Improvised wound management

Overview

Principles of Care

• 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

Procedure

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

See Also

• Wound care dressing basics, laceration repair