Managing traumatic or infected wounds with no formal equipment.

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pa4ortho
Posts: 14
Joined: Wed Dec 14, 2016 8:42 pm

Managing traumatic or infected wounds with no formal equipment.

Post by pa4ortho » Fri Mar 10, 2017 4:17 pm

*draft*

Managing traumatic or infected wounds with no formal equipment.
Traumatic wounds can be managed successfully without formal equipment. In some cases formal medical care demonstrates superior outcomes in others its not a big difference. Some old less effective methods can still improve outcomes over no treatment even though they are not state of the art anymore.
Here is the basic sequence of events for 2 people in a remote setting with scant equipment, The patient has a 8 inch long 1 inch wide and 1 inch deep laceration. I don't focus on elaborate story line as much as Clean/contaminated-bite, fecal. This wound is relatively clean.
Step one- global survey: scene survey and head to toe survey while applying direct pressure. It is important to clear for other sources of trauma. Get a baseline.

Step two- focused assessment and initial intervention: Assess the severity of the bleeding. Blot and identify the source of the worst bleeding whenever possible.
If only modest bleeding is noted on an extremity, 2" strips of the patients t shirt are packed tight into the wound. Apply focused pressure on the site of bleeding or if not identified pack deep in the wound north south east west. build up the packing to fill the wound. the goal is to create ideally an inverted pyramid of packing with the tip on the source of the bleed. To practice this skill I have students make a loose fist. take the other hand and pack the gauze against your small finger deep inside the fist. Pack the whole fist tight with cloth. When you are done if you press on the packing at the thumb side of the fist it should be felt firmly on the small finger. The remainder of his shirt is wadded up over the wound and another strip is tied in a prussic knot wrapped over the top of the wound packing and around the limb or torso in a pressure dressing configuration. This presses the entire wad of dressing directly on the bleed ideally. Other techniques can be used to apply pressure to wounds in junctional areas like the armpit, groin and surrounding areas of the torso. These include figure 8 and modified figure 8 dressings around the shoulders or front to back looping around a belt to compress the inguinal and groin area.
If there was no significant bleeding wounds do not really need initial packing. skip it and go to washout and clean dressings as described below. Most wounds stop bleeding on their own.
If there was severe or arterial bleeding in an extremity or there was a doubt such as at night or if there was a need for packaging and transport down the mountain where monitoring is poor, a temporary TQ would be applied initially to prevent blood loss. Have a low threshold for early temporary TQ use. You can take it off as outlined in TQ removal protocols. In short removal between 30 min and 2 hrs preferred, but only if your patient is hemodynamically stable and you can monitor the wound closely and the environment is safe.
Usually at this point someone asks about sterility. At this stage in the management of bleeding, blood loss is the issue. The wound is not sterile and is no cleaner than the patients own shirt or the skin around the wound. The unwashed hands of the person rapidly packing the wound are the likely the most contaminated item in this case. In austere settings bleeding is a much more serious problem. Transfusion or even good nutrition to recover from anemia may not be available. Infection rates are higher in anemic patients. When available kerlex or advanced clotting agents should be used. When not available use the cleanest thing you have. Don't fail to act because its not sterile.
Step 3- definitive care
After packing the wound tightly and binding it the wound is reassessed frequently for the need for more packing or a TQ. The patient is also instructed in how to self monitor while the rescuer builds a fire and starts boiling water to make clean bandaging and irrigant. The old adage of the solution for pollution is dilution applies here. We need to create water and dressings that are cleaner than the contaminated wound.

The patient is rechecked every 5-15 min for hemostasis and stable pulse rate.
After 30 min to 1 hour of tight packing or TQ use the initial bleeding should be better maintained as clots form.
If hemostasis is achieved, we need to change our focus from hemostasis, to managing the wound and prevention of infection.
Place 2-3 inch wide strips of t shirt materiel into the boiling water and let it boil a bit. This can decrease the bacterial load and will render the shirts cleaner than the wound. Knit fabrics like t-shirts are preferred over woven fabric like bed sheets as there is less loose threads that can come loose and form a nidus of infection in the wound if they are lost in there.
But boiled water still not sterile!! Remember it just needs to be cleaner than the wound. The effect of boiling water is variable based on altitude however below 10,000 ft it is highly likely that almost all wound pathogens are killed by the time you can get the water to boil at all, let alone for some cryptic number of minutes. Most pathogens start dying at 70deg C and are long dead by the time its gets to 100deg C of boiling. There are a few heat stable pathogens like hepatitis virus that need 92 deg water but they are just not often encountered at high elevation. Even above 10k you now have cleaner water and cleaner packing. Cleaner is the goal here. The wound is clean not sterile. Even kerlex straight from the wrapper even if the wrapper is intact will soon be clean rather than sterile in this environment. If available a pressure cooker can improve the quality of the water and is most beneficial at elevation.
Cover the water while its cooling, so bugs and sticks don't fall in and contaminate it.
After at least 30min have passed from the time of injury so clots have had an opportunity to form, we can try to irrigate the wound and pack with clean moist dressings. If the bleeding is controlled by packing on an extremity, Place but do not tighten a TQ and slowly remove packing. Be prepared to reapply direct pressure or a TQ if needed. Next if bleeding is stable (a small amount of capillary bleeding is ok) Pour the now cooled water, from a few feet up to provide pressure irrigation into the wound to wash out any contaminants. Any gross contamination should be mechanically removed. If you have the skills this is where debridement of devitalized tissue can occur as well. Using well washed hands or gloves if available, pack the wound with the clean moist cloth. Wring out excess moisture prior to packing it in. Place the gauze in the wound to contact all surfaces loosely. This is not a tight packing into the wound. Repack every 8 to 12 hours irrigating each time until healed. Its old school wet to dry dressings. They do a good job removing any non viable tissue. Adding a few drops of mild dish soap or using a brush can help with stubborn oily or particulate debris.
Contingencies:
If water is very limited a small amount can be used to steam the cloth suspended in a pot. A hot piece of metal can be used as an iron to cook cloth or to steam treat cloth.
If you have clean dressings, a backpack filter can be used to remove bacterial pathogens. A steripen can render inert virtually all bacterial or viral pathogens in clear water. Filtration and steripen or iodine tabs allows use of irrigant without waiting for cooling by removing bacteria and rendering inert viruses.

Suture:
I generally don't close contaminated wounds in austere settings with the exception of well vascularized places like the face and scalp or critical functional areas like the hand. Delayed closure 3 days later when the wound is clean from dressing changes and has granulation tissue is safer if you must close it. Keep in mind a wound infection can be lethal when working without modern ABO. Going from 6% to 18% infection rates in dog bites by closing them early for example is a bad idea.
That being said.... improvised suture should be a monofilament single strand like 6 lbs fishing line. Not woven thread with high infection rates from sequestered bacteria in the thread. Not horse tail hair or other highly reactive foreign proteins. A standard sewing needle can be heated to red hot to break the temper, then bend it into a curve with small pliers. Another improvised suture needle can be made by carving the plastic hub off a 18ga needle and inserting the fishing line. Crimp with pliers to swage it into the needle. Curve just the tip of the needle into the size curve needed for the wound you have. when done the needle looks like a J shape with the line coming out of the top of the J. the nice thing about this is it slides better then the sewing needle design and you don't need pliers as a needle driver because you can hold the needle by its straight section while sewing.
On the scalp, ones own hair can be tied across a wound to help close a wound.
Various adhesives can be used on small cuts like superglue. Keep in mind this seals the wound shut and can trap infection. However on a small clean wound it also keeps the outside badness out in contaminated environments.

A few summarized pearls from studies:
1) no difference in traumatic wound infection rates with sterile gloves, clean gloves, and well washed hands.
2) No difference in traumatic wound infection rates with chlorinated tap water vs sterile saline.
3) Back pack filters effectively remove bacterial human pathogens.
4) Most human wound pathogens are destroyed with 1 min heat at 70 deg C
5) Wound closure increases infection rates in contaminated wounds.
6) 2 drops of dawn dish soap per liter in irrigation solution for traumatic wounds reduced infection rates.

Some complex wounds may benefit from further intervention.
Wound packing with bactericidal dressings.
To understand this think of the world as a big battle between plants, fungus, and animals (bacteria) for available resources. Each exudes chemicals to inhibit the others. There are thousands of chemicals in a simple plant. They keep roots from growing into each other and a whole host of other non related to us tasks. Root crops must survive over winter in the ground. Everything else decomposes but they do not because they are full of bacterial suppressing chemicals. So packing with shredded carrots potatoes garlic have all shown some help in heavily contaminated non healing wounds. Bee vomit AKA Honey also is packed full of bactericidal and fungal inhibiting enzymes and is a very effective wound agent. Sugar mixed with iodine (sugar dine) lyses bacterial cell walls with osmotic pressure. Remember Iodine alone is not effective and over time can slow healing in open marginally healing wounds. Pseudomonas will grow in liquid iodine. Penicillin is the exudate of a fungus. Amoxicillin is from bacteria.
The term "natural medicine" is just silly. Its only natural if it came from a gland in your own body. Otherwise its all interfering with the natural course of your illness with a risk and benefit ratio to be managed. This discussion however is about improvised medicine when other or better options are not available. This is your reminder to use good judgment. Arsenic asbestos uranium and tobacco are "all natural" and therefore by some peoples definition harmless. Natural does not imply better.
For heavily contaminated wounds packing with honey or root crops may be a good option to reduce the bacterial load and promote wound closure.
The route of administration is important. Just because it works topically does not mean that if you eat root crops it will heal your wound. They get digested as food. Your body does not like foreign proteins floating around in its system so quite simply the digestive tract busts all that stuff up.
Silver solutions topically or nebulized and inhaled topically can have a good bactericidal action as well. Drinking the stuff creates a silver salt on contact with the HCL in the stomach. When in salt form it no longer has an effect on bacteria. However as a salt it is readily absorbed and circulates in the body indefinitely with no way to excrete it. The only way it stops circulating is with exposure to UV light where it precipitates (think photo film) and turns the skin blue over time.
Broad leaf plantain is found all across the US and, unless you are OCD with the spray, is likely somewhere on your property as a weed. It is particularly useful for burns and abrasions. A well washed leaf applied is chemotaxic to WBC causing a robust immune response locally. Again there are better options in modern medicine but the leaves are non stick and I have seen good response in burns and abrasions in resource poor environments as well as communities with an aversion to modern medicine. Again yes you can eat it, but only if you like that sort of thing in your salad as that won't make you heal faster.
Continuous Irrigation
When antibiotics are not available or not winning try continuous irrigation. Its used for wounds or infections of incarcerated spaces like tendon sheaths and joints and contaminated bone. An IV cath can be placed in a tendon sheath and a drain or another cath placed distally. A continuous drip can be run for 2-3 days flushing out the space and reducing bacterial damage the local structures. Joints can be flushed similarly short of an open wash out (preferred if you have a surgeon) if that's not available.
Exposed bone is prone to osteomylitis and should be washed and covered by well vascularized tissue as soon as possible. Bone that can not be covered may need amputation or debridement. Bone that has been exposed and presents late may respond to a trial of coverage with irrigation placed along the bone. This is a last ditch attempt to save a limb risking sepsis and further infection. However in resource poor environments where amputation likely leads to inevitable death from being unable to work each day it is an option.
negative pressure dressings
Application of open cell foam or open weave gauze in the wound sandwitched around a drain tube covered with clear occlusive dressing and placed on -100 mmHg suction presure give or take 25 mmHg based on patient tolerance has been shown to improve wound healing and provide rapid draining of exudating wounds. This can result in lower infection burden, a sealed wound in contaminated environments, and the ability to cleanly irrigate continuously and suction away drainage imediately. This also works wonders with skin grafts. Treat the wound with negative pressure to promote rapid granulation tissue formation. Next take a split thickness or pinch grafts and apply them to the graft site, cover with xeroform or petrolium gauze. non stick is important here. Next cover with a negative pressure dressing to adhere the graft to the wound base and remove any excess edema or fluid that can saturate the graft.
retention sutures
large wounds that are gaping open may heal faster if tension is off the wound and wound margins are pulled together but not closed to prevent trapping of infection deep in the wound base. Take large bites with big suture and partially pull the wound margins together. Often cut sections of foly or IV tubing is used at the surface to pad the suture from pressing to tight on the skin. By increasing tension granulation tissue at the base of the wound can be approximated and heal together. Then the suture can be progressively tightened to bring the open wound together. Think about this in a large wide open wounds only.
tendon repair This is taught in more detail in my suturing workshops but basically its a ..... well here you go its a post unto itself.... http://www.mltj.org/materiale_cic/704_3 ... rticle.htm

austerenurse
Posts: 11
Joined: Sun Dec 18, 2016 8:02 pm

Re: Managing traumatic or infected wounds with no formal equipment.

Post by austerenurse » Sat Mar 11, 2017 12:33 pm

Good read...

In the past few weeks I posted this on the old site. Feel free to talk what you would like if useful.

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It is interesting how the pharmaceutical companies have marketed wound dressings in the 1st world. Lots of really cool and really expensive stuff out their for burns and problem wounds such as diabetic foot ulcers.

I think the simpler the better. Especially for RAWTHM. I have used the ICRC techniques for some time in a number of areas of the world with excellent luck, despite the do not align with the American hospital way of doing business. I have some people I work that have just returned from the battlefields of Ukraine and they noted also that they well. These methods work very well in resource constrained environment where the nursing staff may suffer from lack of training.

Once hemorrhage control is obtained and you are now dealing with a clean'ish wound that you want to start to heal. This process follows the concept of delayed primary closure or healing by secondary intention which are the mainstays of remote medicine in my opinion (and most of the humanitarian medicine community).

1. Use dry fluffed-up sterile gauze layers or absorbent cotton / wool layers. Essentially you are putting a bulky fluffy layer next to the wound to absorb exudate. Do not pack tightly into the wound. Exception - exposed tendons and joint capsules should have saline soaked gauze placed over them.

2. Hold in place with an elastic bandage, tape, or something stretchy like vet-wrap. Depends on size and location. You are just trying to keep the bulky dressing in place. Bandage over the gauze / absorbent layer in a non-circumferential (figure 8 manner) in case the limb swell and nobody is around on the ward to notice. You do not want to make a tourniquet with your dressings. In Afghanistan we just used cloth crepes for bedridden patients and laundered them for re-use.

3. The problem with this technique is that dressing changes, when warranted due to exudate (and not routinely) then need to be done under conscious sedation or anesthesia due to the pain of changing them (the gauze and cotton will stick to the wound in parts where the exudate does not keep it afloat). This can be avoided by impregnating the gauze that is right next to the wound with white petroleum jelly to prevent it from sticking. If you do this, you can change dressings on the ward, with a little pain control +/- adjunct drugs. The problem with Vaseline gauze is that is does not absorb exudate or allow it to pass through to the bulky dressing thereby creating a plug sometimes.

4. Dressings should not be removed "just to take a look at the wound". In sketchy medical clinics this just opens the wound up to infection. Open the dressing up when it is time to do delayed primary closure on day 2-5 (normally 4-5 days) in the surgical area. If the casualty is eating and comfortable wound healing is occurring. If the dressing becomes soaked in exudate over-dress with more bulky gauze / absorbent cotton, or take down the bandage and wet bulky gauze / wet and replace without disturbing the gauze compress that is in direct contact with the wound. The state of the dressing is not an indication of the state of the wound. This is much different than in America where we do doctor ordered dressing changes every 8-12 hours or daily. You need to be comfortable with the process. Pro-tip. You will smell a sour odor after several days... this is the "good-bad smell" of ammoniacal products from the breakdown of serum proteins. It should not be confused with the infected wound that has that characteristic offensive odor also known as the “bad-bad smell”.

5. For most wounds there is no value in impregnating the dressing with iodine, chlorohexidne, sodium hypochlorite, etc. In fact it likely does more harm than good.

6. If a wound continues to bleed you need to take the dressing off and conduct an immediate re-exploration. If you have vascular changes indicating ischemia, the same. If you have obvious signs and symptoms of infection: fever, toxicity, excessive pain and tenderness, warmth, redness or shiny surface in dark-skinned people, edema and induration, or a moist wound dressing with an offensive smell you need to take down the dressing and surgically re-explore the wound (often requires additional surgical excision). This is not a bed-side nursing problem and the infection will not be solved with simple nursing dressing changes.

7. You are starting to see more and more negative pressure dressings used in austere medicine. When I was in Afghanistan (2010) this was just coming to light in remote medicine but it now being used somewhat routinely in places like the Ukraine and Iraq / Syria. The negative pressure helps to keep the dressing dry by removing the exudate. This decreases the frequency of dressing changes thereby freeing up limited nursing staff / OR time and supplies. You should only use negative pressure dressings on wounds that have been well debrided.

So in my wound management kit. Lots of gauze that I can fluff out. Some ace bandages, tape, a little bottle of tincture of benzoin and Vet-wrap. Truly inexpensive. If I am going to use negative pressure dressings then I add open cell foam (ideal, not required) , tubes with perforations, suction, clear membrane dressing.

I hope that is of some interest.

AN

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pa4ortho
Posts: 14
Joined: Wed Dec 14, 2016 8:42 pm

Re: Managing traumatic or infected wounds with no formal equipment.

Post by pa4ortho » Thu Mar 16, 2017 3:21 pm

very nicely done
thanks

pa4ortho

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