Wound Care: An Emergency Room Doctor's Perspective, by E.C.W., MD

Saturday, Feb 24, 2007

Arguably the most important factor in wound healing is the potential for infection. Ever since Semmelweis and Lister demonstrated that strict hand washing made a tremendous difference in reducing the incidence of postoperative infections and puerperal fever after childbirth, health care workers have tried to refine methods for decreasing bacterial contamination of wounds in an effort to avoid infection. Thus we have some practitioners who still soak wounds in betadine solutions lengthily even though more modern research has shown that this kills viable tissue and makes wounds less amenable to suturing. For the concerned individual who must deal with a wound outside the emergency room or clinic setting, for whatever reason, I have some reasonable advice on avoiding infection that is not widely taught, even in some health care settings. (The following applies to wounds that an experienced parent could evaluate and immediately know that a band-aid alone would not be appropriate.)
Bleeding is Nature's way of cleaning a wound, but a little goes a long way. Remember that as long as the wound is "down-stream" from the heart (pump), bleeding will be under pressure. So don't forget to elevate a bleeding extremity above the level of the heart to get control of bleeding. This may be accomplished in some novel ways in the field, and may require improvisation. To elevate a leg or foot, for example, you might need to place the patient on the ground and prop the leg on an ice chest or stump. Scalp wounds especially bleed profusely and may be frightening to the uninitiated: Use multiple layers of absorbable material---sterile gauze or a clean towel (or the cleanest cloth you have available)--- and hold direct pressure until bleeding ceases or is at least reduced to a slow ooze. A patient who is taking aspirin will have a prolonged bleeding time, so you will have to hold pressure for a longer period of time.
Plain soap and tap water have been shown to be just as good for washing the wound as an antiseptic soap and sterile water. It turns out that some of the antiseptic solutions available kill so much good tissue that they are not preferable to regular soap. I would recommend a liquid soap, to avoid the bacterial culture waiting to launch itself from the bar on the counter, but would avoid the "antibacterial soap" (with triclosan) widely available that has been shown to increase bacterial resistance. In a perfect world I would prefer Hibiclens, but would certainly use a "no-tears" baby shampoo (neutral solution) or even diluted Dawn. One could apply it to a clean washcloth wet from the tap and use it to gently scrub the wound.
The sterile water solutions that are available bottled are fine, as long as they have not been opened previously, since they are contaminated when opened, but non-sterile bottled water is not preferable to tap water. Studies have shown that tap water is sufficient for cleansing of most wounds. I would not use this for an open fracture, although you would certainly not be dealing with one in the field or at home if you had the option of doing otherwise. Of course, freshly boiled water would be more reliable than non-sterile bottled water or water that you have previously drawn up in a clean milk jug, but better to wash a soiled wound immediately if you have clean water available than to take the time to boil and then cool water, leaving a heavily contaminated wound to stay in its dirty state. One could always re-rinse the wound with sterilized water. The length of time that the cleanser is in contact with the wound and the degree of flushing that takes place will determine the number of bacterial contaminants remaining and thus have a significant effect on wound infection rates, so spend several minutes on this step. Of course the examiner/caregiver should scrupulously wash his own hands and any instruments used to probe the wound beforehand. Thoroughly cleaning the wound will usually result in resumption of bleeding: When finished, pressure can again be applied as before.
A foreign body remaining in the wound can be a focus of infection and prevent healing in a wound that has been well cleaned and closed, so it is imperative that care is taken to rid the wound of any and all particles that may be present. This is why a relatively clean knife wound can be simply washed prior to closure but a contaminated wound or one sustained through layers of clothing must be explored and scrubbed. It may take a long time, and I have done just that in the ER, picking out particles of wood dust or grit of various types. This is why I sometimes prevail on the surgeon to take a patient to the operating room to debride a wound under anesthesia. A large syringe or squirt bottle can be used to administer a stream of water into the wound under a little pressure in order to thoroughly clean and dislodge particulate matter. Chainsaw wounds may require debridement of the margins with a scalpel to remove seared tissue in addition to removal of particles and clothing fibers, as searing prevents the wound edges from closing together in healing.
In the hospital or clinic setting, I use a sterile scrub brush for contaminated wounds. If I were in a wilderness setting and had the option of boiling or sterilizing equipment such as a scrub brush or tweezers, I would certainly do so, but in any case removing all foreign material from the wound is necessary. (Cleaning instruments with alcohol and/or soap and water would be better that nothing.) Blood clotted in the wound must also be removed by scrubbing, as dried blood serves as a "foreign body" in this setting. After thorough cleansing with soap and water, if a wound is to be sutured, betadine (if available) could be swabbed on the skin in pinwheel fashion, from the skin at the wound edges out to two or three inches away from the wound.
Anesthesia is certainly desirable prior to any painful manipulation or procedure, and if it is possible should be mercifully administered prior to any vigorous cleaning. Even the most stoic among us can appreciate pain relief, even if it is only temporary. So a vial of Lidocaine (1% or 2% ) and a syringe to administer it may be part of your wilderness medical kit. If the Lidocaine (xylocaine) has epinephrine mixed in, it will help a lot to keep the wound from bleeding as you try to sew it, but you must not use epinephrine in a wound on an extremity such as a finger or toe, as it could result in necrosis (tissue death). On the face or scalp epinephrine is a welcome additive, since these wounds tend to bleed so freely that you can scarcely see what you are sewing without it.
Adjuncts in keeping the bleeding slowed while you are attempting wound closure are elevating the wound above the level of the heart (always recommended) and limited tourniquet banding with a wide strip. (In the ER I might use a blood pressure cuff pumped up to the point where it stops the bleeding). This should be very temporary in order to maintain a bloodless field for closure only. Carefully and slowly infiltrating the margins of a wound with a few milliliters of an anesthetic solution, a learned technique, will result in control of bleeding and pain (for closure). Then you must give the anesthetic a few minutes to be absorbed before commencing your repair. Whether you use anesthetic or not it would be wise to administer pain medicine of some kind, either orally or by injection, since the wound will throb even after the repair is done.
Wound closure is a key factor in healing and infection rate as well. Wounds left open will be infected to some extent. The six-hour rule for closure is followed for minor wounds; that is, if care is sought within those limits the wound can be cleaned and sutured with impunity. This follows from studies that showed infection rates increasing after that time-frame, and of course there is leeway for wounds that were clean a priori. But for large wounds or cosmetic disasters the rules are frequently bent. Field studies from Vietnam proved that delayed closure of wounds (up to several days old) could be performed with good results if the wound margins were "revised" (old tissue cut out with a scalpel) and the new margins sewn together. And surgeons will usually close facial wounds up to or even over twelve hours old even without revising the margins.
Closure may involve suturing (sewing), or may be as simple as using Dermabond (super glue), steri-strips or staples made for this purpose. In the ER I tailor the method to suit the patient and the situation, but you might not have that option in the wilderness or homebound setting. If you do, or if you can reach qualified medical help within a suitable time-frame, I wholeheartedly advise you to do so. But if that is not possible, even duct tape may be preferable to non-closure.
One must be careful to hold the wound margins together tightly to apply Dermabond, as any solution that makes its way into the wound may itself prevent healing, and with Dermabond the trick is to keep one's fingers from being glued to the wound as you wait the few seconds for it to dry. I do not advise Dermabond for a wound that has a tendency to continue bleeding the minute pressure is removed, nor in a wound that is deep or under stress. It works well on some facial lacerations, but really I trust steri-strips to do the job and they could easily be part of a medical kit. Dermabond is expensive but really comes into its own when trying to repair a wound in a very small child who could be expected to try to remove strips. Dermabond should be left on the skin to dissolve on its own, which will occur in several days, usually too soon for larger wounds or wounds of the lower extremities.
If applying steri-strips or tape, wound margins should be closely approximated prior to the application of any binding material. If I were reduced to using duct tape, I would tear several inches off the roll (use for another purpose), so that what I used on the wound would not have been in contact with a dirty surface. Then I would tear or cut three or four inches off and cut that into 1/8 to 1/4 inch strips, taking care to keep my hands from touching the part of the tape that will be over the wound. Pressing the wound edges together with one hand, or having a helper hold them together by pushing from each side, I would apply the strips of tape, starting on one side and pulling firmly to apply some tension before allowing it to adhere to the other side of the wound. I would space these strips 1/8 to 1/4 inch apart to allow the wound to breathe and then cover my work of art with sterile gauze secured by tape or an ace wrap (or cotton bandage) to keep it from being re-contaminated.
I would not worry about small defects or ragged edges unless I could easily trim this and have plenty of loose skin to work with. Individuals who are sensitive to adhesives may develop blisters where the steri-strip or tape is located, but this is usually just a local reaction and does not cause systemic allergic symptoms. In someone known to be unable to tolerate them sutures or staples should be used for larger wounds requiring closure.
Suturing is a technique that is learned, and should be practiced prior to use, which is not to say that any accomplished seamstress couldn't master it. Many wounds will be greatly benefited by needle and thread. However, to reinforce the importance of asepsis in wound care, I should again point out that a wound should not be sutured by an untrained individual in a non-sterile environment if there is an alternative. If there is not, then any asepsis that can be accomplished by boiling or autoclaving (pressure-cooking) would be of benefit, and extreme care should be taken not to further contaminate the wound while attempting to close it in the best possible way. There are manuals or courses that teach sewing technique available for the motivated person, and that is outside the scope of this short essay. What is obvious to medically trained personnel---microbial contamination and how to avoid it--- is the major impediment for the "lay-person". Sterile drapes and sterile gloves are a bonus. But most medical staff would agree that primary closure is better than a large wound left open in most cases. In our current political-legal climate one could be prosecuted for "practicing medicine without a license" if it appeared that extraordinary measures were undertaken by the layman who had other options, so be sure that you are doing it from necessity and not just for fun. :-) In a TEOTWAWKI setting, you will probably wish that you had at least studied the technique (and had obtained the proper equipment and had practiced on some animal skin).
Some wounds are by definition contaminated or infected and are better left unclosed. These include puncture wounds, stab wounds (=deeper than they are wide) that are not bleeding profusely, and animal or human bites. These should be cleaned and scrubbed as above, taking even more care to flush them out if possible, and bleeding controlled with pressure only if at all possible. If not, then one or two sutures or steri-strips can be strategically placed, in this case being careful to only draw the wound edges together enough to control the bleeding and not to closely approximate them, as you want the wound to be able to drain easily. These are the wounds for which an ER doctor would probably give antibiotic prophylaxis, with an older drug such as doxycycline or trimethoprim-sulfa or a cephalosporin like cephalexin (Keflex). Crush wounds of the extremities also should not be sutured, even if they look awful, but should be cleaned as much as possible given the level of contamination and then bandaged. Because they can be expected to swell so much, primary closure of crush wounds could be detrimental.
Keeping the bandaged extremity above the level of the heart will help to prevent pooling of blood and swelling and therefore reduce the proclivity for infection. This holds true as long as inflammation is present. Elevation is important in pain control as well, and the patient may need to be reminded of this when the wound starts to throb. Propping an arm or leg on a pillow will be a very useful adjunct to any analgesia you have available, as is an ice pack applied over or adjacent to the bandage. Ice will definitely help to slow swelling in the first 24 hours and can be used to alleviate pain even longer than that if it seems to help that particular patient.
In a Katrina-type setting, where it could be days before a medical professional would be consulted, it might be good to know that sutures of the face (and scalp) should be removed in four to five days, lest the sutures themselves cause scarring. An uninfected facial wound should be healed in that time. Steri-strips can be left off at that time if they are employed on the face. For wounds of the upper extremities leaving sutures in for 7-10 days is advisable, depending on the extent of the wound, and for the lower extremities up to 2 weeks. If steri-strips have been used (or tape) the strips may need to be re-applied during that time period. Keeping the wound clean and dry is the goal, but if sutures are used to close the wound it can be washed daily with soap and water after the first 24 hours. If a wound becomes obviously infected, with purulent (yellow or green) discharge and swelling and redness, it will have to be opened up at least partially and allowed to drain to prevent septicemia.
Tetanus prophylaxis should also be addressed. Puncture wounds and deep, heavily contaminated wounds are considered "tetanus-prone" wounds, and I can testify that tetanus does exist and it is not pretty. It could easily be deadly in this setting, although I have seen a young victim recover after six weeks on the ventilator. The vaccine for tetanus has been used for several decades and is considered very safe if one is not allergic to any components, so I would advise you to keep your vaccination status for tetanus up-to-date. It is considered up-to-date if it has been given within the last ten years, unless the wound is very large and very heavily contaminated (think a tractor accident in a muddy barnyard), in which case I would be more conservative and say within five years. If tetanus toxoid is not available and the patient has had the primary series in the past but is not up-to-date, a booster should be given as soon as it becomes possible.
I will close with the most valuable advice: The best way to avoid wound infection is to avoid the wound in the first place. Be careful. Make your children wear their shoes outside of the house. Lacerations from stepping on broken glass and puncture wounds from thorns or tacks in the feet are fairly common in the ER and are usually preventable. Acting "macho" or being a daredevil is one thing when emergency care is a short distance away, but stupid when there is none available. A dull knife will slip and cut you when you put more force on it instead of taking the time to sharpen it. Accidents will happen to even the most cautious, but they will be proportionately less than to the heedless or reckless.
With the hope that this will not be needed in the future, but that if it is it will prove to be useful. - E.C.W., M.D.


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