Improvised wound management

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Overview

Principles of Care[1]

  • Hemostasis
  • Anesthesia
  • Irrigation
  • Closure

Indications

  • Improvisation of wound care may be necessary when in the wilderness or when there is a lack of access to traditional medical supplies

Contraindications

Equipment Needed

Procedure[2]

Hemostasis

  • Direct pressure dressings should be first line care to obtain hemostasis
  • Vasoconstricting sprays (1 mL of 1 : 1000 aqueous epinephrine in 400 mL normal saline) or gels (1 mL of 1 : 1000 aqueous epinephrine mixed with a tube of K-Y Jelly) are useful for superficial wounds
  • Tourniquets should only be used in cases of severe extremity bleeding when direct pressure fails

Anesthesia

  • If available, use standard infiltration (e.g. lidocaine or bupivacaine) or topical anesthetics (LET [4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine])
  • When standard options are unavailable, alternatives can be considered:
    • Injections
      • antihistamines (e.g., 1 mL of 5% diphen-hydramine in 4 mL NS for injection)
      • Sterile Water
      • Bacteriostatic normal saline (alone or 0.2 mL epinephrine 1 : 1000 mixed into a 20 mL vial of NS containing benzyl alcohol 0.9%)
      • Opioids
    • Topicals
      • Ice can be effective to decrease pain before needle injection but can be detrimental to crushed tissue in a wound
      • Vapocoolant sprays (ethyl chloride) are ineffective

Irrigation

  • Use sterile water or normal saline if available
  • Non-sterile water is still preferable to no irrigation at all

Closure

  • Glues
    • Ideal method in the wilderness as it precludes need for anesthesia and is less painful than suturing
    • Cyanoacrylate (“superglue”)
      • Most commonly used as it is readily accessible
      • Disadvantage is more frequent wound dehiscence due to lower tensile strength compared with sutures
        • Petroleum-based ointments and salves, including antiseptic ointments can weaken glue increasing risk of dehiscence
        • Using cyanoacrylate on wounds under tension, such as over joints, can also increase risk for dehiscence
    • Other glues such as wood glue, panel adhesive, hobby cement, and various native (e.g., plant) substances may be used but may cause irritation, increase dehiscence risk, or contain toxins
  • Staples
    • use if available (cannot be improvised)
  • Binding and Taping
    • Useful for shallow, non-gaping wounds
    • Reduce need for anesthesia
    • Any tape may be used
    • Tapes do not stick well on areas that are hairy, wet, prone to perspiring, or that are under tension
      • Fortification of tape closure with glue, bandaging, or more tape can mitigate this effect
  • Improvised Sutures
    • Needles
      • Swaging a Hypodermic Needle (may be done at bedside or in advance)
        • Thread suture from sharp end of needle to hub end
        • After suture appears on hub end, break the hub off
        • pull the suture through the needle so that only a small amount remains within the needle
        • Use pliers to crimp the needle at the hub end to hold suture in place
      • Alternatively, insert hypodermic needle through both wound edges and thread suture from sharp end to hub. Then retract needle leaving the suture in place and tie
    • Suture Material
      • Fishing Line
      • Horse hair
      • Silk or Linen Thread from clothing
      • Agave fibers or other plant material
      • Dental Floss

Complications

See Also

External Links

References

  1. Auerbach, Paul S., et al. Auerbach's Wilderness Medicine. Elsevier, 2017.
  2. Auerbach, Paul S., et al. Auerbach's Wilderness Medicine. Elsevier, 2017.