Medical Monday 25 Nov 2019

The internet here has not been cooperating at all the last few days so I am writing this on Monday. The extra post from last week is still coming. But enough excuses, on to the post.

This week we are going to talk about lacerations. Lacerations are tears in the skin, underlying tissues, muscles or organs caused by blunt force trauma. These are different from cuts or incisions.

Lacerations can vary in size and depth. You need to keep in mind basic anatomy as well, what underlying structures could have also been damaged? If it’s on their abdomen, are their intestines damaged? What about their kidneys, or their spleen? If it’s on their chest did they break some ribs, rupture their lungs? Depending on what is underneath, the damage can lead to much bigger issues than just an opening in their skin.

Our skin is our largest organ. It serves many purposes, one of those being our first line of defense against the environment. Once you break the skin it lets in all sorts of nasties that we wont to keep out. Infections are no joke either, before modern antibiotics and wound care techniques, it was the leading cause of death on the battlefield.

The first step after stopping any life-threatening bleeding is going to be cleaning the wound. Cleaning not only removes contaminants that can cause infection but it allows you to fully inspect the wound to check severity and size. Cleaning does not need to be performed with massive amounts of hydrogen peroxide or isopropyl alcohol. The military has found that the use of those and similar fluids have no noticeable effect on infection rates. At a minimum, you can get by with just potable water. The more fluid the better. Pressure higher than 15 psi not only damages tissue but it has little to no effect on decreasing infection rates. It simply pushes contaminants and bacteria deeper into the wound. One recommended way is to puncture a hole in a water bottle and use that in combination with mild scrubbing. The recommended solution is Dakin’s solution. Dakin’s solution is a cleaning fluid made of water, household bleach, and baking soda. It was first used in the First World War before the creation of modern antibiotics. The dilution recommended is known as a modified Dakins. Take 1 liter of potable water, add 5 ml of unscented household bleach, and 1/2 teaspoon of baking soda. Shake to mix it all up and it should keep for about a week in this form, but bleach and baking soda separately will keep for much longer. Then to use this for irrigation dilute that 1:10 with more potable water for irrigation. Use 1-3 L for small or clean lacerations, 4-8 L for intermediate or dirty wounds, and >9 L for large or very dirty wounds. Make sure you remove all sources of infection and any puss that is visible. Squeeze it to make sure you have all the puss and infection out. Topical creams like bacitracin or Neosporin work great for care after you have cleaned the wound. Just make sure to not put it inside of the wound.

After you’ve fully cleaned and inspected the wound you want to decide if you need to close it or not and how to dress it. This all depends on several factors. Location, size, and depth of wound all play a factor in whether or not to close it and how to dress it. You don’t want to close a wound when it is infected or is about to become infected. If you close an infected laceration it will form an abscess and may lead to an infection in the blood called sepsis, which untreated is deadly. Infected wounds will be red, the area may be hot, swollen, and it may be draining purulent discharge (fancy word for pus). Normal drainage will be light yellow or clear. If you start seeing large amounts of white puss you need to re-clean the wound and make sure you got all of the infection out. Also if the area you are at is normally dirty you want to leave the wound open as well. These types of wounds we want to heal through granulation, or from the inside out. You also don’t want to try to close a wound that is over a joint, the constant movement will just cause it to rip stitches out and the healing may prevent full range of motion further down the line.

Wounds you can close will be small, cleaner wounds, anything that isn’t over a joint, and wounds that don’t create pressure when you try to close it. Butterfly bandages work great if you don’t know how to suture. Superglue works great as well. Both have been used in third world countries for decades with lots of success. I even keep superglue in my larger aid bag and at home for situations just like this. If you do know how to suture you can do so here as well.

After you’ve made the decision to close or not close you are going to want to keep it covered to prevent infection. If it’s larger or more wide you will want to place a non-adherent pad down first to allow the healing process to be restarted every time you do a dressing change. You can always cut larger pads down to size to help make your supplies stretch. Medical tape will also be your friend here. There are a few things that I am brand particular on, and tape is one of them. I prefer 3M durapore medical tape in 1, 2, and 3-inch widths. I don’t like duct tape because if left on for too long it can cause tissue damage. Don’t overuse the tape, a little can go a long way. Always cover non-adherent pads with regular gauze.

Now on to dressing changes, they do not need to be performed daily. You can look at the wound daily, but you don’t need to change it daily. Current recommendations from the US Military’s CPG’s on prolonged field care are 2-5 days between dressing changes, depending on how the wound is healing. When you do the dressing change you are looking at the wound to see how it is healing and to check for signs of infection. Every wound doesn’t require antibiotics. It depends on the environment and the wound. This is where clinical judgment comes into play. This is also why it is really important to have a true medical provider in your group. Even just having a Physitians Assistant is your group is a HUGE advantage medically. They provide a much higher depth of knowledge than just a medic or a nurse can provide. Even if they aren’t directly where you are, having the ability to telemedicine with them can make a difference in the level of care that you can provide.

If you have any questions feel free to comment below and I will try to clarify the best I can. And remember, all the information in the world means nothing without quality training behind it. So go get training. NC Scout offers some great training, and I do teach medical classes (which I plan to start back up when I get back stateside). If you like what I am doing here share it with everyone you know! Don’t be left bleeding out like a stuck pig!

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