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. Controlling severe bleeding is a much higher priority than wound cleaning. Once all severe bleeding has been controlled:
Cleaning a wound will involve a combination of the following procedures in an order that seems appropriate:
a) Explore the wound and remove foreign material as completely as possible.
b) Wash the surrounding skin with soap and water or other cleanser.
c) Irrigate the wound with (filtered) water clean enough to drink. Water of questionable quality should be sterilized by creating a 1% povidone-iodine (betadine) solution.
High-risk wounds (embedded debris, devitalized tissue, bites, open fractures, deep structure involvement or any wound which gapes > ½ inch wide) should be irrigated with copious amounts of clean water under pressure (using a syringe with an 18 gauge catheter or irrigation tip). If the wound cannot be completely cleansed of foreign material or the quantity of irrigation water is insufficient, rinse the wound with 1% povidone-iodine solution. DO NOT use pressure irrigation on puncture wounds where irrigation fluid cannot easily drain away. DO NOT use pressure irrigation for any ocular (eye) injuries or lodged debris.
Cover the wound with a sterile bandage, but allow for drainage if possible. Splint or otherwise immobilize high-risk wounds if safe to do so. DO NOT close any high risk wounds with sutures or tape.
Change the bandage and clean the wound at least once daily; more if the wound seems to show signs of infection, etc.
If an infection develops (e.g., red, tender, swollen, drainage of pus), irrigate with clean water, allow for drainage, and apply warm compresses. Infected wounds should be evacuated to definitive medical care for further care.
High-risk wounds require tetanus prophylaxis every five years, all others every ten.
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.
Animal bite wounds require risk assessment for rabies exposure. The probability of rabies varies by geographic location. Check with state or local health agencies for recommendations. Prophylaxis should be administered as soon as possible, but a period of several days between the bite and immunization is considered safe. Antibiotic prophylaxis may also be indicated.
SHALLOW WOUNDS (ABRASIONS + MINOR BURNS)
Clean the wound by rinsing with (filtered) water clean enough to drink. If the wound cannot be completely cleansed of foreign material or the quantity of irrigation water is insufficient, rinse the wound with 1% povidone-iodine solution.
Apply an antibacterial ointment or cream and cover with a sterile bandage. Immobilize wound area if possible.
Inspect the wound and change the bandage daily or as needed.
Impaled objects should be removed in the field and the wound cleaned as soon as practical. This is especially true of any object that blocks the airway or contributes to airway-related issues.
Exceptions include objects in the globe of the eye, and situations in which removal would result in significant tissue damage, debilitating pain, or bleeding that cannot be controlled.
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.
Last Updated: Nov. 2019
These protocols were written by Jeffrey Isaac, PA-C (of Wilderness Medical Associates International) and have been edited and authorized by the executive medical and curriculum directors Kathryn Vaughn, MD, FAWM & Jennifer Kay, RN, BNS, CCRC, CCRP, WALS, for use by Center for Wilderness Safety, Inc.