I am learning the recommended methods for dealing with wounds in the field. Most is what I’ve picked up here, and in the book Back Country First Aid by Buck Tilton, which I think I bought because I saw it highly recommended here.

Here is where I am so far, and I would appreciate any critique or feedback:

1. Direct pressure will stop almost any bleeding. Forget pressure points and especially tourniquets.

2. Disinfect wounds with a non-alcohol based disinfectant. I used to like hydrogen peroxide, but am leaning more toward diluted povidone-iodine. BUT: Back Country First Aid says to not bother unless the wound is really filthy. They advocate using just a stream of plain sterile water, using povidone-iodine only to sterilize the water if it is suspect. I am having trouble with not disinfecting a wound.

3. I’ve been a believer in topical anti-bacterial treatment, i.e. Polysporin. But it seems here at ETS most people advocate just keeping the wound dry and clean, uncovered. The old folk wisdom, “Just let air get at it”, seems to be making a resurgence. But Back Country First Aid recommends something completely different for dirty or infected wounds: pack it with moist gauze, and cover with dry gauze. I guess I like a mix of the two: keep it dry, except for a light dab of Polysporin, and keep it covered, but vigilantly changing the bandage when damp. I find with uncovered wounds I am constantly bumping them and getting them re-opened or dirty, and a protective bandage is a comfort.

4. Sutures are out, and Steri-strip butterflies can handle just about anything a suture will without the risk of causing infection or irritation.

So what’s the general opinion on this topic, and the points I mention in particular?

Thanks!

David

Yup, this all makes sense to me.

I highly recommend a Wilderness First Aid course - look on nols.edu for one in your area. Well worth the weekend commitment, and you will understand the sense of these treatment methods better. There is also a whole lot more about patient treatment in wilderness settings that you need to know to keep people alive and kickin. And Wilderness First Aid translates pretty well to other scenarios where medical assistance in the form of hospitals and ERs are not available, such as during isolating disaters like earthquakes.

Almost forgot - the ideas like "forget tourniquets" will rightly get some criticism because Tilton's book is based on backcountry or wilderness first aid, when there is no ER handy within 10 minutes to help your patient. Its you and them and what is at hand for 24 hours. Even the WFA treatment protocols are becoming much more accepting of tourniquets in particular to treat massive bleeds (where pressure and elevation can't effectively stop bleeding). Tourniquets are good, as long as you have a quality one that's designed correctly - not paracord, or shoe laces etc.

I don't carry a tourniquet in the backcountry but have considered it; I also know though that the same 1 inch webbing I routinely carry can be improvised to help fashion a tourniquet should push come to shove.

Hit send too soon - "forget pressure points" is also somewhat incorrect: pressure to the wound will stop the majority of bleeds, pressure points and TQs are good for the last 1-5%.

Anyway, I highly recommend WFA training and certification if you intend to apply this - know your limits, and give aid to the extent of your knowledge and certification.

I am no practitioner or expert. Much of what I learned came from a trauma care class I took aimed at firearms instructors and RSOs. The class was based on the TCCC Guidelines, and taught by a former combat medic and civilian paramedic. If you haven't taken such a course, I strongly recommend it.

1) Direct pressure is great and works much of the time. Pressure points don't work. Hemostatic agents work extremely well and should be used for life-threatening bleeds or where direct pressure fails. Tourniquets are called for in life-threatening extremity bleeds. While its best to use a purpose-made tourniquet its better to improvise one and deal with the tissue damage than have your patient bleed to death.

2) Use lots and lots of clean water to wash out wounds that need cleaning. BZK towelettes are good for cleaning and disinfecting wound sites. Alcohol disinfects but it also damages tissue and retards healing.

3) I tend to use Neosporin on small wounds, it appears to me that they heal faster. Medical practitioners recommend against topical antibiotics because they attract dirt. Cover wounds when you have to but keep their bandages dry and clean.

4) Never close a wound in the field if you're not a practitioner and have any other option. Steri-strips can still trap germs in the wound.

My training comes from wilderness first aid courses so I would like to see what those in the medical field on this site have to say.

My instructors have taught me to clean and sterilize any wounds with copious amounts of diluted iodine solution the color of light tea. Straight iodine is too harsh on healthy cells in the wound. Backcountry water is not always clean and can introduce nasties into the wound site.

Experts please weigh in.

I agree. When someone blows half their fingers off with an M-80, direct pressure is hard, but pressure point and elevation does the trick. Been there done that. As they say, Stupid Should Hurt.

Bill

I agree w/ Chaos. Don't write off tourniquets. It's better to lose a leg than bleed to death.

Peroxide damages viable tissue as much as rubbing alcohol. Both can theoretically retard healing, but if it decreases the risk of infection ... it's a judgment call.

Steri strips have no where near the flexibility and wound-closing ability of sutures. There's a reason why sutures are used in an OR, and steri strips aren't. Having said that, yes, steri strips can allow things to drain better. If it's that bad, though, you're probably better off leaving it open and keeping it clean (once bleeding controlled)

TCCC and WMA are differing viewpoints, but both are valid given different circumstances. Best advise is to learn the pro/con of each, and pick and choose your course of action. Cook-book medicine is usually not the best practice.

I have an EMS background as well as wilderness medicine and TCCC. In a non-tactical environment, you can still have a risk of serious hemmorhage situations. Getting hit with a hunter's .308 negligent discharge, accidentally chopping an axe through your lower leg, or surviving a plane ditching can result in life threatening bleeding where minutes count. In addition to direct pressure and wound packing (like this, I don't mean long term wound care/packing) being knowledgeable and skilled with a tourniquet and hemostatics has application here.

I carry Combat Gauze in the woods because it is effective, lightweight, packable, versatile, and very hard to improvise.

For truly serious wounds the current wisdom is that elevation and pressure points are not useful. If a bleed responds to elevation or pressure points, then it should also respond to direct pressure. On a bad bleed you are wasting time and red blood cells with elevation & pressure points.

Most people don't have the skill to suture correctly. IMO unless you have significant professional experience with suturing you shouldn't be doing it. Done wrong it causes more problems than it solves. I was taught to suture by a surgeon and I practiced on pig's feet but that was years ago and today I don't think I could do a proper job on a human.

I have to disagree with the folks saying to leave wounds open to the air (other than minor abrasions etc.)--I was always taught in nursing/NP school that wounds heal best when they are kept moist and covered. This also keeps crud out of the wound once you've cleaned it up. As far as disinfecting or not, I think that depends on the situation and resources available. If you have clean water, irrigating with that (and scrubbing if you have to, to get dirt out) should be fine; if you have soap that's even better. Antiseptics are hard on healthy cells, but if the water you have is not clean then using them is probably the lesser of the two evils. For example, I was on a medical mission trip to Kenya and one of the patients we saw was a woman who'd had surgery on her leg at the country's major hospital...the dressing had not been changed since she got home a week prior to our seeing her! We had to soak the dressing off as it was stuck to the wound...given that the tap water was questionable we used a bottle of antiseptic solution that we had in the clinic. Under normal circumstances here in the US, I would not hesitate to use plain tap water for something like if I didn't have sterile water or saline available, but there we didn't dare.

So, I have no experience in wound treatments or medical care other than bandaids and triple antibiotic ointments....

However, I do make sure I have a first aid kit with me for minor things.

I was wondering if anyone here had any experience with Celox? (It's a blood-clotting cloth/powder that apparently can help with bleeding until first responders can arrive)..

Is this a good product to have in your car emergency first aid kit?

Also, I saw some good books on first-aid in this post, so I will be checking those out as well.

Once again, thanks to everyone here who contributes to these discussions, I am picking up a lot of great info!

Don't get Celox, especially in powdered or granulated form, until you've been trained in its use. Find a class in basic first aid, another class for CPR, and then take a class on treating trauma, such as a "Trauma for CCW Operators" class.

Having been through quite a bit of training for a non-practitioner, I do carry Combat Gauze, and my primary trauma kit has Celox-A.

Quality training, and even practical experience, is far more significant than any gadget carried in the kit. Knowing how to effectively improvise is one of the important skills.

I would agree with others - direct pressure has always worked, including one in which we had to deal with an amputated arm.

Agreed, wholeheartedly. Get trained. Then get trained again and again.

I'm just an amateur here - but try to stay up with what's happening because I might really need to use it overseas (at least on myself).

1. Get the best training you can. In the USA - this is unlikely to be a standard wilderness med course. They just don't teach enough stuff. You can enroll in the tactical med courses, which are often taught because US military people are going overseas. That's a lot better. Keep in mind that you cannot go out and do that stuff on US citizens within our own borders ... but you can do it on yourself. Otherwise, go to some country like Israel and take training there.

2. The subject of what to do about open wounds seems to keep going thru cycles. Yep, for a long time the advice was to avoid strong iodine and just use soapy water. That's probably OK if the contaminating environment is somewhat user-friendly. Probably not OK of you are in a very unhygienic situation. Your idea of dilute iodine is interesting. I often put Neosporin on minor cuts and scrapes. I knew a nurse who insisted that Neosporin was too aggressive and that silver medications were the best - but they cost a fortune. I've never had a problem with Neosporin.

3. Do not throw away tourniquets and pressure points. There are definitely ways that you can have blood vessels penetrated and "direct pressure" wont' work. It's uncommon - but could happen. I think it's best to keep all options open.

4. The military has made some major advances in stopping blood flow. Look into the products QuickClot and Celox. This stuff is amazing! QuickClot will develop heat - so be careful applying a lot of it. Celox is based on organics made from shrimp - so might be a problem for people with seafood allergies. But these new inventions can be true lifesavers in a case where you have critical arterial bleeding. I will be adding some syringes filled with Celox to my personal med kit this month (but that's because I am travelling out of the US).

good luck.
and I am interested in what everyone has to offer.

Pete2

I was taught to use it for a life-threatening bleed that isn't on an extremity, such as a gunshot wound to the torso, if wound packing and direct pressure doesn't work.

The granular forms are phased out (if not entirely, then mostly). The military SOLELY uses combat gauze at this time.

Has everything to do with embolisms and little to do with heat.

makes sense. after thinking about it - the gauze is the most practical and least risky application.

Pete2

I don't know if this has been covered but....25 years in the field as a paramedic (NYC and Florida). I have never used or seen a torniquet used. Personal opinion.....not needed. Direct pressure (pressure dressing-ie. ace bandage) has been enough for everything I encountered including traumatic amputations. Never needed more.....that includes arterial bleeds. Doesn't mean I forget it....I've just never needed them. FWIW.

You probably don't also have transport times measured in hours, with relatively limited supplies (ie, your jump bag). And I bet you rarely have multiple traumatic patients while under fire.

I agree that I've never used them (started in EMS in '96), but they do have a role.

The big reason they're being re-consider is that their main use is in battlefields. There's not the resources or time to apply pressure for 10 minutes to every traumatic injury. A TQ works and frees up the medic to move on to the next casualty.

Wow. A lot of good responses here. This is a big help for me figuring out a basic first aid system.

I look forward to reading more.

David

here's one thing ... and I want to get the opinion especially of the paramedics on this forum.

for a case of serious (or critical) bledding from an extremity I am considering the following technique.

1. While one person gets gear ready (bandages, celox dressings, water for irrigation), a second person applies immediate pressure at the site of the wound.

2. when ready to go, someone takes a piece of surgical tubing and wraps it around the uppermost part of the extremity with some tightness. not enough to be a tourniqet, but enough to reduce blood pressure in the extremity.

3. with blood flow temporarily reduced ... wound is uncovered, irrigated to clean out foreign matter, new bandages applied, pressure applied again on new banadages. goal of this step - 60 secs maximum time.

4. surgical tubing is removed and pressure is maintained on the wound site.

the idea of this technique is to temporarily reduce blood flow to allow quick cleaning and better application of proper bandages. the aim is to be smooth and fast, so blood pressure to the extremity is only reduced for a short time.

and by the way, you could essentially do the same thing if you used a blood pressure cuff on the extremity (and pumped it up) to reduce blood flow. just don't pump it to the point where it gets to systolic pressure - allow some blood to keep flowing.

thoughts??

Pete2

Here in OR, their use was recently covered at one of my monthly classes for my First Responder Cert. The class is delivered by a retired FD Lt. at the local Station. It's new material to the class this year.

I'll comment on the wound that isnt bleeding out.

You will be stunned and fearful of treating that wound,but if you have no choice,you have no choice.

I wont go into what to clean with,you will use what you have.Just get it as clean or sterile as you can throughout treatment.

Use common sense to clean wound and keep clean as best you can.

A wet packing,not dripping wet but moist enough that it isnt dripping,and covered with a dry dressing will work in that situation.Change daily.Protect both victim and yourself from wound and infection,that means gloves if you have em.

As long as victim agrees that what you are going to do isnt the optimal,but the best you have,and is willing to accept the risk,then you just buck up and do it.

BTDT one time,dont want to do again,wound healed but......not a good thing to deal with.

Boy, this is a mixed one. First, surgical tubing probably won't be tight enough for a true arterial bleed. Arteries tend to be deep, veins shallow. So, if it's veinous, your tubing is going to make the bleeding worse, because you block the "uphill" flow. Kind of like when you give blood, and they wrap tubing around your bicep to bulge out your elbow veins. A BP cuff would be better, but to truly stop bleeding, you NEED to overcome systolic blood pressure.

Second, I wouldn't ever do this under rare circumstances.

I think most folks reading this are confusing 2 concepts: bleeding control, and infection control. Guess which comes first?

AFTER the bleeding has stopped, THEN start the infection control. Stop the bleeding however you have to - gauze, TQ, celox, finger on a blood vessel ... the hold it for a while. If it's critical bleeding, you might not be able to stop it, in which case the person dies. But, after 10-15 minutes of serious, HARD direct pressure, most bleeding will stop. Wait a while, an hour or 2, before even thinking of infection control. Honestly, if you're within 24 hours of a medical center, I would barely consider going back there. If it's difficult to control once, it's going to be hard to control a second time.

Sometimes, you don't just do something - you stand there.

In my SAR incidents, we always concentrated on stopping the bleeding, first and foremost. The patient was usually within the ER within twenty-four hours. We had the opportunity for good feedback from the receiving hospitals and I don't recall any comments relating to infection.....

If the victim had a pulse and respirations when entering, they eventually walked out of the hospital in reasonably good shape...

i was talking about a constriction proximal to the wound.

what I got out of the responses is that possibly it's not worth the effort - and just better to go with direct hard pressure.

let's set aside the possibility of a constriction band. and we'll just look at a practical situation. suppose you've got someone with arterial bleeding, maybe from a forearm as a result of a slash with a knife. The immediate response (from me or bystanders) would be to get direct pressure on the wound. most likely this could just involve skin against flesh, or possibly some loose clothing pressed against the wound.

it seems as though it would be preferable to actually remove the clothing (used as a bandage) and replace with bandages, or better still bandages impregnated with Celox. Hence if bleeding has not stopped in say a few minutes (3-5 mins) ... maybe try a very fast release of pressure, removal of blood-soaked clothing, and application of new bandages and more pressure.

the issue here is what the first responder does immediately (and this could be the patient themselves), and what the first-aid provider does as soon as they arrive.

Pete2

- IIRC the only granular hemostatic that was shown to cause emboli was WoundStat. WoundStat is a fundamentally different material than the zeolite comprising early QuikClot. Too bad too, 'cuz WoundStat worked incredibly well at achieving fast hemostatis. It formed into a putty-like material that was fantastic for sealing up a torn artery without heat.

- Chitosan hemostatics with shrimp shells are made such that the protein in some seafoods that affects certain people is not present. You will not have a seafood reaction to Chitosan.

- Here in my county where I worked for years at EMS, we now have CAT tourniquets on the trucks. I have old pals who successfully used the CAT on a dialysis pt whose fistula split open. They tried direct pressure first but it didn't work. Recently a deputy sheriff was shot in the thigh with a 40S&W resulting in a bad femoral bleed. His partner used a CAT carried in an ankle holster to save his life.

- Complete amputations are not the most catastrophic injury to cite in an effort to champion direct pressure. A complete amputation is actually LESS serious (in terms of bleeding) than a fat artery that has been torn lengthwise. Completely amputated vessels often clamp off pretty well (at least for a while) on their own as the smooth muscle encasing them spasms in response to the trauma. The effect is greater with a sharp clean cut, less so with a ragged/shredded wound (like a blast injury). This is a 'grace period' that gives you time to get to the hospital, so some EMS providers overlook it and think the 5 minutes of direct pressure they applied did the trick. Not all cases, of course.

I worked a motorcycle wreck where the rider got T-boned by a car. The rider's lower leg was cleanly cut off when it got pinched between the motorcycle and the car's bumper. We were looking right at the exposed bone and flesh. It only oozed, it barely bled. He would have bled a lot more had his popliteal artery been shredded by a rifle round instead.

"we now have CAT tourniquets on the trucks"

Can you explain that a bit more. CAT tourniquet??

tx, Pete2

Sorry Pete, I lapsed into jargon-speak!

Here ya go:

CAT home page

at North American Rescue

thanks. I don't think any of us like to really contemplate wounds of that severity. but it seems like they've done a good job with the design of the CAT tourniquet. I'll buy one and throw it into my med kit :-)

Pete2

They're the ones they had at our class.

My thought (and I'm obviously no expert since I posted the original question!) is that any wound that is bleeding that profusely has already flushed itself out with it's own blood. My instincts tell me not to get too fancy fooling around with it, but just stop the bleeding.

FWIW,

David

Do not buy a tourniquet until you have been trained in when and how to use it.

Just for completeness, there are still second-generation zeolite-based QuikClot products that you may find out there, such as QuikClot ACS+, QuikClot 1st Response, QuikClot Sport, and QuikClot Sport Silver. I don't recall ever hearing of any heat issues with second-gen QuikClot products.

Products like QuikClot Combat Gauze and QuikClot Emergency Dressing are the newest kaolin-based products.

somewhat surprising results. tests of new wound care gauzes on actual femoral bleeding show no big improvement.

http://tacmed.tumblr.com/post/12327052888/standard-gauze-versus-haemostatic-agents

interesting study. don't know if this carries over to all possible wounds.

Pete2

I'm not saying they don't have a role....I have had countless very traumatic injuries.... all controllable. Yes I am aware of recent combat applications and the great outcomes. Just saying I've never needed or seen one used. That said....I still keep it in my mind.