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.