Wound Care Part 2 Assessment and Cleaning
In our prior news letter we talked about wound care. First we went over the stoppong part. This week we go over the assesment and cleaning of a wound.
Assesment of a wound is much more than wiping off the blood and taking a peak. Like everything in medicine certain steps need to be done.
In this case step one is stop the bleeding. Next after the bleeding is stopped then you can start looking at the wound, wiping off blood and assesing the damage. Here it is a combination of touch, feel and sight. In some cases smell is used also.
The type of wound matters on how to proceede.
Gunshot/Puncture wounds
Gun shots you need to check for entrances and exits. Also it is important to have equal numbers of wounds. Its possible to have more exits than entrances and vice versa. Do. Not. Stick. Anything into a wound. We are not John Wayne carving out a 44-40 slug with a Bowie knife and slug of whiskey. Palpate gently the area on both the entance and exit. What you are looking for is abnormal hard or soft tissue. One thing you may feel is Crepitus. This is the grinding crunching feeling you feel when there is a broken bone. The bullet(s) may have hit and or shattered a bone(s) During this assesment you are also looking for debris in the wound. Remember even if it is a FMJ anything that the bullet touched is now in the wound.
If it is a pentrating puncture, IE The person fell on a piece of Rebar, LEAVE IT IN PLACE. By removing you could be opening up a major artery that was occluded and when the rod is pulled it is now open and your have another problem on your hands
Cuts, Gashes and rips.
The assesment of this type of wound is different than punctures. Yes you need to look for and count entrances and exits. In addition after any blood is cleaned away the depth direction and what is damaged. The direction of cut depth and what is cut makes a differeance on how it is treated. Items to check are:
Depth. What is involved Epidermis, Dermis, Facia Muscle, Vessels
Is the bone damaged.
Tendons and ligaments intact.
Is the muscle torn or cut. Also with the grain or against.
Is the muscle still attached to the bone
Is the muscle smooth or knotted.
Here the use of the best surgical instrument ever invented is of great use. That instrument is the Index Finger. By gently using the index finger to open the wound to be able to see what is damaged and to see if any gross forigen material is in the wound. Again like the puncture wounds do not probe with any tools or even fingers past the outer layer of skin. This will wait til we have the wound intially cleaned out
Crush injuries
Crush injuries are horrible This is where the bone tissue and skin is crushed and then ruptures like a popped balloon. Like the other two injuries first control the bleeding. next once again lok for not so much entrance and exits but for multiple exits. The skin will be evulsed “Pooched Out” Careful palpation of the area and gauge the area of crepitus if any. Sometimes crush injuries will be totally internal and the only way to tell is by discoloration and by palpation of the area.
Now that we have got the diagnoses of the wound(s) out of the way its time to clean ther wound.
There are multiple methods to clean one out. The standard of the industry is 100 CCs per centimeter of length. For us non metric folks about 3 fluid ounces per 1/2 inch of wound length. And for wounds deeper than the dermal layer, (To the muscle) double the amount of fluid.
The types of wound flush is entirely up to:
1. What you have on hand.
2. Patient allergies
3. Personal preferance.
The most common non herbal ones are, Chlorhexadine, Betadine an antibiotic such as Kefzol and Dakins solution. The herbal side is limited to what you have and what you prefer.
On thing. In ALL the flush recipies normal saline is MANDATORY. Sterile water Prepared by distillation, sterile water is nonpyrogenic and contains no antimicrobial or bacteriostatic agents or added buffers. It is often used in irrigation, particularly in developing countries, as a less expensive alternative to isotonic saline. Sterile water is hypotonic and may cause hemolysis and will be readily absorbed by the tissues during surgical procedures; therefore, its use under such conditions is not recommended. Water toxicity may result when excess volumes are used. We’ve talked about this in our classes. Now if that is all you have then use it. The tissue damage risk is much less than the risk of infection
First Chlorhexadine: We use about 60-80 cc’s in a liter of saline or 2-2.5 ounces in a quart of saline. I am a fan of the bulb syrnge technique to flush a wound. Some are proponents of the high pressure pulsitail flush. I like the turkey baster because I have better control. Its a high volume low pressure method
Betadine.
Betadine (Povodone Iodine) has been used for decades prior to the introduction of Chlorhexadine. The mix is the same as chlorhexadine. A couple of reasons its fallen out of favor is current studies of it have shown 1% betadine has the same infection rates as sterile saline. Also more and more people are showing iodine allergies and it is cyto toxic to new skin cells.
Dakins Soultion
Dakins solution is the oldest of the “chemical” wound washes. Invented in 1916 by Dr Henry Dakins it is a mix of sterile water, sodium bicarbonate and sterile water.
How To Make Dakin’s Solution:
Wash your hands
Measure out 32 ounces (4 cups) of tap water. Pour into the clean pan.
Boil water for 15 minutes with the lid on the pan. Remove from heat.
Using the sterile measuring spoon, add ½ teaspoonful of baking soda to the boiled water.
You can make the solution in one of four strengths. Measure bleach according to the chart and add to the water also:
For full strength – add 3 oz. bleach or 95 ml.
For 1/2 strength – add 3 tbls. + 1/2 tsp. or 48 ml
For 1/4 strength – add 1 tbls. +2 tsp. or 24 ml.
For 1/8 strength – add 2 1/2 tsp. or 12-14 ml.
Dakins is not shelf stable. It only lasts about 3 weeks after being made. After being opened it needs to be tossed after 48 hours
Comercial Antibiotics.
Where I work out we use a prepared soultioun of Bactitracin and Polymyxin B in 500 cc of saline or we use 1 gram of Kefzol (Cephlasporin) or Vancomycin in 500 cc’s of normal saline. These work very well. the only negative thing I can say is, it is an expensive wound wash and Kefzol and Vanco are better suited as systemic antibiotics. And again the allergy issue crops up.
Herbal or Alternative irrigation.
A couple of weeks ago I was teaching a wilderness/disaster medic class at Shots Ranch, (www.shotsranch.com). One of the students came to class from hospital and my wife noticed she was limping. She asked her why and was told that she had gangreen, but was not missing the class. Long story short I made a wound wash of Calundula flowers, Palntain yarrow and Thyme. A strong Tisane was made using 1 quart of boiled water then the herbs where allowed to steep for about 20 minutes in a covered dish. This was strained first though a wire strainer then a coffe filter. After filtering another quart of boiling water was added then 2 pints werre reserved. I had the patient soak her foot in it til the water cooled, then the reserved 2 pints was used with a 60 cc syrnge to irrigate and wash any necrotic tissue and debris out. This was done twice a day and after each time the wound was dressed. By the end of the 4 day class the wound had shrunk by over 50% and no foul smell remained.
Collodial Silver
This is a FANTASTIC wound wash. Used full strength it will burn but it will kill any and all bacteria in the wound. I have also seen it used effectivly on MRSA infected wounds and tissue cultures I did showed no MRSA bacteria. It can be diluted up to 50% with sterile water. Saline is not a good choice with CS since it can react with then Chloride in salt and form silver chloride. This can cause the area to turn “blue” upon exposure to sunlight.
Berberine containing herbs.
Berberine is about one of the best topical antibiotics. Safe, gentle and available in most parts of the country. Oregon Grape Root, Barberry and here in the desert southwest greasewood, creosote bush, chapperal (All the same plant) Used as a tincture added to strerile water or saline, or a tisane.
Tea Tree oil.
Tea tree is one of natures wonder plants. Tea trea diluted 4-5 drops to fluid ounce of water and shaken vigorously and then the wound washed has been shown to be very effective on MRSA and other bacteria. The only bad thing is that the oil does expire. When tea tree starts to smell like turpentine it is time to throw out. This short shelf life and since the plant does not grow here. makes it a lower choice to have on hand
Current Training Schedule
These are the classes for The Medic Shack. For local central NM classes they will be held at Lovelace Medical Center. (LMC)
601 Dr. Martin Luther King Jr. Ave NE Albuquerque, NM 87102
July 8-10t 2016 POSTPONED TO AUGUST 11-13 DUE TO RANGE SCHEDULING CONFLICT. Personal Defense Handgun II and III (TMS is just helping sponsor. I’m taking the class also!!) Sign up here!!! http://www.southwestshootingauthority.com/#!pdh-iii—nm/cqd2
Herbal First Aid Course July 23rd and 24th Albuquerque NM
Early Bird Special! Type in EARLYBIRD in the coupon code area for a 20% discount!
https://themedicshack.net/herbal-first-aid-course/
Wilderness/Disaster Medic Class.
August 12th to Monday August 15 At the Eagles Lodge in Bethany Missouri
https://themedicshack.net/wilderness-medic-bethany-mo/
1 more week and then the drawing for the Tactical Hot pack. Sign up for the news letter and get entered into the drawing!
And don’t forget to check out the Medic Shack Home page. We have a multitude of classes to suit all levels of medical preparedness
To get even further ahead of the game pick up Cat Ellis’s book
Prepper’s Natural Medicine: Life-Saving Herbs, Essential Oils and Natural Remedies for When There is No Doctor.
I have 2. Not totally because she my friend and co host. But because I consider it GEAR. One is on my desk and one is vacuum sealed and in the bug out med kit
This is her newest book Prepping for a Pandemic. I’ve had a peak into it and yes this another piece of gear for your med kit
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