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Wilderness Medical Society - snowmass 2005 (Page 195)

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Wilderness Medical Society - snowmass 2005
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Ascertain tetanus status and give recommendations for updating after leaving the
wilderness. Observe wounds daily for signs of infection, that indicate the need for further
irrigation, drainage, or debridement.

III. GUIDELINES FOR EVACUATION
Rapid evacuation from the wilderness is advisable for: 1) severe animal bites or bites
from potentially rabid animals; 2) deep or highly contaminated wounds with a high risk
of infection; 3) wounds that open to fractures (other than the distal phalanx) or to joint
spaces; 4) infected wounds not responding to reasonable field treatment; and 5) wounds
associated with severe blood loss. While not an urgent matter, consider evacuation for
wounds that severely limit an individual's ability to participate in the trip and wounds that
require closure for cosmetic reasons (such as wounds on the face). Delayed primary
closure of facial wounds can be performed in 3 to 5 days if the wound is kept clean with
daily packing.
IV. CONTROVERSIES:
A. Should wounds be closed in the wilderness? Although sterile techniques are virtually
impossible in the wilderness, primary closure with sutures, staples or wound closure
strips may be feasible for relatively clean wounds. Staples provide a cosmetic result
identical to that of interrupted sutures, but not subcuticular sutures. The patient's comfort
and ability and willingness to function are increased, and healing time is usually
shortened. For ulcerations, abscess cavities, deep puncture wounds, and animal bites, do
not close wounds but allow to gradually heal by granulation and eventual re-
epithelization. Grossly contaminated wounds, excessively contaminated with soil or feces
must be cleaned and observed for 4 to 5 days before closure, if the wilderness trip lasts
that long.
B. Should antibiotic prophylaxis be considered for wilderness wounds? The following are
general indications for antibiotic prophylaxis: 1) significantly contaminated wounds
requiring extensive cleaning and debridement (especially in patients with pre-existing
valvular heart disease, prosthetic joints, or immunosuppressed patients), 2) violation of
cartilage, joint spaces, tendon, or bone, 3) crush-mechanism wounds with a high potential
for devitalization, and 4) mammalian bites (see Wild Land Animal Attacks). For
prophylaxis use amoxicillin-clavulanate, a 2
nd
or 3
rd
generation cephalosporin, a
quinolone, a penicillinase resistant penicillin, or a tetracycline antibiotic. Five days of
prophylactic therapy suffice.
C. Should tourniquets be released every five minutes with continued direct pressure to
assess clotting or should tourniquets be left in place once applied until definitive medical
care has been reached? Several military studies have indicated an increased death rate if
tourniquets are removed, even temporarily, in the field. The reason for reassessing
clotting with direct pressure and attempting tourniquet release has been that wilderness
evacuations might take days or even weeks to accomplish. A tourniquet used for that
length of time would result in necrosis of the distal limb with devastating consequences
for the injured patient. Additionally, arterial tourniquets are extremely painful in a

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