wound care - from Plainsmans cabin - McGyver

[tangent]

Cleaning the Wound
The moment skin is injured, bacteria begin to multiply inside a wound, and any blood and damaged tissue left in the wound creates, feeding frenzy for hungry germs. The goal of wound cleansing, therefore, is prevent infection by ridding the wound of as much bacteria, dirt, and damaged tissue as possible.

The best cleansing method is to use a high-pressure stream of disinfected water to wash out the bacteria and debris. You can use the disinfected water as is, or you can use it as the base for an improvised saline solution. A 10cc to 30cc syringe with an 18-gauge catheter tip attached to the used like a squirt gun, creates an ideal water pressure of 7 pounds per square at the wound surface, which is forceful enough to flush out germs without harming the tissues. (A bulb syringe can only muster a pressure of 0.5 pound per square inch, making it ineffective for wound cleansing.)

To irrigate the wound.
1 .Draw the disinfected solution into a 10cc to 30cc syringe attach an 18-gauge catheter tip.

2. Hold the syringe so the catheter tip is just above the wound at a 90* angle to the skin surface.

3. Push down forcefully on the plunger while prying open the edges of the wound with your gloved fingers, and squirt the solution into the wound. Be careful to avoid getting splashed by the irrigant as it hits the (put on a pair of sunglasses or goggles to help protect your eyes from the spray).

4. Do this procedure until you have irrigated the wound with at least (about 1 3/4 cups of solution, depending on the size of the wound). The more you use the better. Remember, "the solution to polution is dilution."

5. Inspect the irrigated wound for any residual particles of dirt or dried blood, and if present, carefully pick them out with tweezers. This is crucial because even one or two particles of dirt lefi in a wound will increase the likelihood of infection.

6. Control any renewed bleeding by direct pressure on the wound (see MM#2). Note. Once-popular wound-cleansing agents such as hydrogen peroxide and Betadine (a 10 percent povidone-iodine solution) are useful for cleaning intact skin and removing dried blood and dirt from around a wound but should never be poured directly into a break in the skin because they are destructive to delicate tissues and can delay healing. (Betadine, however, can be used to disinfect water for irrigation.)

Disinfecting Water to Irrigate a wound

The Water you use to irrigate a wound will in the bush should be clean and non toxic to the tissues. Although a sterile saline is most proper in a hospital setting in the bush you can uses wild water just sterilize as if wound be drinking it. Or add 50 drops to a quart and allow it to sit for 15 min before using.

Field made Saline solution
To make an improvised saline solution for wound or eye irrigation, add 1 tablespoon of salt to one liter of water (roughy a Qt)of disinfected water to create a normal saline solution (0.9%)

If you dont have a syringe and a catheter use a clean plastic bag (ziplock or garbage)and a safety pin. Fill the bag with irrigation fuild and puncture the bottom of the bag (usually the corner) with the pin you can make it a liitle bigger by wiggling the pin a little. Hold above wound and squeeze the bag hard into wound to irrigate. this method is still better than bulb syringe.

You can get a syringe at livestock or vet supply stores.

Abrasion that are really dirty
At a minimum wash them
If they have imbeded gravel and such they such be scrubed this will speed healing ,lesson the chance of infection, and minimize scarring.
This hurts so given the guy something for pain (tylenol)and if posible spray a syringe of lidocaine over the wound first.
Then scrub wound as lightly as possible while still doing some good.

Animal or human bites (or other deep puncture wounds)always pose a high risk of infection. Bite puncture wounds must be mechanically flushed out if possible. And closing of the skin should be avoided to allow the puncture to drain and reduce bacterial growth. (If the puncture is a tear or laceration wound closure should be delayed as long as possible(6-8hrs max)and max distance between sutures/staples/steri-strips)if they are necessary

Antiseptic towelettes or(solution) with benzalkonium chloride also should be used since it can kill the rabies virus on wound from a inflicted animal.
AS MIKE SAID, IF RABIES IS SUSPECTED SEE YOUR LOCAL DR or ED!! Also with wounds of any type its a good survival measure to get Tetanus Booster you have a 48hr window of time to recieve tetanus shot if your ten years are up and tetanus is a UGLY SLOW way to go!

[tangent]

Mcgyver wrote:
6. Control any renewed bleeding by direct pressure on the wound (see MM#2). Note. Once-popular wound-cleansing agents such as hydrogen peroxide and Betadine (a 10 percent povidone-iodine solution) are useful for cleaning intact skin and removing dried blood and dirt from around a wound but should never be poured directly into a break in the skin because they are destructive to delicate tissues and can delay healing. (Betadine, however, can be used to disinfect water for irrigation.)


HU? - can you point me at references for either of these notes? specifically:

hydrogen peroxide is contraindicated for cleaning in wounds. Everything I'd heard was that it helps, particularly the bubbling action. I mean the stuff breaks down to water? - how nasty can that be? also, a RN I know that works plastic surgery had told me that frequent use of hydrogen peroxide on healing wounds (many times a day) will eliminate scarring. I have found this to be true.

as to the iodine - I agree that iodine is necrotic (kills) living tissue and should never be placed in an open wound. Your statement that is should it should be used to sterilize water, prior to use to clean out a wound in the field, I believe is conjecture on your part, based upon some bad assumptions. To whit:

assumption 1) iodine will sterilize water - OK, true... if your willing to wait there the 20-40 minutes for it to do it's thing... a detail you left out. Leaving a wound open and exposed while you sterilize water is probably not a stellar idea...

assumption 2) having sterile water is more important than leaving a small amount of iodine in solution. I don't agree. iodine kills living tissue, period, and dead tissue leaves a home for infection to set in.

assumption 3) you must have sterile water - why? a wound, by definition is contaminated. This is as silly (to me) as putting sterile dressings on a wound - clean dressing/water are fine - you're just going to contaminate them when you expose them to the wound.

you may have a point if you are worrying about micro-organisms entering the body through the wound, but I have never heard of this as a vector pathway. Comments, anyone?

I do agree with you, that the solution to pollution is dilution!

Otherwise, good post! - thanks!

[Flotsam]

You can safely use a _dilute_ betadine solution to irrigate wounds - works fine (I, like many others, prefer a 10:1 water:betadine solution). Hydrogen peroxide - I typically don't use it - it's not really a bacteriocidal/static agent, although the release of oxygen may have some affect on select microorganisms, typically not those found on the skin. The breakdown of h202 by catalase is an exothermic reaction - excess heat is generally not good for wounds. Peroxide "works" by its rapid degradation - the bubbles help break up films/debris & in that way may promote some level of healing. Generally, you'll get better results w/ copious irrigation (I like the betadine solution followed by 3-5 further irrigations w/ sterile NS), mechanical (sharp) debridement, and closure/appropriate dresssing as indicated. For most wounds, you'll get good results by keeping it clean & dry (good old soap & water), and an application of standard bacitracin ointment to just the wound edges (this is what my plastic surgeon uses w/ good effect.) YMMV.

It is fairly easy to get a systemic infection from an untreated localized infection.

Sam

[tangent]

any other takes on this?

we were taught to never put iodine in a wound. but protocols change and I could be wrong.

as the the HP - I've never found it being exothermic to be an issue, and use it a lot at home. maybe warm - but nothing that would damage tissue.

[Flotsam]

Betadine is not the same as Iodine - the addition of Povidone decreases the available iodine - it's less toxic. As for closed wounds, you should have a barrier of epithelial cells within 24-48 hours, so the wound should be essentially watertight - h202 would serve little purpose on this type of wound. For better wound results, you typically want a clean wound, closed tension free w/ the appropriate method, removal of sutures when applicable, and good wound care , including limiting exposure to UV radiation, afterwards. A scar undergoes a fair amount of remodeling (and this can last up to a year), and UV can produce a discolored or thickened scar. We occasionally use h2o2 in the OR, mainly to clean off blood - works great at this - we've never used it to clean a wound.

Sam

[tangent]

I was using iodine and betadine interchangably - to clarify: we were taught never to apply betadine directly to a wound as the iodine it contains is necrotic to tissue.

I'm not sure why H2O2 decreases scaring, but I've used it on myself and it does work!

I've also used H2O2 on open wounds and it seems to do a great job of dislodging contammination - it's the bubbles...

interesting about the betadine, though - I didn't know that!

[RESQDOC]

There are days I wish I was Jewish, so I could use the term “Oy Vay...” and not sound so, well, gentile. Having trained in Miami however I was given honorary use of certain
Yiddish terms.

First, “Betadine” a povidone-iodine solution comes in two forms 1) Surgical Scrub, which
has a detergent added, and 2) plain i.e. no surgical detergent. It is the detergent that is harmful to healthy cells and should not be used in open wounds at all, most especially after the healing process has begun. The amount of free iodine in Betadine is very low, as noted above, and this is why it is not especially toxic to tissues. We even use it on eyeballs.

Generally a 10% or weaker dilution is used, mostly to make the doctor feel better and the
patient to feel like something is being done for their $1000 ER bill. Sterile saline is a
perfectly adequate cleaner for the majority of wounds, and Betadine has shown no
advantage for most things. I deal with a very high percentage of contaminated wounds
versus “clean” simple cuts, mostly contaminated with manure, and various worse stuff, so I often use a weak Betadine so that I feel better about it. Joint wounds and open fractures are an area where I feel that it has been proven to be helpful. Not everyone agrees on this.

The intent is to have a non-ionic surfactant agent that will reduce the surface tension and ionic charge of contaminants, aiding their removal via flushing, as well as at least some potential anti-infective component. All anti-infectives other than Betadine have been shown to cause damage at the cellular level thus increasing the chance of infection developing. Several artificial surfactant agents are available, very expensive, and no better than saline in functional outcome studies, so I don’t use them.

Other agents, such as iodopher, hexachlorophene, chlorhexidine, bleach, and hydrogen peroxide have ALL been shown to have a negative impact on wound healing, cause damage to fresh tissue, increase infection rate, and impair epithelialization and growth of new healthy tissue. This has been demonstrated in countless studies. Do a search on contaminated wounds, wound cleaning, and the individual products. I occasionally use hydrogen peroxide in a wound to remove dried blood and clots or large amounts of pus, as it is very effective in breaking down proteins and heme products (and getting blood out of your clothing, FYI) with the understanding that in fact I am harming healthy tissue vs.
the benefit of removing the contaminants. I do not recommend it for regular use. It is not a part of modern wound care protocols. There is no objective evidence that it reduces scarring. It does not store well, breaking down in several months even when stored in the dark. Use it if nothing else is available but sterile irrigation water is best. It's fun to watch it foam though.

Regarding sterile vs. clean, sterile is better, because it’s sterile. The idea is to reduce the contamination load as much as possible. That being said, clean water is fine if that is what you have. I have many times used lots of clean water to wash wounds while sterilizing some for a final rinse and subsequent cleanings. Better the clean water you have now than the sterile water you will have in a few hours, IMO. Bacterial counts in wound increase
exponentially for the first hours after injury, wash as many of the buggers out as soon as possible.

Now, regarding “high” pressure irrigation of wounds, i.e. about 7-8 p.s.i., that produced
by a syringe and soft catheter tip, it has both up and down sides. Pressure irrigation in this range does reduce the bacterial load in contaminated wounds by up to 80%, depending on which study you use. It also however produces lateral spread of the fluid into the wound margins, increases post cleaning edema, and for that reason can increase the wound infection rate (it does not seem to spread the infective agents themselves). Thus I only use this technique on contaminated wounds. “Clean’ simple wounds probably have a higher infection rate from the pressure irrigation than from the wound itself. Low pressure irrigation from a bulb syringe or pouring does not significantly reduce the contamination
but does not produce secondary damage either. So pressure irrigation is a judgment call.

When in doubt, hose it out.

Finally, lets mention scrubbing wounds. Coarse material, such as gauze pads, further
damage the tissue, increase infection rates, etc. There are fine synthetic high porosity
sponges that are much more gentle, and much more expensive. I don’t use them. I just
resist the temptation to scrub, blot the tissue gently, and individually pick out foreign bodies, small bits, etc.

In summary,
1. Clean water is better than no water.
2. Sterile water is better than clean water.
3. Sterile isotonic saline (0.9%) is better still.
4. Plain Betadine, especially 10% or less concentration, is acceptable, especially in joint and bone injuries.
5. Don’t put anything else in/on wounded tissue although other products are fine for
cleaning intact skin.
6.Re-read #5.
7. Pressure irrigation is best used in contaminated wounds only.
8. When in doubt pressure irrigate.
9. Don’t scrub, but blot & pick out crud as needed.
10. Re-read #5.

The above represents my opinion, experience, and training. As in much of medicine wound
cleaning is based partly on science, partly on experience, and partly on myth. Other
individuals and other parts of the world have their own take on this topic.

You pays yur money and yur takes yur chances.

_________________
Do No Harm. Do Know Harm.

[Flotsam]

Doc, I tend to agree w/ you - I see a fairly wide variety of wounds, many grossly infected (these tend to be diabetics w/ severe PVD & already known poor wound healing). We use a variety of modalities - operative & bedside debridement, systemic antibiotics, collagenases/hydrocolloids, acetic acid/dakins solution wet to dry dressings, and wound vacs, and we sometimes can get these wounds to heal. Sometimes we just get them clean enough to do flap or stsg coverage. My initial treatment usually follows what's been laid out above - clean the wound, remove devitalized tissue/debris, and then choose the appropriate modality to promote healing. The betadine solution used may not significantly affect the final outcome, but I don't believe (and I have never seen data to support) that it has a negative affect, either - I guess it falls into the doesn't necessarily hurt, but could potentially help category, and I've had pretty good results w/ it. Many of the wounds that don't heal well are in part (sometimes in whole) due to the patient - poor compliance w/ wound care instructions & follow-up, as well as preexisting conditions (diabetes, steroid use, etc.) make some patients extremely difficult to treat (as I'm sure you're well aware).

[SwedeGlocker]

Hallo
In sweden it seems to be two schools about woundcare. The first one like to put in all sorts of woundcare products in the wound and mess a lot. Other prefer large amount of clean tapwater. On the wounds i have taking care of, in 90% i only used ordinary tapwater. In my opinion one product that really help with healing of the wounds is Mepitele. I use it on most wounds with exellent results.