Advanced Wound Care - _.org

Advanced Wound Care
TCCC First
Stop Bleeding EarlyTourniquetscan be converted or reduced laterWound PackingResuscitate with warm fresh whole blood if possibleEarly antibiotics buy timeErtapenam
Convert or Reduce Tourniquets to Save Tissue
Jan 2016Afghanistan 3rdSFG Teamwith NationalGaurdFlight MedicSF Soldier single gunshot to lower extremityTourniquet applied after signs of hemorrhagic shockMEDEVAC Helicopter stuck on objectiveActivefirefight too hot for another pickup19hoursuntil role 2
LessonsLearned From Marjah
Get tourniquets on early to prevent blood loss90% survive when tourniquet applied prior to shockSoldier’s life saved by blood products fromhelo(2 units PRBCs)90% die when tourniquet applied after shockSoldier’s leg saved by 6 attempts to reduce tourniquet to pressure dressingNoted pulse was present when tourniquet was removed despite bleedingNo arterial involvementRan out of pain medsExtra equipmentmonitor on theheloExtra training and experienceFlight medic is also an ER nurse when not activated
EarlyIrrigation Can Buy Time
Copious Low pressure Irrigation OnlyHigh pressure pushesbad bacteriafurther into woundSalineSterile H20CleanH20NEVERSEA WATER(Vibrioand otherbacterial contamination)
Surgical Debridement is Definitive Care for Combat Wounds
HemostasisMajor and minor vesselsRelieve TensionCompartments and skinRemove devitalized tissue4 CsColorConsistency,Contractility,Capillary Bleeding
Make and Sterilize Pack
Complete Slide show available in-TacticalMedicineCollective Google Drive-SurgeryFolder:https://drive.google.com/open?id=0B7OAVQuGtbzAejlTLUFEVmxqcFU
Pre-Surgical Checklist
Resuscitated and stableVitals normalizedHematocrit > 21Normal UOPAntibiotics 2gAncefIVTXA prior to cuttingPrepare for Monitored Anesthesia Care (MAC) with MSMAIDMachine or DripSuctionMonitorAirwayIV/IODrugs
Prep and Drape
Gross decontamination of entire limb withchlorihexidinescrubIrrigate and DryDon hat, mask and boot coversPrep pack, gown and glovesApply tourniquet at this time if neededScrub inDon gown and glovesOpen packs and create sterile working spacePaint everything with Povidone IodineDrape 3 layersAir barrierWaterproofsteridrape layerOuter working surface
Debridement
Elongate wound edges and trim devitalized skin with scalpelNo more than 3mm beyond necrotic tissueUndermine skin as little as necessary to visualize tissueFind and ligate or transfix known vessels with absorbable sutureRelease all compartment tension with Mayo scissorsExtend ruptured compartmentsPerform fasciotomy on all compartments in the affected extremityBegin excising necrotic tissue with Mayo scissorsWork systematically from one muscle group to the nextClamp and ligate bleeders after all devitalized tissue is cut awayDO NOT BACK TRACK as the healthy tissue will turn dark in color after a few minutes
Dressing the wound
Irrigate 1-3 liters until fluid is clearNO DAKINS SOLUTION for Delayed Primary ClosureEven very weak solution cures muscle to jerky if left for 4-7 daysPack and dry woundCount gauze in or use single rollLoosely apply gauze matrix to wick exudate away from woundMust touch all tissueBuild bulky dressing and cover with compression bandage or stockingCheck distal pulsesUse wet to dry dressings only if bone, tendon, nerves or vessels exposed
Delayed Primary Closure
Attempt surgical Closure 4-7 days after initial woundAnesthetizeRip bandage offshould bleed but not profuselyNo bad smellAmmonia = goodFruity = Pseudomonas infection(bad)Other bad smells that fill a room indicate infectionCollagen ok, just scrape it out with back of instrumentUndermine skin no more than 5cmIrrigate until clear and DrySuture closedInfections caused by closing under tensionBacitracin not recommended on suture line
Nursing care
Surgical Drain only indicated for voids larger than a fistBacitracin not recommended due to skin macerationIf bacitracin is used, it must be changed dailyKeep wound covered until sutures/staples come outSplint in extension to prevent contracturesImmobilize for first 24 hours to preventrebleedingGet up and moving around after 24Daily physical and visual examPalpate to make sure there is no collection of fluidIf signs of infection present you must open and surgicallyredebride
Infected Wounds
Re-debrideall infected tissueClosure by allowing to heal by secondary intentSugar or HoneyDressingsHigh pressure pulse irrigation to break up biofilmMedical Maggot therapy when all else fails
Sugar or Honey Dressings
Re-debridedevitalized and necrotic tissueRemove any contaminants or fragmentsIrrigate and Disrupt all biofilmDry as beforeFill void with regular sugar or honeyCover withTagodermor occlusive dressingChange every 24 hours
Maggot Therapy
Put animal or fish guts outsideharvest tiny white eggsPlace on 2x2 and put on woundcover with silk tea sack and tape edgesRemove in 48 hoursReapply more if needed