William W. Forgey, MD
Soft Tissue Care and Trauma Management Part 3 - Special Considerations and Other Types of Wounds.
Updated: Nov 12, 2020
Excerpt from The Prepper's Medical Handbook. Page reference numbers point to more in-depth treatment and self-reliant care available within the book.
Shaving the Wound Area
It has been found that shaving an area actually increases the chance of wound infection. Scalp lacerations are hard to suture when unshaven due to the matting of hair with blood and accidental incorporation of hair into the wound. However, catching hair in the wound is not detrimental. Just pull it loose from the wound with a pair of forceps or tweezers when you are through suturing.
Bleeding from Suture or Staple Use
You will note that entrance and exit points of the needle puncture anywhere on the body will bleed quite freely. A little pressure always stops the bleeding—it is not necessary to delay your sewing to even worry about it. Just complete stitching the wound, then apply pressure until the bleeding from the needle punctures stops, cleanse the skin when you are done to remove dried blood, and dress the wound.
Scalp wounds bleed excessively—expect this. Spurting blood vessels can be clamped with the needle holder and tied off with a piece of the 3-0 gut suture from the Topical Bandaging Module. To tie, simply place a knot in the flesh to fall beneath the tip of the needle holder. Someone may have to remove the needle holder while you are cinching the first loop of the knot. Or you may simply suture the scalp wound closed and apply pressure between each suture to minimize intraoperative bleeding. Apply firm direct pressure after suturing to minimize hematoma (blood pocket formation) from bleeding within the wound.
I have read many times that a scalp laceration can be closed by tying the hair on either side into a knot, thus holding the wound together. I have sutured a lot of scalp lacerations, and I doubt this technique would work very well. A scalp laceration bleeds so profusely, blood is so sticky and slippery at the same time, and the hair would have to be long enough and of the right texture. See the discussion on head injuries on page 165.
Eyebrow and Lip Closure
If sewing an eyebrow or the vermilion border of the lip, approximate the edges first with a suture before sewing the ends or other portion of the laceration. Never shave an eyebrow. Use 5-0 nylon suture on the face and remove these sutures in 4 days, replacing them with strips of tape at that time.
Mouth and Tongue Lacerations
When sewing the inside of the mouth, use the 3-0 gut suture. These sutures tend to unwind very easily, especially if the patient cannot resist touching them with his tongue. When making the knot, tie it over and over. The mouth heals rapidly, and even if the sutures come out within a day, the laceration has generally stopped bleeding and may heal without further help. These mouth sutures will generally dissolve on their own, but any remaining ones can be removed within 4 days.
Lacerations on the tongue can almost always be left alone. The wound may appear ugly for a few days, but within a week or two there will be remarkable healing. Infections in the tongue or mouth from cuts are very rare. If the edge of the tongue is badly lacerated, so that the tongue is cut one-quarter of the way across or more, sewing the edge together is warranted. Use the 3-0 gut suture.
Control of Pain
For anesthesia you will require a prescription to obtain injectable lidocaine 1% and a syringe with needle. Inject into the wound, just under the skin on both sides of the cut. Cleansing and suturing soon after a cut may help minimize the pain, due to tissue “shock” in the immediate post-trauma period. Ice applied to the wound area can help numb the pain, but local topical anesthetic agents are of no help in pain control. Two Percogesic or 2 or 3 ibuprofen, 200 mg, given about 1 hour prior to surgery may help minimize pain.
Most sutured lacerations leak a little blood during the first 24 hours. Increased pain or apparent swelling is a reason to remove the dressing to check for signs of infection (see page 147). The dressing should be removed, and replaced, when it is time to remove staples or sutures as indicated above. When using a hydrogel dressing system, it is not necessary to remove the dressing, as it facilitates more rapid healing and provides protection from the environment while in place. There are many brands of these dressings at local drug stores. Look for a bandage that has a gel pad construction.
Alternative dressings in the Topical Bandaging Module are the Nu Gauze pads and the Tegaderm and Spenco 2nd Skin dressings. An initial covering that can soak up leaking wounds is the Nu Gauze pad. After the wound becomes dry, the Tegaderm dressing will keep the sutures visible and the wound protected even if it must be submersed in water. Wounds that continue to leak considerable serum and/or blood should be covered by Spenco 2nd Skin and managed as discussed above.
OTHER TYPES OF WOUNDS
An abrasion is the loss of surface skin due to a scraping injury. The best treatment is cleansing with Hibiclens surgical scrub, application of triple antibiotic ointment, and the use of gel pad dressing, all components of the Topical Bandaging Module. This type of wound leaks profusely, but the above bandaging allows rapid healing, excellent protection, and considerable pain relief. Avoid the use of alcohol on these wounds as it tends to damage the tissue, to say nothing of causing excessive pain. Lacking first aid supplies, cleanse the wound gently with mild detergent and protect it from dirt, bugs, and other contaminants the best that you can. Tetanus immunization should have been within 10 years; see discussion in chapter 9.
A significant question on the mind of the victim and the medic is how aggressively ground-in cinder and dirt should be removed from a road rash. Having raced bicycles for several years on a cinder track (Indiana University’s Little 500), I have had personal experience with this—which perhaps clouds my perspective. Before I raced, I aggressively cleaned these wounds with a wire brush. During my racing years my approach changed to simply coating the wound with a layer of the antibiotic ointment and allowing the resultant scab formation to lift the cinders out of the wound when it fell off. A recent publication has shown that antibiotic salve, if applied within 3 hours of a surface wound, significantly decreases wound infection in animal studies. I have not experienced problems with cinder tattoos or wound infection using a gentle scrub (e.g., Hibiclens) with a soft cloth, removing deeply embedded debris carefully with tweezers, and liberally coating triple antibiotic ointment, reapplied daily or as necessary until the wound heals. I like to avoid a bandage, leaving the wound open to the air, or using a gel pad dressing when a covering is required over the ointment.
Briefly allow a puncture wound to bleed, thus hoping to effect some irrigation of bacteria from the wound. Cleanse the wound area with surgical scrub or soapy water and apply triple antibiotic ointment to the surrounding skin surface. Do not tape it shut, but rather apply a warm compress for 20 minutes every 2 hours for the next 1 to 2 days, or until it is apparent that no subsurface infection has started. These soaks should be as warm as the patient can tolerate without danger of burning the skin. Larger pieces of cloth, such as undershirts, work best for compresses, as they hold the heat longer. Infection can be prevented or treated with antibiotics as described in the section on cellulitis (page 148). Dress with a clean cloth. If sterile items are in short supply, they need not be used on this type of wound. Tetanus immunization should be current (see chapter 9).
Wash the wound with Hibiclens surgical scrub or another solution that does not discolor the skin. Minute splinters are hard to see. If the splinter is shallow, or the point buried, use a sharp blade to tease the tissue over the splinter to remove this top layer. The splinter can then be pried out more easily.
It is best to be aggressive in removing this top layer and obtaining a substantial bite on the splinter with the tweezers, rather than nibbling off the end when making futile attempts to remove it with inadequate exposure. When using tweezers, grasp the instrument between the thumb and forefinger, resting the instrument on the middle finger and further resting the entire hand against the victim’s skin, if necessary, to prevent tremor. Approach the splinter from the side, if exposed, grasping it as low as possible; see figure 6-9. Apply triple antibiotic ointment after removal.
Tetanus immunization should be current (see chapter 9). If the wound was dirty, scrub it afterward with Hibiclens or soapy water. If deep, treat as indicated above for Puncture Wounds, with hot soaks and antibiotics.
The first aid approach to an impaled fishhook is to tape it in place and not try to remove it if there is any danger of causing damage to nearby or underlying structures, or if the patient is uncooperative. Cut the fish line off the hook. Destroy triple hooks, but do not cut the hook close to the skin with your wire cutters. This makes subsequent manipulation by the surgeon more difficult. Anyone fishing with barbed hooks needs to include side-cutting wire cutters in their tackle equipment.
If you will be more than 2 days from help, it is important to remove any impaled object, including a fishhook, as such objects are a high risk for infection. And, since fishhooks are relatively easy to remove anyway, you may wish to do it yourself to prevent a long trip back to town and the doctor’s waiting room.
There are three basic methods for removing a fishhook, which I refer to as “the good, the bad, and the ugly” techniques. I will let you decide which is which:
Push through, snip off method: While the technique seems straight forward, consider a few points:
Pushing the hook should not endanger underlying or adjacent structures. This limits the technique’s usefulness, but it frequently is still an easy, quick method to employ.
Skin is not easy to push through; it is very elastic and will tent up over the barb as you try. Place the side-cutting wire cutters, with jaws spread apart, over the point on the surface where you expect the hook point to punch through to hold the skin down while the barbed point punches to the surface.
This is a painful process and skin hurts when being poked from the bottom up, as much as from the top down. Once committed, finish the push-through portion of this technique as quickly as you can.
This adds a second puncture wound to the victim’s anatomy. Cleanse the skin at the anticipated penetration site before shoving the hook through, using soap or a surgical scrub.
When snipping off the protruding point, cover the wound area with your free hand to protect yourself and others from the flying hook point. Otherwise you may need to refer to the section on removing foreign bodies from the eye on page 38.
The steps are simple:
Push the hook through.
Snip it off.
Back the barbless hook out.
Treat the puncture wounds. If you do not have wire cutters, you may still use this technique, but be able to crush the barb flat enough that you will be able to back the hook out.
The string jerk method: This is the most elegant of the methods.
Fingers are loaded with fibrous tissue that tends to hinder a smooth hook removal. This technique works best for the back of the head, the shoulder, and most aspects of the torso, arms, and legs. It is highly useful and can be virtually painless, causing minimal
See figure 6-10: (A) Loop a line, such as the fish line, around
the hook, ensuring that this line is held flush against the skin. Pushing down on the eye portion of the hook helps disengage the hook barb, so that the quick pull (B) will jerk the hook free with minimal trauma. Many times a victim will ask, “When are you going to pull it out?” after the job has been completed.
The dissection method: At times it just seems we are not as lucky, and we must resort to what will probably be a difficult experience for the victim and surgeon alike.
This is the case with embedded triple hooks, a hook near the eye, or other situations when the above methods cannot be used. No person in his right mind would attempt this on his own if evacuation to a physician’s office was at all possible. It is tedious and, without a local anesthetic, such as injectable lidocaine, extremely painful.
The technique employs the use of either a sharp, thin blade or an 18-gauge or larger bore hypodermic needle. Examine a hook similar to the one that is embedded in the victim to note the bend in the shank and the location of the barb. You will need to slide the blade along the hook shank, cutting the strands of connective tissue so that the hook can be backed out. If using the needle, you will have to slide it along the hook and attempt to cover the barb with a hollow tube, thus shielding connective tissue strands from the barb, allowing the hook to be similarly backed out. This is an elegant method and can result in minimal tissue damage, with only the entry hole left. But it can take time and, without local anesthesia, the victim has to be stoic. If available, inject a little 1% lidocaine from the Rx Injectable Medication Module. Practice this technique using a piece of closedcell foam sleeping pad, rather than human skin, prior to your trip in the bush.
Blisters can be prevented if immediate care is taken of any hot spot as soon as it develops. Generally, a simple piece of tape placed directly over the hot spot will eliminate any friction causing the problem. An easily obtainable substance has revolutionized the prevention and care of friction blisters: Spenco 2nd Skin, available at most athletic supply and drug stores. Made from an inert, breathable gel consisting of 4% polyethylene oxide and 96% water, it has the feel and consistency of, well, most people would say, snot. It comes in various-size sheets and is sterile and sealed in watertight packages. It is very cool to the touch; in fact, large sheets are sold to cover infants to reduce a fever. Three valuable properties make it so useful: It will remove all friction between two moving surfaces (hence its use in prevention); it cleans and deodorizes wounds by absorbing blood, serum, or pus; and its cooling effect is very soothing, which aids in pain relief.
2nd Skin comes between two sheets of cellophane. It must be held against the wound, and for that purpose the same company produces an adhesive knit bandage. For prevention, 2nd Skin can be applied with the cellophane attached and secured with the knit bandaging. For treatment of a hot spot, remove the cellophane from one side and apply this gooey side against the wound, again securing it with the knit bandaging.
If a friction blister has developed, it will have to be lanced. Cleanse it with soap or surgical scrub and open it along an edge with a sharp blade. There is no advantage to making a small hole as opposed to a wide incision. Allow the skin covering to collapse by expressing the fluid, and then apply a fully stripped piece of 2nd Skin. This is best done by removing the cellophane from one side, then applying it to the wound. Once it adheres to the skin surface, remove the cellophane from the outside edge. Over this you will need to place the adhesive knit. The bandage must be kept moist with clean water. The 2nd Skin should be replaced daily. If the skin cover is still covering the wound, it should be cut off after 2 days, as the skin underneath is now less raw and the dead skin will start to decompose. Until you use it on a friction blister, you’ll find it hard to believe how well 2nd Skin works!
It makes good sense to coat all open blisters with triple antibiotic ointment. This acts as a barrier to prevent infection.
The old blister-care technique using rings of moleskin is seldom effective. Moleskin should be relegated to the dark ages of medicine. But it is cheap, and for that reason most commercial first aid kits include it rather than Spenco 2nd Skin.
As soon as possible remove the source of the burn. Quick immersion into cool water will help eliminate additional heat from scalding water or burning fuels and clothing. Do not overcool the victim and cause hypothermia. If water is not available, suffocate the flames with clothing, sand, or other flame suffocating material. Do not allow a victim to panic and run, as this will fan the flames and increase the injury.
Treatment of burns depends upon the extent (percent of the body covered) and the severity (degree) of the injury. The percent of the body covered is estimated by referring to the “rule of nines,” as indicated in figure 6-11.
An entire arm equals 9% of the body surface area; therefore, the burn of just one side of the forearm would equal about 2%. The chest and back equal 18%, and the abdomen and back equal 18%. The proportions are slightly different for small children, the head representing a larger percentage (18%) and the legs a smaller percentage (13.5%). Severity of burns is indicated by degree. First degree (superficial) will be red, dry, and painful. Second degree (partial skin thickness) will be moist and painful, and have blister formation with reddened bases. Third degree (deep) involves the full thickness of the skin and extends into the subcutaneous tissue with char, loss of tissue, or discoloration.
For purposes of field management, victims can be divided into three groups depending upon a combination of the extent and severity of the burn.
First-degree burns, regardless of the extent, rarely require evacuation. The severe pain initially encountered in a first-degree burn usually disappears within 24 hours.The patient’s requirement for pain medication can range from ibuprofen, 200 mg, 4 tablets every 4 to 6 hours, to Percogesic, 2 tablets every 3 to 4 hours. After a few doses, further pain medication is generally not required. Surface dressings are not indicated, but soothing relief of small burns can be obtained by either applying a Spenco 2nd Skin dressing or a damp cloth.
Second-degree burns covering less than 15% and third-degree burns covering less than 10% of the body surface area do not require rapid evacuation, but they should receive professional care. Provide pain medication as above. Cleanse the area with either a gently applied surgical scrub or nonmedicated soap. Do not attempt to remove debris that is stuck to the burn site. Gently pat it dry. The general consensus is to remove skin from blisters that have ruptured or that are blood filled. I find it best to initially leave the skin covering the blister, removing it after 3 days. People generally feel better when you open turgid blisters with a long cut using a sharp blade. Apply Spenco 2nd Skin dressing and change it twice daily. Second-degree burns will slough off the skin after 3 to 4 days. An unopened or covered blister surface will turn white in 3 days, and frequently an ooze of pus may develop in the underlying blister fluid. If the underlying skin does not become red and swollen, this is a normal development. White, moist, dead skin should be cut away. If you have no ointment or dressings, leave a secondor third-degree burn alone. The surface of the blister, if it is drained, will dry out and slough off on its own. Either way, healing will take place in 2 weeks or less for a seconddegree burn. A third-degree burn greater than 1/2 square inch will require a skin graft to heal. Red swollen skin under and around the burn site probably indicates an infection. If this develops, provide antibiotics from the Rx Oral/Topical Medication Module, such as Levaquin, 500 mg once daily, or from the Rx Injectable Module give Rocephin, 500 mg by intramuscular injection twice daily. Elevate the burned area to minimize the swelling.
A third-degree burn greater than 10% and second-degree burn greater than 15% of the total body surface area, any serious burn to the face, and any third-degree burn of hands, feet, or genitals require urgent evacuation of the patient. Wound management is the least important part of the care of these patients. Burn wounds are sterile for the first 24 to 48 hours. Burn management is aimed at keeping the wound clean, reducing pain, and treating for shock.
An important aspect of treating for shock will be maintaining adequate fluid replacement. Generally patients with less than 20% of their body surface area burned can tolerate oral fluids very well. If they are not vomiting, those with between 20 and 30% of their body surface area involved can be resuscitated by drinking adequate fluids. This individual will be prone to go into shock. If the victim is vomiting, he will fall behind in fluid replacement.
The replacement fluid should initially consist of Gatorade diluted 1:1 with water, or a mixture consisting of 1/3 teaspoon salt and 1/3 teaspoon baking soda in 1 quart (1 liter) of flavored, lightly sweetened water. Avoid the use of potassium-rich solutions (orange juice, apple juice), as serum potassium can rise to high levels during the first 24 hours. During the second day the oral fluids should be diluted Gatorade and lightly sweetened, flavored water (such as Wyler’s dried fruit crystals or dilute Tang). Push as much fluid during these 2 days as the patient can tolerate without becoming nauseous. Attempt to keep urine flow at 12/3 to 31/3 ounces (50 to 100 ml) per hour. Nausea can be suppressed with adequate pain management and the use of Atarax, 25 to 50 mg every 6 hours, from the Rx Oral/Topical Medication Module, or Vistaril, 25 to 50 mg by intramuscular injection every 4 hours as needed, from the Rx Injectable Module. Pain relief will require Nubain, 10 to 20 mg intramuscular, the nasally inhaled Stadol (see page 289), or the oral medications as tolerated. Patients who lapse into a coma during the first 48 hours will require intravenous fluids to save their lives. Physicians equipped with IV fluids are aware of the massive doses that are required to succeed at this point.
Starting on the third day, the patient should be given a moderately high carbohydrate diet, rich in protein. Approximately 200 mg of vitamin C and substantial vitamin-B complex should be started daily. This would equal about 4 each One-A-Day multiple vitamin (Miles Laboratories) or equivalent. Continue to push fluids.
Spenco 2nd Skin is the ideal dressing for these severe burns. It provides a breathable cover that is sterile and will exclude bacteria from the environment. It is also easily removed with whirlpool or gentle cleansing. Otherwise, apply a topical dressing such as triple antibiotic ointment. Occlusive dressings must not be used. The ointment may be placed on thick gauze dressings that are then held against the wound with a single layer of gauze roll dressing. The wound should be cleaned daily, removing obviously dead tissue. This can be done with gentle scraping using a sterile gauze and clean water with a little Hibiclens surgical scrub added, about 30 minutes after proper pain medication has been provided. Lacking Hibiclens, use a very dilute soap solution. Elevate the burned area, if practical. Have the victim gently and regularly move the burned area as much as possible to minimize contraction of burn tissue across joints. This will be a concern only with long-term care lasting many weeks.
Avoid the use of oral or injectable antibiotics to prevent wound infection. If you suspect an infection has developed because the underlying tissue is becoming red and swollen, red streaks are traveling from the burn toward the heart, or the burn was grossly contaminated (such as from an explosion), use antibiotics as described above.
Unless group discipline has really degenerated, human bites are due to accidents such as falling and puncturing flesh with teeth. Bites within the victim’s own mouth seldom become infected and are discussed in the section on mouth lacerations (see page 110). Human bites to any other location of the body have the highest infection rate of any wound. Scrub vigorously with Hibiclens surgical scrub, soapy water, or any other antiseptic that you can find. Pick out broken teeth or other debris. Coat the wound area with triple antibiotic ointment. Start the application of hot, wet compresses as described under Puncture Wounds (page 133). Start antibiotics with Rocephin, 500 mg IM every 12 hours, or from the Rx Oral/Topical Module use Levaquin, 500 mg once daily. Bite wounds to the hand are extremely serious and should be seen by a qualified hand surgeon as soon as possible.
Animal bites tend to be either tearing or crushing injuries. Animal bite lacerations must be vigorously cleaned, but hot soaks need not be started initially. Some authorities state that bite lacerations should not be taped or sutured closed due to an increased incidence of wound infection. This has not been my personal experience, nor that of many ER physicians with whom I have discussed this problem. After vigorous wound cleansing I would close gaping wounds as described under Wound Closure Techniques (page 126). Only gaping wounds should be closed—not puncture wounds. Start antibiotic coverage immediately, as described in the preceding section on human bites.
The massive lacerations from a large animal bite, such as bear or puma injuries, are another matter. The entire goal of treatment is to stop the bleeding, treat for shock, and evacuate. You may need to close these massive lacerations to help control bleeding.
If an infection seems to start, treat as indicated in the section on wound infection (page 147) by removing the closures and starting hot soaks and antibiotics.
Treat crush injuries with cold packs and compressive dressings. Large lacerations can also be treated with compressive dressings. The ideal item would be a 6-inch elastic bandage. Cold sources can be chemical cold packs or the coldest water available, safely packaged in poly bottles or similar containers. - Refer to Rabies, page 233.
View related Soft Tissue Care And Trauma Management posts
Part 2 - Wound Closure Techniques
Part 4 - Finger / Toe Problems, Wound Infection and Skin Rashes