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Wilderness Medical Society - snowmass 2005 (Page 194)

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Wilderness Medical Society - snowmass 2005
24
drain hematomas. A major soft tissue injury in proximity to a bone should arouse a high
suspicion of a fracture. Apply splints for comfort.
Subungual hematomas: May be drained by drilling a hole in the nail with a red-
hot paper clip, a sharp sterile blade, or hypodermic needle to provide pain relief.
Abrasions: May be cleaned with soap and water or with a surgical scrub such as
.5% chlorhexidine gluconate or a 1% povidone-iodine impregnated sponge. Follow
scrubbing with copious irrigation with clean water. Water safe to drink is clean enough
for wound cleaning. After the abrasion has been cleaned, apply a thin coating of a topical
antimicrobial first-aid ointment and dress with sterile gauze. If water is in short supply,
the simple application of antibiotic ointment within three hours may reduce wound
infection (Category 2). Honey and sugar are useful for field-expedient antisepsis.
Lacerations and Avulsions: Use copious irrigation with clean water. Using water
that is not at least potable is discouraged, unless the wound is grossly contaminated and
no other irrigation is available. Boiled, then cooled, water is safest for open fractures or
joints. Pressure irrigation with a syringe and needle or a barrel irrigation syringe is the
most effective technique. Improvised equipment could include a plastic bag with a hole
the size of a toothpick in it. Optimal pressure for irrigation is 5 to 8 psi, which would
equal the force that could be applied to water using a barrel syringe with an 18 gauge
needle. Irrigate with at least 500 ml of water. Take care to avoid splashing fluid into the
irrigator's face. Following irrigation, inspect the wound and remove remaining debris
with a sterile (flamed or boiled) forceps. If water is in limited supply, it may be helpful to
irrigate grossly contaminated wounds with 1% povidone-iodine solution (not surgical
scrub).
Do not close heavily contaminated or high-risk wounds because of the increased
chance of wound infection. Pack heavily contaminated wounds open with wet-to-dry
dressings. Wounds that open into joint spaces, that involve underlying tendons and
ligaments, that open the face (for cosmetic reasons), that affect areas of special function
(e.g., hands), and bites from wild animals (see Wild Land Animal Attacks), are best
cleaned and dressed without closure and the patient evacuated for definitive care. If
evacuation is not feasible, or will take longer than two days, it is reasonable to treat
significant wounds with thorough cleaning and closure with tape, wound closure strips,
sutures, or surgical staples. Minor wounds do not require urgent evacuation and may be
closed with tape or wound closure strips. Limit sharp debridement to obviously
devitalized tissue. Splinting and elevation will help maintain wound closure, hemostasis,
and pain control, although this is probably only feasible under limited circumstances..
If bone is exposed or if the wound is a deep puncture or highly contaminated, give
appropriate antibiotics.
Traumatic amputations necessitate proper management of the amputated part, if
there will be any opportunity for re- implantation. Gently clean the amputated part and
wrap in slightly moist sterile gauze, seal in plastic, and keep as cool as possible without
freezing (ice water is best). Some parts, such as fingers, may be reattached up to 32 hours
after the injury.

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