Protocol 4: Wound Closure + Debridement

In the management of all wounds, bleeding must be controlled using well-aimed direct pressure with whatever means are necessary. Control of severe bleeding is a higher priority than wound cleaning. Once bleeding has been controlled:


OPEN WOUNDS

1.
Remove foreign particulate material as completely as possible.
2.
Wash the surrounding skin with soap and water.
3.
Irrigate the wound with at least 100 ml (ideally 1000 ml) of the cleanest water available. Highly contaminated wounds (i.e. some particulate material remaining, deep punctures, dead tissue within and/or surrounding the wounds, bites, open fractures, injuries involving damage to underlying structures) may be irrigated with and covered by a bandage soaked in a 1% povidine-iodine solution.
4.
Cover the wound with a sterile bandage and immobilize the wound area if possible. Splint if necessary. Do not close with sutures or adhesive closure strips (CWS advocates closing simple, clean wounds with steri-strips or butterflies).
5.
Change the bandage and clean the wound daily with soap and clean water.
6.

If signs of infection appear (i.e. red tender, swollen, drainage purulent material, apply warm compresses, allow drainage, and irrigate open wounds. Infected wounds should be immobilized if possible.

7.
Assess need for tetanus prophylaxis. High-risk wounds require tetanus prophylaxis every five years, all others every ten. Decide if the patient needs to be evacuated for immunizations.
8.
If the wound was the result of an animal bite, assess the risk of rabies exposure. The probability of rabies exposure from animal bites varies by animal and geographic location. Check with state or local health agency for recommendations. Generally, a period of several days between the bite and immunization is considered safe.


SHALLOW WOUNDS (ABRASIONS AND BURNS)

1.
Cleanse the wound with soap and the cleanest water available.
2.
Apply an antibacterial ointment or cream and cover with a sterile bandage. Immobilize wound area if possible.
3.
Inspect the wound and change the bandage daily.


IMPALED OBJECTS

1.
Only remove impaled objects when they interfere with safe transport or they cannot be effectively stabilized (i.e. will cause more damage if left in place) and then only if removal can be done safely and easily.
2.
Treat as an open wound (see above).


DISCUSSION

Field providers are often rushed to evacuate an open wound because of the perception that wound closure (sutures) must be accomplished within six or eight hours of injury. In the EMS context with short transport times, it makes sense to bandage and transport an open wound for care in the clean and controlled environment of a hospital or clinic. However, it is not so much the time to closure that matters, as it is the time to wound cleaning.

Early and complete wound cleaning substantially reduces the chance of later infection. In the remote environment where definitive care will be delayed, thorough irrigation and debridement of an open wound reduces the urgency of evacuation and leads to a better long term outcome.
 

 

These protocols were written by Jeffrey Isaac, PA-C (of Wilderness Medical Associates International) and have been edited and authorized by Kathryn Vaughn, MD & Clifton Castleman, WEMT, for use by Center for Wilderness Safety.



Download the CWS Wilderness Medical Protocols

 

 
 

– PROTOCOLS –

   •  - Overview
   1 - CPR
   2 - Asthma
   3 - Spine Clearance
   4 - Wound Closure
   5 - Dislocations
   6 - Anaphylaxis

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