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#252944 - 11/06/12 04:51 AM Re-thinking wound care
bigmbogo Offline

Registered: 02/11/05
Posts: 82
I am learning the recommended methods for dealing with wounds in the field. Most is what Iíve 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. Iíve 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, ďJust let air get at itĒ, 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 whatís the general opinion on this topic, and the points I mention in particular?



#252946 - 11/06/12 05:01 AM Re: Re-thinking wound care [Re: bigmbogo]
Lono Offline
Old Hand

Registered: 10/19/06
Posts: 1013
Loc: Pacific NW, USA
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.

#252947 - 11/06/12 05:06 AM Re: Re-thinking wound care [Re: Lono]
Lono Offline
Old Hand

Registered: 10/19/06
Posts: 1013
Loc: Pacific NW, USA
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.

#252948 - 11/06/12 05:09 AM Re: Re-thinking wound care [Re: bigmbogo]
Lono Offline
Old Hand

Registered: 10/19/06
Posts: 1013
Loc: Pacific NW, USA
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.

Edited by Lono (11/06/12 05:09 AM)

#252949 - 11/06/12 06:38 AM Re: Re-thinking wound care [Re: bigmbogo]
chaosmagnet Offline
Carpal Tunnel

Registered: 12/03/09
Posts: 3048
Loc: USA
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.

#252950 - 11/06/12 08:41 AM Re: Re-thinking wound care [Re: bigmbogo]
Quietly_Learning Offline

Registered: 05/29/12
Posts: 164
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.

#252963 - 11/06/12 02:37 PM Re: Re-thinking wound care [Re: Lono]
williamlatham Offline

Registered: 01/12/04
Posts: 238
Loc: Stafford, VA, USA
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.


#252972 - 11/06/12 05:57 PM Re: Re-thinking wound care [Re: williamlatham]
MDinana Offline

Registered: 03/08/07
Posts: 2184
Loc: Deep south... Carolina
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.

Edited by MDinana (11/06/12 05:58 PM)

#252981 - 11/06/12 08:05 PM Re: Re-thinking wound care [Re: bigmbogo]
Glock-A-Roo Offline
Old Hand

Registered: 04/16/03
Posts: 1076
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.

#252986 - 11/06/12 11:13 PM Re: Re-thinking wound care [Re: Glock-A-Roo]
Jolt Offline

Registered: 11/15/10
Posts: 90
Loc: Maine
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.
The rhythm is gonna get you...and if it's v-tach or v-fib, the results will be shocking!

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