First line treatment of all wounds should entail the basic first steps which are Assess, Clean, and bandage or stabilize.
Types of wounds to the skin that can be targeted by the non-medical outdoorsman will be either abrasions or lacerations. Lacerations resulting from direct trauma such as a rock falling on a finger, getting hit with blunt force and/or a de-gloving incident where part of an extremity is crushed and you withdraw quickly and your skin is then peeled away. All of these injuries should be assessed, treated and bandaged before transport.
Assess the injury and find out what the mechanism of injury was. If you walked up on a hiker, hunter or another outdoorsman, it is beneficial to know how the injury occurred. Why is this important? Being cut by a pocket knife and being cut by a pocket knife while cleaning fish is a much different scenario. Getting cut while digging in the soil exposes you to different pathogens for infection as opposed to incurring a wound while cutting rope to hang your tarp. This bit of information should be helpful for the healthcare provider you go to when you have the wound professionally closed. Updating one’s tetanus is also of extreme importance. A Tetanus shot lasts for about ten years and covers you for Clostridium tetani. You also want to assess wound severity. Is this a wound that can wait six hours or longer and will not need sutures, or should you hightail it to an urgent care clinic or emergency room to have it closed? A few ways to differentiate this, is by the depth of the wound, location of the wound, and is there any nerve, tendon, or joint damage with the laceration. If you speculate that any of the above could be possible, transport the injured to a clinic or emergency room.
The old medical statement; “The solution to pollution is dilution” holds true. Do: Use water, but be wise not to use all of your drinking water if you are miles from transportation. You do not want to deplete your hydration source. Even stream water is better than no water. You can put water in a plastic bag and cut a tiny hole in the corner to create an irrigation system with a forceful stream. In a pinch, you can also use a plastic glove as an irrigator. Do Not: Use alcohol or peroxide to clean the wound. Both will impede healing. In fact, when we discharge trauma cases we have to be cognizant of telling patients this as old drivers are hard to break. Daily use of peroxide on a wound will actually delay healing. Do Not: Shave the area. Studies show shaving will increase infection since hair holds bacteria. You are literally shaving bacteria into the wound. If the hair is an issue on arms or scalp, carefully use scissors to trim it. SALT to clean a wound? NO. We often do irrigate with normal saline however, that is diluted. If you want to piss off an injured person, rub a little salt in their wound. Not Helpful. Myth: salt water from the ocean will help cleanse a wound – Nope! An organism called Vibrio vulnificus is a common pathogen in brackish water and in sea water that will cause a nasty infection.
For the purpose of basic wound care, we are not talking about suturing. Suturing can be time-consuming and in the vast majority of cases, you will be transporting to a clinic or emergency room. PLEASE SEE YOU TUBE VIDEO, Seeing/visualizing has higher learning retention versus only reading the technique. Steri-strips and duct tape are excellent types of closures; however, use CAUTION with any super glue compounds for closing wounds. My life in urgent care is made much more difficult when super glue is used on a wound. The glue frequently gets in the wound and more often then not I will have to re-excise the wound margins to get fresh epidermis and dermis to close the wound. With perfect vertical lacerations as in a knife wound, decent wound margin approximation can be achieved by holding tension at each end of the wound while you close. SEE VIDEO. CAUTION. Blood coagulants are plentiful on the market. If you are able and will be driving to an urgent care facility or Emergency Room, please try to avoid these. They become a huge burden to the provider and the wound must be cleaned and at times so much is used I have re-excised the wound to obtain clean margins. Of course if there is excessive bleeding and transport is long or difficult, then yes, there is a place for these. Good judgement and experience are key.
Topical antibiotics to use or not to use. There are four main topical antibiotics for wounds. Neosporin, Triple antibiotic ointment, and Bacitracin – all of these can be purchased over the counter. Then there is Bactroban ( Muciprocin) and Sivadene both of these require a prescription in the United States. Another topical that is rarely used but has excellent anti-microbial effects is honey. Honey draws fluid out of the wound making it less moist and as many are aware, a moist environment is perfect for fungus and other bacteria to grow. Honey also helps hemoglobin release more oxygen making the wound more acidic and less habitual for bacteria. I always try to carry a few honey packets in my pack.
In one study by the University of Chicago, they had 426 patients with wounds using triple antibiotic ointment ( Neosporin), Bacitracin, Silvadene and the control group used petroleum. Wound infection rates were as follows 17.6% Petroleum group, 5.5% Bacitracin group, 4.5% for Neosporin group and 12.1% Silvadene group. Most of these infections were post-wound closure with sutures.
Be advised, the rate of allergic dermatitis using Neosporin is close to 15 %. I NEVER use Neosporin or Triple Antibiotic Ointment as not to risk that secondary allergic reaction potential. It should be noted that Bactroban ( Muciprocin) when used daily for seven days on wounds was as effective as oral Keflex 500 mg twice daily. Of course for all my wilderness wanderers out there, you would need a script for that. Many healthcare providers should easily write you a script for a 15 gm tube before you go on any expedition in the wilderness.
Bandages. I am a big fan of non-stick bandages, Telfa, and Adaptic . Who wants a bandage sticking to a wound and making the provider or nurse to be “the bad guy” who has to pull it off? There is no reason for this other than you do not have access in your medical kit for a non-stick bandage. Burns are when non-stick bandages should be used. Then one can use Ace Wrap, tape, Medi-Rip also called Coban as a wrap over the primary bandage. These also can add some pressure to the wound to control bleeding.
Splints are also very useful when hiking out of the woods. Splints should be used on any joint with a laceration for many reasons. One, any movement will reopen the laceration and splinting also allows less pain due to less movement.
After bandaging, a process of healing is just as important. Too many times, I see providers closing wounds, nursing bandaging the wound with non-existent to minimal post care instructions. If you are days from returning to civilization, follow these instructions: 1.) Keep covered for 24 hours. 2.) After 24 hours, wash with soap and water if available. If soap and water are not available, do cover during the day when hiking and leave open to air at night. Healing all lacerations becomes a balance of not getting it too wet and allowing it to become too dry. If covered too long, and the skin becomes white (maceration), it is too wet. If left open to air too long, the skin becomes too dry. Hence, the balance. When getting a wound repaired at an urgent care or ED, make sure the provider explains how you are to take care of it. All too often, it becomes a repair and a good bye. It is your body, your injury and you’re paying for it. Ask for their opinion on post-repair treatment.
Benadryl ( Diphenhydramine) in its liquid form, can be used on the wound as an anesthetic. In fact, when some patients are allergic to lidocaine, Benadryl can be injected into the wound with a very good response. So imagine you are with your seven year old. The child falls and cuts their chin on a rock while walking on a trail. Apply some Benadryl on a 4”X4” gauze with a dab of Bacitracin, cover with a bandaid and by the time you get to the clinic your child will have some numbness to the wound. It will be less traumatic when he or she has to have sutures. A win-win scenario and the child walks out with a good experience. I always carry some liquid Benadryl in my pack.
Afrin (an over the counter nasal spray) will help slow bleeding. Afrin has Neo-synephrien which is a vasoconstrictor. Spray some Afrin onto gauze, apply it to the wound then bandage. Voila, bleeding is stopped or slowed.
A few possible complications that you should be aware of – but clearly not all of them. When something can go wrong it usually does.
Be aware if the person who has a laceration is on any blood thinners, anticoagulants which could be Warfarin, Xarelto, Coumadin or Aspirin. Stopping their bleeding can be a tad more difficult. One 85 mg Aspirin can clearly cause more bleeding than one anticipates. Apply direct pressure for a minimum of fifteen minutes. This should stop most bleeding.
Arterial vs venous blood. Cutting an artery will commonly pump blood, but this is not the case all of the time. There is rarely a one hundred percent scenario in medicine. Also, it should be known that if an arterial branch is cut it always is mixed with some venous and it may not be this bright red color that you read about. If the bleeding is excessive, apply direct pressure. A tourniquet should only be applied as a last resort and not be left on more than an hour with some relief in-between. I personally try to give the patient some relief briefly after every thirty minutes, of course depending on the severity of the injury.
Lacerations over joints and near joints should be splinted and one should assume there is tendon damage. This is always a good assumption to make as it will will allow you to proceed in being cautious rather than causing more damage by just rapidly bandaging and transport.