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  • Writer's pictureWilliam W. Forgey, MD

Soft Tissue Care and Trauma Management - Part 1 - The Bleeding Wound

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. Probably no issue will distress the prepper more than worrying about managing wounds and with good reason. It is estimated that the rate of home accident lacerations requiring hospitalization is approximately 24.9 per 100,000 persons.

A quick review of table 6-1 can help you plan the relative risk of various common non-fatal injuries that you as a prepper should be prepared to handle. This chapter will provide guidance in your approach to managing these conditions. Bites and stings are covered in chapter 8, orthopedics in chapter 7, poisoning symptoms in chapter 3, and overexertion in chapter 10.

THE BLEEDING WOUND The first aid approach to a bleeding wound is to stop the bleeding, treat for shock, and transport the victim (with appropriate assessments) for definitive care. Off the grid it will be very appropriate for the party to provide its own definitive care. Stop the Bleeding Wound care, whether on or off grid, can be broken into chronological phases. The first phase consists of saving the victim's life-by stopping the bleeding and treating for shock. Even if the victim is not bleeding, you will want to treat for shock. Shock has many medical definitions, but bottom line, it amounts to an inadequate oxygenated blood supply getting to the brain. Lie the patient down, elevate feet above the head, and provide protection from the environment—from both the ground and the atmosphere. Grab anything that you can find for this at first-use jackets, pack frames, unrolled tents, whatever. Eventually you will be able to pitch a tent, put up a rain fly or sun shield, and prepare materials for further wound care. (See also Shock, page 13.) Direct pressure is the best method to stop bleeding. In fact, pressure alone can stop bleeding from some amputated limbs! When the accident first occurs, you may even have to use your bare hand to stem the flow of blood. Ideally, you will have something to protect yourself from direct contact with blood and to protect the wound from your dirty hand. The best item to carry would be a pair of nitrile gloves. These can withstand long-term storage, as well as heat and cold, better than latex gloves. In their absence, grab a piece of cloth (bandanna, clothing article) or other barrier substance (plastic food wrapper) and press. My book Basic Illustrated Wilderness First Aid, 2nd edition (Falcon Guide, 2016) describes the various glove materials and their suitability for long-term storage. In general, nitrile gloves will prove to be the best solution. Control of blood loss is a priority. This makes the "tourniquet first” approach appropriate if blood loss cannot be controlled by direct pressure on an extremity wound. The military has approved two commercial strap and windlass-style tourniquets: the Combat Action Tourniquet (CAT) and the Special Operations Forces Tactical Tourniquet Wide (SOFTT-W). The Special Operations Forces Tactical Tourniquet Wide (SOFTT-W) pictured in figure 6-1a is the latest model, specially constructed to give a true 12-inch circumference without pinching when tightened using the windlass. Due to the interest in the national "Stop the Bleed" awareness programs precipitated in the United States by active shooter incidents, the American Red Cross is also co-marketing the SOFT-T tourniquet. Once applied, keep the tourniquet in place until definitive care has been reached. A careful exception might be made for a remote situation. To quote from the current Boy Scouts of America Wilderness First Aid (BSA WFA) doctrine: In a very remote area where care might not be reached for days, continuous application will result in loss of the limb. It is more important to save a life than a limb. In all situations, it is better to apply a tourniquet prior to seeing the signs and symptoms of shock. A rule of thumb is to leave a tourniquet on an extremity with severe arterial bleeding, not venous bleeding, no longer than 2 hours, and attempt to transition to wound packing and a pressure dressing to control severe bleeding. If a tourniquet is left on an extremity longer than 6 hours then it is recommended to leave on until definitive care can be reached. Tourniquets should not be released periodically just to resupply the limb with blood. The control of blood loss is a critical step in a remote care situation. Only remove the tourniquet if it seems feasible to apply adequate direct pressure to fully control the bleeding.

HEMOSTATIC DRESSINGS There are now three hemostatic dressings approved by the military. Since the addition of Combat Gauze (ZMedica LLC, Wallingford, CT, USA; in April 2008 to the Tactical Combat Casualty Care (TCCC) guidelines, based on recent analyses of battlefield results in hemostatic dressings used in Afghanistan and Iraq as well as other special operations combat areas, Celox Gauze (Medtrade Products Ltd., Crewe, UK, and ChitoGauze (HemCon Medical Technologies, Portland, OR, USA; have been added. To use, place the gauze on the wound on top of the bleeding vessel-not on top of other bandage material. Direct pressure must be applied continuously for a minimum of 5 minutes or as per the manufacturer's recommendation. If direct pressure does not stop the bleeding, immediately apply a tourniquet. Extensive military experience has indicated that even temporary removal of a tourniquet results in a higher loss of life. Additionally, placement of an effective tourniquet can be difficult. Ineffective placement allows continued bleeding. Continue applying direct pressure while the tourniquet is on to facilitate the clotting process. If an inadequate result is obtained, immediately place a second tourniquet about an inch proximal from the first one. If the patient has lost a massive amount of blood, do not attempt to remove the tourniquet. Sometimes bleeding control with direct pressure may require hours of direct pressure, but this is unusual. There are three main lessons to remember concerning a tourniquet: First, applying it sooner rather than later is critical; if bleeding is not controlled by pressure on an extremity, apply the tourniquet immediately. Second, a wide tourniquet is better than a narrow one. Third, don't remove the tourniquet. Improvising an adequate tourniquet is difficult to achieve. Belts seldom work, cords and surgical tubing will not adequately stop bleeding, and an appropriate fastening technique is not easy to maintain. The minimum width for a tourniquet is 12 inches. Tie a short stick or another rigid object into the tourniquet material to create a windlass technique and twist it, tightening the tourniquet until bleeding stops and no more. Attach the stick to the windlass by incorporating it into the knot and fasten one end of the windlass when it has been adequately tightened by tying a square knot over it and the limb. In areas where a tourniquet cannot be applied, plunge two fingers into the bleeding wound. This always stops bleeding and works anywhere on the body, shy of a massive explosive injury. Use your index and middle finger held together. This is the technique used over and over again during surgery when something cuts loose and blood wells up in the surgical field. A third technique is an internal pressure packing using a moist piece of sterile or clean cloth. Wet the cloth with sterile or at least drinkable water, wringing it out until it's practically dry. Then stuff this cloth into the wound firmly, continuing to pack more cloth into the wound until the bleeding is stopped by the tamponade, or compression. If bleeding continues, do not remove the material, but firmly stuff in more. Cover this dressing with a dry, clean cloth. It should be replaced in 24 hours. With the bleeding stopped, even using your hand, and the victim on the ground in the shock treatment position, the actual emergency is over. Her life is safe. And you have bought time to gather together various items you need to perform the definitive job of caring for this wound. You have also treated for psychogenic shock-the shock of fear. In the first aid management of this wound, the next step is simply bandaging and then transporting the victim to professional medical care. For those who are isolated and must provide long-term care for wounds, further management will go through several more phases: cleaning, closing, dressing, and treating the possible complications of infection. Clean the Wound Adequate cleansing is the most important aspect of wound management. Especially when in an isolated or survival situation, the prevention of infection is of critical importance and can only be assured by aggressive irrigation techniques. There is an adage in nature: "The solution to pollution is dilution." In wound care this means copious irrigation. The whole purpose of scrubbing a wound is to reduce the total number of potentially harmful bacteria. You won't get 'em all out, but if the total number is sufficiently small, the body's own defense mechanisms can take over and finish the job for the patient. To best provide water for irrigation, prepare sterile water. This can be done by boiling the water for 5 minutes. Lacking the ability to do that, try to use water that is fit for drinking (see page 89-94 for techniques of water purification). In a pinch, clean water from a stream or lake can be used as long as you are not downstream from the sewage pipe of a third-world village, or the bloated, rotting carcass of a moose.

To provide adequate force to the irrigation stream, there are two items of potential importance. One is the bulb syringe (see figure 6-2). The 1-ounce model is adequate for most wounds. The other approach is to use a syringe (10 to 35 ml size) with a device attached called a Zerowet Supershield (see figure 6-3). With either technique one can increase the velocity of the water to aid in dislodging debris and those all-important germs. Forceful water irrigation is the mainstay of wound cleaning. The use of a bota bag, a squeezable plastic water cube, or simply a ziplock plastic bag with a small hole poked in it to bring a stream of water to the wound is very helpful, but the stream generated using them is not fully adequate to provide the irrigation force required. Adding mild surgical scrub solution to the initial batch of irrigation water is a good step but does not make up for the lack of adequate forceful irrigation. Adding mechanical abrasion can be helpful and probably is the only hope of adequate wound cleansing. Several products can be particularly useful for this technique. The most effective is Hibiclens surgical scrub. Another is povidone iodine (Betadine) diluted to a 1% solution (the stock solution is 10%). Another approach is to use a very dilute soap solution. Err on the side of making the soap solution too weak, because strong soap solutions can damage healthy tissue. Make the solution weak enough that you could drink it without purging yourself. Many cleaning techniques and compounds should not be used: Tincture of iodine. Mercurochrome, and alcohol are very harsh, and hydrogen peroxide destroys good flesh as well as germs. Red-hot branding irons and pouring gunpowder into a wound and lighting it, while effective in killing germs and among Rambo's favorite techniques, also destroy good tissue. And destroyed tissue is not something you want when you are off the grid. When stuck with a weak irrigation stream, perhaps being able to pour water into the wound only from a container, the mechanical abrasion technique saves the day. Besides irrigation, a technique of cleaning used by physicians in the operating room is called debridement. This amounts to cutting away destroyed tissue. Of course, there is no way a person can do this in the bush-especially with inadequate lighting, equipment, and training. But we can safely approximate it by vigorously rubbing the area with a piece of sterile gauze or clean cloth. The rigorous scrubbing action will remove blood clots, torn bits of tissue, pieces of foreign bodies-all items that generally result in higher bacteria counts or foci for bacterial growth. This scrubbing process has to be accomplished quickly-it is painful and the victim will not tolerate it for long. Have everything ready: clean, dry dressing to apply afterward; the water supply; an instrument to spread the wound open (a pair of tweezers or the needle holder are ideal); and sterile gauze to use for scrubbing this wound. To sterilize cloth and any instruments, boil for 5 minutes, if necessary in the water you are preparing to use for irrigation. While having adequate sterile dressings would be ideal, you may find yourself slicing and dicing your wool shirt or Polarguard jacket into bandaging material. A rough cloth works better at wound cleaning than a smooth cloth, such as cotton. Once everything is ready and assistance is at hand (perhaps someone to squirt the jet of water into the wound and another to assist shooing the black flies away or comforting the victim), go to it! If this job is performed well, the final outcome will be great. This part of wound care is far more important than wound closure technique. It will be messy. And it will hurt. But spread the wound apart, blast that water in there the best you can, and scrub briskly with the gauze pad. This whole process will have to be completed in 20 to 30 seconds. In the operating room, or under local anesthesia in the emergency room, we might take 15 minutes or longer. You won't be able to take that much time, but you must be thorough and vigorous. You should use at least 1 cup of water for a very small wound and 1 quart (1 liter) for most other wounds. When in doubt, do more if the patient can tolerate it within reason. Once the irrigation is completed, the wound will bleed vigorously again, since the blood clots were knocked off during the cleansing process. Apply a sterile dressing and use direct pressure as long as necessary to stop bleeding; 5 to 10 minutes usually suffice, but if an hour or more is required, keep at it or use the pressure dressing technique described above. If you fail to adequately clean a wound, the resulting infection could cost the patient his life. It would simply be a slower and more painful demise than bleeding to death. Antibiotic Guidelines

It is always tempting to place a person on antibiotics after a laceration, but I would advise against doing this unless the wound was from an animal or human bite (see pages 143-144), the wound occurred in contaminated water, or there was an open fracture (see page 163). Bacteria are jealous creatures and do not like to share their food source with other species. If an infection develops, it will generally be a pure culture, the other species originally contaminating the wound having been killed off by the body's defense mechanisms and the winning bacterium. If the patient is on an antibiotic from the beginning, the winning bacterium is guaranteed to resist your medication. If no antibiotic is used initially, there is hope that the emergent bacterium will be sensitive to the antibiotic that you are about to employ. If it is necessary to start a prophylactic antibiotic, from the Rx Oral/Topical Medication Module use Levaquin, 500 mg once daily for 3 days. In case of infection, see page 147.

Look for future posts on the subject of Soft Tissue Care and Trauma Management where we will cover wound closure techniques and special considerations.

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