CHAPTER 14
D aily survival activities like cooking and cutting wood can result in various soft tissue injuries (those that do not involve bony structures). Any injury to the skin—from a minor cut to a serious burn—punches a hole in your body's defenses.
Because each wound is unique, each one needs to be assessed separately. If the patient is not there when the wound is sustained, the medic should start by asking, "What happened?" By looking around the accident scene, you can get a sense of the kind of debris you could discover in the wound and the likelihood of infection. Always begin by assuming that a wound is filthy. You should also inquire about the victim's medical history, including any chronic conditions like diabetes and medication allergies.
The following things must be evaluated during the physical evaluation of a wound:
• Where it is on the body
• The size of the injury
• The extent of the injury
• Involved tissues types (skin, muscle, bone)
• Nerve and circulation involvement
Ask the patient to demonstrate the whole range of motion for the injured extremity during your examination, if possible. This is particularly crucial if the injury affects a joint.
The evaluation and treatment of various injuries are covered in this section.
W hen a soft tissue injury doesn't reach the dermis, the deepest layer of the skin, it is regarded as mild. This would incorporate scrapes, bruises, and cuts:
Scrapes and cuts. These skin rips seldom become infected in a healthy person since they only reach the epidermis (superficial skin layer).
Abrasions. Here, a small section of the epidermis has been removed. You undoubtedly went through a lot of these as a kid.
Contusions or Bruises. These result from blunt trauma and barely pierce the skin. However, blood vessels damaged by the impact are seeping into the skin.
All of these minor wounds are easily treatable:
• Thoroughly clean the wound.
• An antibiotic ointment like Neosporin, BactrobanTM (mupirocin), honey, or an antiseptic like Betadine might help prevent infection.
• Use over-the-counter medications like acetaminophen and ibuprofen to treat minor discomfort.
An object typically used for shaving wounds, a moist styptic pencil can stop minor bleeding. If the skin is broken, a protective adhesive bandage should be applied to the wound to stop infection. A liquid bandage, like New-SkinTM, is a great approach to treating a minor wound.
Anywhere a bruise appears to be spreading, apply pressure and ice (if available) to stop it from getting worse. As bruises heal, their hue will vary from blackish blue to brown to yellow.
An alternative procedure to address these problems is as follows:
• Lavender oil
• Tea tree
• Rosemary
• Eucalyptus
• Peppermint
• Additional natural antiseptics include St. John's wort, raw, unprocessed honey, Echinacea, garlic, and raw honey.
4. Apply fresh gauze to the wound. Avoid wrapping too tightly.
5. Up until the wound has healed, switch the dressing, apply more antiseptic, and check for infections twice daily.
T raumatic wounds may be common in a major tragedy. As a result, the family or group's medic needs to be ready for the worst conceivable injuries. Cuts in the skin might be little or severe, deep or shallow, clean or diseased. Most large cuts, also known as lacerations, penetrate the dermis and epidermis and are accompanied by moderate to heavy bleeding. Venous bleeding can occur, which appears as steady, dark red blood pouring from the site. Blood can also bleed arterially, which appears bright red due to the higher oxygen content and in spurts that match the patient's pulse. A major cut can have both since the vein and artery flow simultaneously.
Large blood arteries, tendons, and nerves may become implicated below the skin's surface. Examine the area's capacity to move, circulation, and feeling. Deep lacerations and crush injuries are more likely to cause vessel and nerve damage.
Consider the capillary refill time when an extremity is injured to check for circulation elsewhere. To do this, press a fingertip, toe, or nail bed. If you are a person with normal circulation, this area will turn white when you release pressure and return to its normal color in two seconds. If it takes longer or the fingertips turn blue, a blood vessel may have been injured. There may be nerve injury if the feeling is diminished (test by lightly pricking with a safety pin beyond the level of the cut).
Considering Blood Loss
A crucial component of treating wounds is assessing blood loss. An adult individual of average stature has roughly 10 quarts of blood. The impact that blood loss has on the body depends on how much blood is lost:
• No more than 1.5 quarts (0.75 liters). The patient feels little to no effect. For instance, you can give 1 pint of whole blood up to once every eight weeks.
• 1.5-3.5 pints (0.75–1.5 liters). Rapid breathing and heartbeat occur. The skin turns cold and could look livid. Typically, the patient is quite agitated. If you're not used to seeing blood, you could also be. An unskilled medic could feel uncomfortable even if only a small amount of blood is on the patient or the floor.
• 3.5-4 pints (1.5–2 liters). Blood pressure starts to fall; the patient can seem bewildering. Heartbeats are often very fast.
• Two liters or more: The patient is now extremely pale and may be unconscious. The patient is in grave danger when the blood pressure continues to fall, the heart and breathing rates slow down, and there is a prolonged period of blood loss.
Wearing nitrile gloves when treating the patient will prevent the wound from being contaminated. Thus you should always have them in your pack as the physician. Try to avoid touching the finger or palm areas as you put on the gloves. If no gloves are available, grab a scarf or other cloth and apply it to the wound.
Direct pressure is the cornerstone of bleeding control. Frequently, using this method will end bleeding on its own. Elevating the affected limb above the heart level can help reduce bleeding in an extremity.
Major arteries can be compressed manually at pressure points since they are situated where they are so near the skin. It may be possible to stop bleeding further down the blood vessel's course by applying pressure on the pressure point for the wounded area.
We can map precise places where we should focus our efforts to stop bleeding using pressure points. For instance, the popliteal artery, a sizable blood vessel, is located behind each knee. Applying pressure on the back of the knee will assist stop bleeding if you have a wound on your lower leg. Below is a schematic showing some of the main pressure spots.
Applying a tourniquet might be necessary if this doesn't work to stop the bleeding. Most are easy to operate and can be put in place using only one hand. Avoid rope or wire when making an improvised version; use a folded bandana at least 2 inches wide and a stick. Tourniquets must be applied tightly; stopping venous bleeding usually takes less pressure than stopping arterial bleeding.
The prudent placing of a tourniquet over a wound is required. The tourniquet slows blood flow via the open blood vessel, but it also stops blood flow through neighboring healthy blood arteries. It is crucial to remember that in survival situations, the tourniquet should be adjusted every 10 minutes to allow blood to flow to uninjured parts. Additionally, this will let the doctor evaluate whether the bleeding has stopped due to clotting.
Long-term use of tourniquets can result in the patient losing a limb due to lack of circulation. Tourniquets are unpleasant if left in place for too long. Additionally, your body may accumulate toxins in the affected area, which concentrate and rush into your body's center when the tourniquet is released. With a tourniquet in place, this issue can arise in less than an hour or two. As a result, you should affix a mark to the victim indicating when the tourniquet was applied.
Release pressure from the tourniquet while keeping it in place after you are confident that serious bleeding has stopped. Use sterile water or a solution of 1 part betadine to 10 parts water to vigorously irrigate (flush) the wound. Most studies reveal that sterilized water is just as effective for wound healing as a concentrated antiseptic solution (sometimes better). While using Betadine or hydrogen peroxide for the initial cleaning is permissible, these concentrated treatments should never be used for subsequent cleaning. Concentrated antiseptics dry up these delicate new cells as they try to increase, which slows recovery.
Bandaging the wound not only helps apply pressure; it also serves as a means of soaking up blood. Make sure to apply the most pressure to the area of the cut where the bleeding was taking place. Start packing if the blood is coming from the top of a sizable wound.
To add more protection, apply a dry dressing to the entire area. An excellent bandage that is simple to use and produced by the Israeli army is sold practically everywhere survival gear is offered. The Israel combat dressing has the benefit of applying pressure to the bleeding spot on your behalf. This gives medical professionals more hands-free time to care for other patients or attend to more victims.
Until the wound has healed, bandages should be changed often, at least twice daily.
T raumatic injuries like knife and gunshot wounds can be treated using the same procedure as above to halt bleeding and bandage a wound. You have probably heard that removing a knife risks making the bleeding worse. More time will allow you to transport the patient to the hospital, but what if there are no hospitals nearby? Transporting your victim to your base camp will require you to get ready to take out the knife. Have enough clotting substances and gauze on hand.
The converse is true for bullet wounds when the bullet is often extracted whenever possible when access to contemporary medical care is available. Avoid digging for a tricky-to-find bullet if you don't have the luxury of taking the patient to a trauma center. Although the equipment is designed for this, manipulation could result in more bleeding and infection.
Consider the instance of President James Garfield for a historical illustration. An assassin shot him in 1881. Twelve separate doctors rushed to remove the bullet, sticking their bare hands into the wound. The wound most likely wouldn't have been fatal, developed an infection. The president consequently passed away. In stark environments, pause before removing a projectile that isn't readily accessible and apparent.
Remember that the above procedure is intended for survival circumstances where aid is not on the way.
Agents for Commercial Hemostasis
In examinations of casualties on the battlefield, blood loss claimed the lives of 50% of those killed in battle, and 25% did so within the first "golden" hour after being wounded. After an hour without care, a victim's likelihood of survival drastically decreases; for every additional 30 minutes without care, mortality increases by three times.
Major bleeding management may fall under the purview of the trauma surgeon, but what if you find yourself without access to advanced medical treatment? Significant developments in hemostasis have occurred over the past ten to fifteen years (stopping blood loss).
Although many different kinds of hemostatic agents are available for medical storage, QuickClot and Celox are the two most widely used. Both are available as powder or gauze that has been embedded with powder.
Zeolite, a volcanic material that was once a component of QuickClot, successfully stopped bleeding wounds but also set off a reaction that resulted in some severe burns. The original component of KaopectateTM, kaolin, a clay mineral, is used to make the present generation. It doesn't include any parts from people, animals, or plants.
The fact that QuickClot does not permeate into the body and can be challenging to remove from the wound is a drawback. This was undoubtedly accurate for earlier generations, but it is now supposedly less of a problem, especially if you use the brand's gauze bandage.
The other widely used hemostatic substance is celox. Chitosan, an organic substance made from shrimp shells, makes up its composition. Despite this, the manufacturer asserts that people with seafood allergies can use it. Blood and Celox combine to produce a gel-like clot when they come into contact. It is available in impregnated gauze dressings, just like QuickClot.
Even in people using anticoagulants like heparin, warfarin, or CoumadinTM, celox effectively produces clotting without further diminishing coagulation factors. Because it is an organic substance, the body's natural enzymes progressively convert chitosan into other chemicals. Celox, like QuickClot, has FDA approval. Celox is compared well to other hemostatic medications in US government studies.
The fact that hemostatic agents may be challenging to remove before surgical intervention is a drawback to their usage. As a result, emergency medical workers hardly ever employ them in everyday situations.
The militaries of the US and the UK have tested and successfully used QuickClot and Celox gauze dressings in Iraq and Afghanistan. Although useful, these substances shouldn't be administered to a bleeding patient as the first line of treatment. Your approach, in this case, should be pressure, the elevation of a bleeding extremity above the heart, gauze packing, and tourniquets. You do, however, have a powerful backup weapon to stop the bleeding if these efforts fail.
O nce the bleeding has been stopped and a dressing has been put on, you are in a safer situation than before. However, in your duty as a medic in a harsh environment, you must monitor the wound's condition until full recovery. There are two ways to heal an open wound:
Watering down the wound
First intention (Closure). The incision is stitched or stapled shut in some manner. Although this leads to a smaller scar, there is a chance that it will unintentionally trap bacteria deep inside the wound.
A secondary goal (Granulation). Granulation tissue, a quickly expanding, early scar tissue packed with blood vessels, forms when a lesion is left open. It fills in any gaps when the margins of the wound are not contiguous. It eventually develops into mature scar tissue. The scar is larger than it would be if the incision had been closed with the main goal, but the risk of infection is reduced with adequate care.
Remember the adage, "Dilution is the answer to pollution." A bulb or irrigation syringe (60-100 ml) can apply pressure to the water flow and remove debris and old clots. Any open wound should be gently scrubbed with diluted Betadine or sterile water. You might have some (often little) bleeding. This is not necessarily a bad sign but rather a sign that tissue is developing new blood vessels. Till it stops, apply pressure with a clean bandage.
For the best chance of a speedy recovery, wound dressings should be changed often (at least twice daily or anytime the bandage becomes saturated with blood or other fluids). It's crucial to clean the wound area before changing a dressing. You can do this by using sterile (drinkable) water or an antiseptic solution, such as a diluted solution made by adding one betadine to ten parts water.
Dakin's solution is an easy-to-make alternative antiseptic solution that uses standard storage items. This treatment, developed during World War I, treats skin lesions like pressure sores in bedridden patients. It is simple to assemble, eliminates dead cells, and is made up of the following:
Baking soda, standard home bleach, sodium bicarbonate, and boiled water are all necessary ingredients.
Add 12 teaspoons of baking soda to 4 cups of sterile water to create Dakin's solution. Once you get the necessary strength, add bleach: Three teaspoons will have a mild antibacterial effect (enough for clean, healing wounds), whereas three tablespoons will have a larger impact on infected wounds. Avoid ingesting Dakin's solution, and watch for adverse reactions like rashes or other irritation. As it quickly loses strength, it stores in darkness at room temperature and often produces new batches. Don't heat or freeze the solution.
We utilize a "wet-to-dry" dressing technique to ensure the quick healing of open wounds. Directly over the wound, apply a bandage that has been sterilized, water-soaked, and wrung out. Keeping new cells in a wet environment prevents them from drying out. Place a dry bandage and some kind of tape to keep it in place on top of the bandage that contacts the healing wound. Consequently, you have a wet-to-dry dressing.
To avoid skin infection from germs, it may also be a good idea to use some triple antibiotic ointment around a healing wound. Natural alternatives include raw honey, tea tree oil, and lavender oil.
You might notice some blackish material on the wound's edges over time. It is best to remove this nonviable material. You might only need to scrub it out, or you could need to remove the dead tissue using a scalpel or pair of scissors. Debridement is the process of removing material that is no longer necessary for healing.