What you shoud know about wounds.

[Patrick Craddock]

I originally posted this as a reply at the end of another thread. But I figure it might be helpful for some people.

As a background, I'm an ER doctor, so wounds are what I deal with.

Here's some advice on wounds:
1. Make sure your tetanus is up to date before you go out. Tetanus is a spore former and most likely to be contracted with dirty wounds. specifically, rust and dirt. Yes, regular old hiking trail dirt has lots o' tetanus. And odds are you may have some dirt in your wounds. The recs, if you've had a fully vaccination series in the past (and if you're from the US you have), are for a tetanus within 5 years for wounds at high risk (dirty wounds, deep wounds, improperly irrigated wounds), and 10 years for other wounds. So, 5 years. Of note, ANY wound can carry tetanus.
2. Studies have looked at all of the aforementioned issues and the only thing that has really been shown to help wounds is irrigation, irrigation, irrigation. I don't really know much about the bloodletting approach, but hey, knock yourself out. Wound infection rates are inversely proportional to the volume of irrigation AND THE PRESSURE WITH WHICH IT IS APPLIED. That's key, thus the shouting. a little 3 cc syringe is pretty crappy. You can get pretty decent pressure with 10 cc. In the ED I use a 20 or 50 cc syringe for dirty wounds. Don't drip water into the wound, spray it in. If you are near a sink a faucet opened all the way does a pretty good job. Making a pressure bag with a big ziplock, or spraying through pressure using a hose from your water filtration device can be useful too.
3. You gotta get out foreign bodies. Leaving a rock or gravel or glass etc. in a wound will highly increase your risk of infection. If you need to use tweezers or more irrigation or your finger, then sterilize the best you can and JUST DO IT! swoosh. If you think there is stuff in it, don't close it.
4. If the wound is deep, then get out the gunk, wash it, then wash it again, wrap it, and be hesitant to close it. We will leave dirty dirty wounds open a few days and then perform a appropriately named delayed closure 3 or 4 days later if it doesn't look infected at that time.
5. Don't use alcohol, or hydrogen peroxide, or iodine or whatever on your wounds. It can be helpful to use a little hydrogen peroxide on a really dirty wound if you can't immediately wash it. It also MIGHT be helpful to mix in a small amount of iodine with your irrigation water. This should be a 10:1 dilution. Be sure to rinse the iodine water out prior to closure. i say might because studies are inconclusive. Since the water may be out of a bag you've been sucking on for 10 miles, I imagine the iodine technique might be a good idea. Don't use hydrogen peroxide, alcohol, iodine etc after you've washed. These things work by creating an environment that kills bacteria. That being said, they also kill healing tissue.
6. Irrigation is key. What you close something with, be it steri strips, stitches, duct tape, superglue, etc., is less important. Studies are limited. There is a study that show that washing a wound under the faucet for a few minutes and then duct taping does just as well as stitches and sterile technique for finger wounds under an inch. I would hesitate to close any deep wound (like a 2 inch deep thigh wound) where there might be a potential space left underneath. In other words, where the top is closed and there is a big unsutured deep cut that isn't pulled together. That is a big space that bacteria love. Warm, deep, with pools of protein. You should also not close deep punctures (stab wounds and gunshot wounds in the er are not sewn up). Of note, did you know that superglue was originally made by the military as a wound closure for field use in Vietnam? It works pretty well for small wounds. There's a little easier to use product named Dermabond although I don't know the availability for nonmedical people.
7; After you've closed something, wash with simple soap and water. I would cover with a antistaph/antistrep antibiotic. Bactroban/bacitracin is a good choice.
8. If you are close to society and get cut, typically wounds can be closed on the body for up to 12 hours. They can be closed on the face for up to 24 hours. If you show up later, they will be washed and then possibly sewn up in 2 or 3 days if there are no signs of infection.
9. Prophylactic oral antibiotics are not a good idea unless a wound is contaminated. Antibiotic ointment won't hurt.
10. If you close a wound and it gets infected, open it up. Let the pus get out, and irrigate it. Staph makes little pockets of pus in a wound that need broken up. If you get it you'll know. Got thick yellow snot coming out of your cut? That's staph. Pop those vicodins you carry, open the wound, wash like hell, and try to break up the walls very gently with your washed and alcohol cleaned finger if you don't have gloves. Don't ignore your big pus filled wound. See a doc fast. And start up some antibiotics! Pus is usually staph. You should have strep coverage too.
11. Wounds you obtain in water are another beast. As are punctures through your shoe. As are bites. Those are high risk and need antibiotics, but you have to know which ones as they are special situations.As are a lot of other situations.

Anyway, I hope that helps!

[Kenneth Reppart]

Wow, thanks Patrick for all the detailed information! It sounds like rather than carry iodine for sterilization a syringe for irrigation would be better. Actually most of this crowd carries platypus bottles and I bet one of those bite valves would make a pretty good stream of water for irrigation.

What would you do in a scenario where you need to irrigate a wound but the only water you have is from the water bottle you've been drinking from? Use the water for irrigation immediately or stop to treat it and wait a couple of minutes for iodine or chlorine dioxide to start doing it's thing? In general how long can you wait to irrigate?

[Dave T]

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[Dave Wilson]

Patrick, after reading your post ive decided the only way to truly help myself if i get a bad cut is to be fully prepared. So ive decided to take you with me but am a little concerned how much of my packpack you will consume :D

thanks for informative post.

[Ethan A.]

Thanks Patrick for the helpful post and ditto Ken's question. That was a great refresher (though no substitute for more knowledge and training). It's been a while since I reviewed first aid.

I worked as an ER volunteer one summer in high school and saw wounds to rival what I later saw in an elite airborne unit after college. Crazy stuff.

[Patrick Craddock]

I imagine that most of the wounds in the airborne unit weren't precipitated by a six pack of Pabst and a statement of "watch this!".

I think I'd wait to irrigate unless the wound was really contaminated with foreign bodies like dirt, etc. In that scenario I would rinse with what I had and rinse again once I could sterilize some water. You can wait a few hours, but the sooner the better. The other exception to this is eye burns. If you splash something acidic or basic in the eye, I would wash immediately with whatever you got, whether it's river water or fruit punch.

[Mark Hurd]

The ziplock pressure bag is just a ziplock filled with water, sealed, fold over the top a couple of times and snip the corner off the bag. (Tiny snip so the opening is a few mm across.) Squeeze the bag and direct the stream of water into the wound. Works pretty well.

-Mark

[John Mowery]

This was very helpful, much appreciated. Great information we can all use.

My primary care physician was able to provide me with some Dermabond – it's not available OTC. It's a great product that I carry in my kit.

I also carry 1mg of a coagulate called Arista (given to me by a physician) for hard-to-stop bleeding. I don't hear many backpackers talk talk about it, but it seems like a no brainer to me. If indirect pressure and elevation don't work and I'm 50 miles from nowhere I'd like to have a back-up beyond a tourniquet.

Does anyone else have ideas on improvised wound irrigators?

[Roger Caffin]

> If indirect pressure and elevation don't work and I'm 50 miles from nowhere I'd like to have a back-up beyond a tourniquet.
Strap with surgical micropore tape. Avaiable OTC. Every first aid kit should have a roll of the 1" size.
And it is a bit more flexible than duct tape!

[Patrick Craddock]

Granted that if you get to this point of interest a wilderness medicine course is a good idea. You can easily make a tourniquet out of your tubing from your water. That being said, I would suggest direct pressure for most any wound where there is a lot of bleeding. A classic example is scalp wounds, which can bleed to the point of exsanguination. I love to teach medical students the value of direct pressure in this scenario. Typically the patient comes in with something that looks like a giant turbin of gauze taped to their head. All that does is hide the wound. I'll have the student take off the 12 pounds of gauze and tape, remove the clot if it's not working, find the wound (which is usually a small arteriole or "little artery"), and put a single finger of pressure on it. If you are persistent and don't keep peeking at it, keeping pressure on for 10 minutes or so at a time, then usually you can get the bleeding to stop. A pressure bandage is helpful too, which is a small amount of gauze and a tightly wrapped piece of tape. It may soak through initially, but it'll usually do the job.

[Mark Hurd]

I would highly recommend Eric Weiss's book:

A Comprehensive Guide to Wilderness & Travel Medicine

Honest to goodness useful information from an ER doc who, like Patrick, has actually been out there. It is written somewhat toward the medical professional, but without the jargon and it is very accessible to the thoughtful layperson. Costs around $15.

-Mark

[Mike W]

…

[Victor Karpenko]

I also agree that Eric's book is excellent. I would also recommend that anyone that goes into the wilderness, as defined by the Wilderness Medical Society, is a remote location more than one hour from definitive medical care, take a wilderness first aid course. A great instructor, in California, is Bobbie Foster. She teaches a course for us every year. The students rave about her curriculum, scenarios, and teaching style. Her web site is:

http://www.fostercalm.com

[joseph daluz]

What Vicodins? I'd like to know how one does approach his/her Doctor about a prescription for a pain medication that he/she MAY need, but doesn't currently have an need for, without sounding like a drug seeker?

[Michael Crosby]

Eventually we all do something stupid enough to warrent pain medication(on purpose or not). Just grin and beer:) it for a day in order to have some left over.

[Ryan Gardner]

I spent last Sunday in the ER and decided to make it worth it – so I asked them for a 20 cc syringe for my kit. Not thinking, I opened it and had fun squirting the water to test it out. Now that I think about it, I probably should have left it in the bag so it was sterile. I figure it probably makes no difference just sticking it as is in my ditty bag right? I mean, if I didn't have a syringe I'd be using a plastic bag with a hole in it anyways. Thoughts?

[joseph daluz]

I'm an OR RN. ("OH ARE YOU") You're right, an "unsterile" syringe is better than no syringe. But if it's not grossly contaminated, I wouldn't worry about it. I'd worry more about the sterility of the irrigant.

[John G]

Posted by Patrick:
"5. Don't use alcohol, or hydrogen peroxide, or iodine or whatever on your wounds. It can be helpful to use a little hydrogen peroxide on a really dirty wound if you can't immediately wash it. … Don't use hydrogen peroxide, alcohol, iodine etc after you've washed. These things work by creating an environment that kills bacteria. That being said, they also kill healing tissue."

Here's my experience: I had a 1" circle on my palm where I lost all the skin. Bandages wouldn't stay on unless the whole hand was wrapped, and it oosed clear liquid constantly (no skin). Not heeding Patrick's advise about antiseptics, I kept putting hydrogen peroxide on it about twice a day (since bandages wouldn't stay on it was constantly getting dirty).

After about 10 days, it was barely skinned over with a hard, yellowish crusty type of scab. The hard crusty stuff kept cracking open every time I flexed my hand… So I trimmed off the crusty cracked mess to allow it to heal up better. The wound was about the same size & depth as the original. This time I didn't use any peroxide. It was skinned over in about 3 days without antiseptics.

So now I'm convinced – peroxide, alchohol & iodine are BAD to use on wounds. But since all the (many) first aid courses I've had say to disinfect a wound before closing &/or bandaging it with one of those 3 antiseptics, I'm still wondering if antiseptics "should" be used on other types of wounds, cuts or abrasions ? ie: Only small cuts, only deep cuts, only dirty cuts ???

Patrick: Can you clarify and elaborate on the role of antiseptics in wound care ?

Thanks.

[John S.]

Irrigate, slap on antibiotic ointment, cover with clean/sterile dressing, and hike on if possible.

[Christopher Kuzmich]

Explain your situation and tell the doctor that you will account for any used when the scrip expires and you need more.

My doctor has been really cooperative- then again I was a WEMT and he's a moutaineer himself.

[backpackerchick]

Standard procedure.

Some nice explanations for the layperson! Like the Valentine's Day one — hadn't heard that! Will put that in my immunology arsenal. Thanks for the great posts.

[backpackerchick]

Your post has generated some interest elsewhere:

http://www.backpackinglight.com/cgi-bin/backpackinglight/forums/thread_display.html?forum_thread_id=11475

[Greg Mihalik]

BC-
ummm…you are referencing page 1 of This very (old) thread…

[Josh J]

Bumping a very good old thread!

[Rex Sanders]

You might find this 2021 BPL article interesting:

Backpacking First-Aid Philosophies
https://backpackinglight.com/backpacking-first-aid-philosophies/

Along with many of the follow-up posts, including an exploration of practical wound irrigation for backpackers, starting here:
https://backpackinglight.com/forums/topic/backpacking-first-aid-philosophies/page/2/#post-3724841

— Rex

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