Wound Irrigation in Austere Environments

Friday, Nov 13, 2009

TEOTWAWKI will result in a lot of wounds, including not just lacerations but scrapes and burns as well.  These will happen regardless of if the injury is the result of a disaster or if post-crash efforts lead to injury.  This is bad enough, but you could be in even more trouble if infection sets into one of these wounds. 

A lot of preparedness/survival-types focus on suturing, including having access to suture material and instruments to allow for laceration repair. While this is all well and good, you shouldn't focus too much on actual wound repair without first being sure that you can provide wound closure with minimal risk for infection. Additionally, abrasions and burns are also at risk for infection and will benefit from good cleaning.

For any wound, infection prevention after injury consists of “irrigation” because as the poison control folks say: when it comes to pollution, dilution is the solution!  Irrigation not only aids in prevention of infection, but also increases the chances of a wound healing without too much pain, functional impact or cosmetic disfigurement.

What should you use to irrigate wounds? In most health-care settings, sterile solutions such as saline are used. Under the best of circumstances, these are expensive. After the Schumer hits the fan, they will probably be in very short supply. If you have access to stored saline, you are in good shape, but what happens if it has run out or you don’t have any?  Lucky for us, there are alternatives.
One “solution” is to make saline with water treated with bleach.  Clean contact lens solution, bottled water or tap water can be treated with household bleach, resulting in a solution that is sterile and non-toxic. The residual bleach may actually have bacteria killing effects as well.  Simply add a tablespoon of table salt to each gallon of clean water to make a suitable solution for wound irrigation. 

There are even options if the grid is down and we can’t rely on delivery of clean water, either from a tap or in a bottle.  Military doctors in one study took surface water from lakes, ponds and creeks. The water was “non-turbid”, so you may need to let it settle and/or filter it.  Next, they treated it with 1 teaspoon (or 5 mL) of common household bleach in each liter of water. This killed 99% of the bacteria in the samples, and even the 1% left was thought to be contamination from the air picked up during testing. Their technique gives us a field-expedient method for obtaining water suitable for irrigation of wounds.
You can also purchase distilled water in advance, store it at room temperature, and make your own irrigation fluid later simply by adding salt (a tablespoon, again) to each gallon.  When stored in a refrigerator at or below 48°, home-made solutions like this were sterile at least 3 weeks after they were made. Theoretically, using sterile (bleach-treated) water derived from the sources above could even be used in place of distilled water as well.  Thus you can replace expensive or unavailable sterile saline without buying it from your pharmacy. Researchers used this fluid safely as peritoneal (abdominal) dialysis fluid as well. 

You don’t need to worry about adding antibiotic to the irrigation solution either.  A physician from the University of Missouri showed that patients with compound fractures of their legs did better if they were treated with irrigation solutions made from non-sterile tap water and Castile Soap rather than water containing bacitracin, a common antibiotic.  Researchers from SUNY-Buffalo also showed that straight tap water was just as effective as sterile saline irrigation in preventing infections in lacerations closed in their emergency room. [JWR Adds: Castile soap is multi-purpose, and a has a long shelf life. Stock up. watch for it a discount stores, or find discount Internet vendors. Dr. Bronner's Peppermint Castile soap is a standby, here ate the ranch.]

Once you have your solution prepared, you need to use it to wash the wound. In general, burns and abrasions should be washed until they're free of visible dirt. Lacerations, on the other hand, may need a little bit more work: It’s best to irrigate them through a syringe and intravenous catheter or needle such that you get good pressure, in order to the blast germs out of the wound. The textbook standard is 50 mL per centimeter of length; this converts to about 4 ounces for each inch long the wound is (not how deep it is.)  Obviously, if the wound was grossly contaminated, you need to make sure to rinse it under pressure (ideally with pulsatile flow like from a WaterPik) until the wound is clean, with no foreign bodies left behind. Only then should you think about suturing a wound closed. [JWR Adds: Wound drainage is subject unto itself. My general advice, based on that reiterated by several experienced trauma doctors that have contributed to SurvivalBlog is to delay wound closure for an extended period, and even then a drainage tube should be left in place, even longer.]

If you don’t have a suitable syringe and catheter set-up for irrigation, one austere alternative is the ubiquitous 2 liter soda bottle; just be sure to clean it well beforehand, and don’t use one that held anything besides drinks!  Next, drill two small (1/16th inch, for example) about 1/8th inch apart in the lid.  Put your solution in the bottle and then cap it tightly with your modified.  Now, simply squeeze the bottle while sweeping the stream across the wound.  Keep in mind that if you don’t know the person is free of disease that you must use personal protective equipment to protect you from body fluids.
Finally, in a severe pinch, remember that we all have our own supply of sterile saline with us:  yes, I am talking about urine.  Dr. Gene Lam, then a Battalion Surgeon in the US Army, was held captive by North Korea.  He describes many ingenious and heroic medical improvisations, including use of urine to rinse off burns and other wounds.  Just be sure that the person “donating” the urine has no pain or burning on urination, cloudy or bloody urine, or other signs of bladder/kidney/urinary infection.  Place it in your irrigation container and use it immediately as well. 

All of the aforementioned techniques are only for a truly Schumeresque situation!  If you have access to the usual care systems, that is the way to go.  Otherwise, if you must provide your own wound care, the cornerstone of good care is meticulous wound preparation with copious irrigation. When you’re in the Schumer, making your own irrigation fluid will work in place of commercially made irrigation solutions and gives a lot of advantages in the fight against infected wounds.

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