscess needs to be incised and drained. This is actually as simple as creating a hole and allowing the infected, purulent material in the abscess to drain out, thus decompressing the abscess.

 The Principles of Incision and Draining of an Abscess:

  • Picture – Assess and evaluate the abscess and surrounding anatomy.
  • Prep – clean and prep the area of the skin to be incised.
  • Pain control – if possible numb the skin with ice or inject with lidocaine.
  • Puncture the abscess – with a scalpel or sharp knife pierce the abscess.
  • Purge – gently compress and drain the abscess.
  • Purify – rinse the abscess clean with iodine solution.
  • Protect – cover with a sterile dressing and monitor during evacuation.

 The Details of How to Incise and Drain an Abscess:

  • Picture: Take the time to study the abscess: note the size, depth, and location, and think about the surrounding anatomy. If you are going stick a hole in the skin to drain the abscess, you need to make sure that you avoid any obvious tendons, ligaments, nerves, or arteries.
  • Prep: Thoroughly clean the area with soap and water and paint with an iodine solution to minimize the bacteria count on the surface of the skin.
  • Pain Control: If you are using a scalpel or other surgically sharp instrument, pain control is probably not necessary. However, pain control can be achieved by either cooling the area down with snow or ice to numb the skin (do not cause frostbite), or infiltrating the area with a 1% – 2% lidocaine injection.
  • Puncture: To avoid important underlying structures, keep incisions to about 1 cm and, make the incision parallel to the long axis of the limb or body. Since arteries, nerves, tendons and other important structures run lengthwise, this helps avoid cutting across one and severing it. The puncture wound has to go deep enough to penetrate the abscess. This will be evident with the bloody, purulent material that will exude from the abscess. The purulent material can be, and most often is, very foul-smelling due to the anaerobic bacteria in it.
  • Purge: Gently compress the sides of the abscess along the margins of the induration to force the purulent material out. Do not be overzealous as you do not want to breech the wall of induration and push the infectious material deeper into the surrounding tissues. With a pair of forceps or other small instrument, you can also gently explore the cavity of the abscess to break up any adhesions (loculations) and help evacuate the “gunk.”
  • Purify: Last but not least, try to rinse the abscess out with some dilute iodine solution. This will help to remove all unwanted material and destroy the bacteria in the abscess.
  • Protect: Cover the surgical wound with a sterile dressing. Change the dressing at least every 12 hours, and monitor for signs of cellulitis or further abscess formation.

Continue to treat with non-scalding hot water salt soaks every 4 hours during the preparation for evacuation. As soon as possible, evacuate to advanced medical care as they may need to administer IV antibiotics or perform a surgical exploration of the abscess.

 A Note on Stitches and Wound Closure:

As already mentioned, wound repair is rarely functional; it is almost always cosmetic. “Functional” means that it is necessary to make the repair to restore proper body function, as would be the case of a lacerated tendon that needs to be sewn back together. When a wound is closed, unless it was thoroughly cleaned and sterilized, the chance that the wound will become infected is increased. And a wound infection is much more dangerous than a scar.

 SPECIAL CONSIDERATIONS:

 Animal Bites and the Risk of Infection and Rabies:

wolfBite wounds are very “dirty” wounds. These wounds are full of bacteria that have been planted directly into the wound from the animal’s mouth. Due to this, these wounds are almost impossible to clean well. Even after a good scrubbing with soap and water and many rinsings, bite wounds are usually left open to heal. This way if the wound does become infected, the infection can drain out onto the skin, avoiding abscess formation. A tetanus booster should be given and rabies’ prophylaxis should be considered as well. Once the wound has healed, a cosmetic repair can later be performed to remove any unwanted scars.

Rabies is a lethal viral infection of the central nervous system. The rabies virus is spread via the saliva of an infected animal, usually a carnivore such as a dog, fox, raccoon, cat, or bat. If there is any question or concern that the casualty may have been bitten by a rabid animal, they will need rabies prophylaxis. Rabies is not treatable, but it is preventable. Be aware that obtaining rabies prophylaxis can be very difficult in remote areas. Hence, know before you go.

 Tetanus Prophylaxis:

Tetanus is caused by the bacteria Clostridium tetani, a bacterium that commonly exists in dirt and in animal manure. It is an anaerobic bacterium, in that it does not like oxygen, and grows very well in dark, moist, warm areas with little or no oxygen, such as deep in a puncture wound. As the bacteria grow in the wound, they produce a neurotoxin that causes paralysis, and this can be lethal. The disease in the past was referred to as lockjaw because one of the symptoms of a tetanus infection was spasm of the jaw muscles, making it impossible to open the mouth.

Tetanus is a rare problem today because of the availability of tetanus vaccines. The tetanus vaccine provides immunity for about 10 years. Tetanus boosters should be given every 10 years. When in doubt, get the tetanus vaccine.

 What about antibiotics?

Antibiotics are prescription medications that are used to treat bacterial infections. Based on their mechanism or action, they are sorted into families: penicillins, cephalosporins, macrolides, quinolones, tetracyclines, and sulfa drugs. When a bacterial infection is suspected, the choice of which antibiotic to use is initially an educated guess. The decision depends upon several factors including which bacteria you suspect is causing the problem, the tissues that the antibiotic needs to penetrate or get into, the casualty’s medical history including allergies, potential drug interactions, and age. So, administering antibiotics is not necessarily an easy decision and not without risk. The key to prevention of wound infection is proper wound care and cleaning to prevent infection.

The primary concern with wound infections is using antibiotics that are effective against staphylococcal and streptococcal bacteria commonly found on the skin. Antibiotics that are commonly used in treating wound infections are:

  • Bactrim DS (trimethoprim/sulfamethoxazole) – a sulfa antibiotic, 500mg po bid
  • Keflex (cephalexin) – a first generation cephalosporin antibiotic, 500mg po tid
  • Amoxicillin – a penicillin antibiotic, 500mg po tid
  • Erythromycin – a macrolide antibiotic, 500mg po bid
  • Augmentin (amoxicillin/clavulanic acid) – a penicillin antibiotic. 875mg po bid

(po is per os, by mouth, bid is twice daily and tid is three times daily)

 Wet-to-Dry Dressings:

Wet-to-dry dressings are dressings that have been soaked with a dilute Betadine or iodine solution and then placed onto the wound and allowed to dry over a period of several hours. As the iodine dressing dries, it sterilizes the surface with which it is in contact. As the dressing dries out, the wound is inspected, and a new iodine soaked dressing is applied. This process keeps the wound as free of infectious bacteria as is possible in that environment. This dressing is very useful in a situation where it is going to be difficult to keep a wound clean and dry.

 Hemostasis Products – Clot-forming Dressings:

Venous bleeding is under low pressure as it flows out of a wound and can be easily controlled with direct pressure and simple pressure dressings. However, arterial bleeding, being under high pressure, can squirt out of the wound and be very difficult to control. Arterial bleeding will require several techniques in addition to direct pressure: digital pressure by plugging the hole in the artery with a finger, using a tourniquet to shut off the blood supply to the entire limb, or using a clot-forming dressing.

 Clot-forming Dressings:

There are two different compounds that are currently being used to promote blood clotting in severe, life-threatening arterial bleeding, Chitosan and Zeolite.

 Chitosan is a polysaccharide (a polymer or chain of d-glucosamine sugars) that is found in the exoskeletons of shrimp, lobsters, and crabs. This polymer is a natural occurring bioadhesive that rapidly binds charged surfaces together. Thus, it promotes aggregation of platelets in the blood to clot off the bleeding arteries. Chitosan is the active compound used in Celox and HemCon products. Celox comes as a powder that can be put directly into wounds, or, like HemCon, it comes embedded in the dressings that are applied directly to the wounds.

Zeolite is a mineral, a microporous aluminosilicate, which is extremely porous and absorbent. Like Chitosan, it is imbedded in the dressings that are applied to the wounds. Being very absorbent, the aluminosilicate quickly forms stable blood colts in the bleeding arteries. Zeolite is used in QuikClot brand hemostatic dressings.

Studies have shown that both of these products are very effective and are used by the US military. The only down side of Chitosan-based products is that they have to be monitored over time as the clots that form at the site of the injury will begin to deteriorate after 2 hours and bleeding can resume. Neither of these products is dangerous to the human body.

 Use of Animal Dung in Wounds.

 This is never, ever appropriate for any reason whatsoever!

The purpose for mentioning it here is because a very common custom in the bush of developing nations is to treat wounds with a compress of animal feces. The problem with this action is that most animal dung is rich with bacteria and, in particular, Clostridium tetani, the bacteria that causes tetanus (lockjaw). Using animal dung is only going to dramatically increase the risk of a serious wound infection. In some parts of Africa, dung is also used to seal the end of the umbilical cord of a newborn. This is obviously a very “ill-conceived” idea.

Use of Honey in Treating Wounds to Prevent Infection.

Unlike animal dung, honey can be very useful in wound care. If you are concerned about a wound becoming infected or if a wound is infected, once the wound has been properly cleaned, honey can be placed in the wound to kill off the bacteria.

Honey is obviously very sweet, rich in sugars, glucose and fructose. Because there is more sugar in the fluid outside the bacterium then in, the water in the bacteria cells will migrate from inside the cell to outside, osmosis, and in the process kill the cell by simple dehydration.

Honey is harmless to the human tissues, and it is water soluble and easily rinsed out of the wound.

Use of Non-Scalding Hot Water and Epsom Salt Soaks to Treat Cellulitis.

Long before the days of antibiotics, the usual method for treating a skin or wound infection was to soak the affected area in a bath of non-scalding hot water containing Epsom salts (magnesium sulfate).

The hot water dilates the vasculature, increasing blood flow to that area. The Epsom salts added to the water creates an osmotic pressure that draws fluid from the wound, and the Epsom salts are directly bactericidal and yet harmless to human tissues.

To accomplish this soak, you need a bucket or tub large enough to fit that part of the human body that needs treatment. A hand or a foot only requires a pail, or deep bowl whereas an infection on the buttocks, chest, thighs, or torso will require an entire bathtub.

The water needs to be as hot as can be tolerated without causing a burn, thus non-scalding hot water. Add the Epsom salts (magnesium sulfate) to the water and soak the area for at least 30 minutes four times per day. You cannot soak it too much.

Inspect the wound twice daily; there should be rapid improvement. You cannot add too much Epsom salts to the water, when in doubt, put in a handful. Directions are normally on the box.

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