Soft Tissue Injuries #4 - Abscess Formation

The Principles of Incision & Draining of an Abscess:

Picture - Assess and evaluate the abscess and surrounding anatomy.
Prep - clean and prep the area of the skin to be incised.
Pain control - if possible numb the skin with ice or inject with lidocaine.
Puncture the abscess - with a scalpel or sharp knife pierce the abscess.
Purge - gently compress and drain the abscess.
Purify - rinse the abscess clean with iodine solution.
Protect - cover with a sterile dressing and monitor during evacuation.

Stitches & Wound Closure:

• Wounds edges may be approximated but, they should not be closed unless the wound can be thoroughly cleaned and closed in sterile fashion.Wound repair and closure is rarely functional; it is almost always cosmetic.If a wound heals with a scar, the scar can later be removed and the wound sutured closed for a better result.

  Bite wounds should never be closed as they are very dirty wounds, from the bacteria from the animal’s mouth. 

  Always consider tetanus booster for dirty wounds. Tetanus immunization is good for 10 years.

  Always consider rabies prophylaxis for animal bites.

So, in the wilderness setting:

• Control bleeding.

  Properly and thoroughly scrub and clean the wound.

  Approximate the edges, but do not close the wound.

  Dress and bandage the wound to protect and promote healing.

  With loss of function splint to support the extremity.

  Change dressings at least two times per day.

  Monitor for signs of infection.

  If the wound is going to continue to get wet, use iodine wet-to-dry dressings to prevent infection.

For more detailed information on wilderness and long-term management of Soft Tissue Injuries see the Jan/Feb 2006 and the March/April 2006 issues of the Wilderness Medicine Newsletter.

Soft Tissue Injuries: #3 Wound Infections

Cellulitis:

Recognition and Management of Cellulitis:
Monitor the wound site for the initial immune response to the multiplying bacteria.
Signs & Symptoms of a wound infection - cellulitis:
Initial:
Rubor:  The redness of the skin caused by the vasodilation.
Tumor:  Swelling of the soft tissue by the fluids that are escaping the dilated vasculature.
Dolor:  Pain caused by the swelling in the tissues.
Calor:  Warmth in the tissues from the vasodilation.
As the infection progresses:
Purulence: Pus formation, a collection of white blood cells (WBC’s) 
Lymphangina: red, tender streaks that progress up the extremity as the lymphatics become infected.
Lymphadenopathy: swollen, tender lymph nodes that occur when the infection reaches the lymph nodes proximal to the area of cellulitis.
If the infection reaches the central circulation, via the lymphatic drainage, then septic shock occurs with high fever, shaking rigors, tachycardia, and hypotension.

Treatment:
Hot water soaks of the area of cellulitis with non-scalding hot water and Epsom salts.  
The area of cellulitis should by heat soaked every 4 hours for at least 30 minutes, until the infection has resolved.  
If the infection continues to spread with lymphangina, lymphadenopathy, or purulence, consider an oral antibiotic such as penicillin, erythromycin, or trimethoprim/sulfamethoxazole (Bactrim).
Evacuate

For more detailed information on wilderness and long-term management of Soft Tissue Injuries see the Jan/Feb 2006 and the March/April 2006 issues of the Wilderness Medicine Newsletter.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

Soft Tissue Injuries #2 Long-Term Wound Care

Control of Bleeding:

Direct pressure
Digital pressure 
Elevation
Pressure dressing

Prevention of Infection - Wound Cleaning:

Hemostasis: 
Apply direct pressure or use a pressure dressing to control bleeding for about 30 minutes.
Supplies:
Sterile cleaning solution:
Can be made by adding Betadine, Povidone, or iodine (any iodine solution) to water and allowing it to stand for 30 minutes. 
Thorough wound cleaning you will require 3 - 4 liters (quarts) of sterile (dilute iodine) water solution for irrigation. 
Wound irrigation:
Is best accomplished with a directed stream of the sterile water under force, such as can be produced by squirting water out of syringe. 
Wound Debridement:
All foreign material must be removed, most can be by gently lifted out with forceps or by rinsing it out with the sterile water.
The Rinsing Process:
Once the visible debris in the wound has been removed, begin the rinsing process. 
First rinse with a dilute soap solution or dilute iodine solution, 5 - 6 times, and then a final rinse with clear sterile water or with the dilute iodine solution. 
The iodine solution has to be less than 2% iodine; if the iodine concentration is too high, it can be toxic to the healthy tissues. 
Once the wound has been irrigated well, apply sterile dressings and a bandage. 
Dressings should be changed every 12 hours and the wound site evaluated for signs of infection.

What are these compounds - Iodine, Betadine, Povidone?

Iodine: Is a chemical element, atomic number 53.
Betadine: Betadine is a commercially available 10% solution of Povidone-iodine in water
Povidone iodine: Povidone iodine is a water-soluble complex of iodine and polyvinylpyrrolidone, it contains a 2% concentration of iodine

 For more detailed information on wilderness and long-term management of Soft Tissue Injuries see the Jan/Feb 2006 and the March/April 2006 issues of the Wilderness Medicine Newsletter.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

Soft Tissue Injuiries #1

The Principles of Wilderness & Long-term Wound Care:

Control of bleeding with direct pressure.
Prevention of infection with proper wound cleaning.
Recognition and management of soft tissue infections, cellulitis, and abscess formation.
Protection of further injury by proper bandaging.
Promotion of healing with proper wound care.
Monitoring the wound site for signs of infection.
Dressing changes twice a day.

The steps of proper wound management are to:
Control bleeding - direct pressure, elevation, pressure dressings.
Examine the wound - remove dressings and explore the wound.
Evaluate function - circulation, sensation, and motion.
Debride - properly scrub and clean the wound with soap and water.
Irrigate - irrigate, irrigate, irrigate until clean.
Dress and bandage - splint to protect and support if necessary.
Monitor for signs of infection - red, swollen, tender, warm.

Recognition and Management of Wound Infections:
Rubor - redness
Tumor - swelling
Dalor - tenderness
Calor - warmth

For more detailed information on wilderness and long-term management of Soft Tissue Injuries see the Jan/Feb 2006 and the March/April 2006 issues of the Wilderness Medicine Newsletter.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.

Toxins #6 - Fish Handler’s Disease

Fish Handler’s Disease:
 
This is an infectious disease caused by the bacteria Erysipelothrix rhusiopathiae, commonly found on fish, oysters, clams, and other crustaceans. 
During the process of handling and cleaning the catch of the day, small cuts and scratches can occur on the hands which allows the Erysipelothrix bacteria to breach the skin and cause a cellulitis.

Symptoms of Fish Handler’s Disease:

• Onset of symptoms is usually 2 - 7 days after exposure from handling and cleaning fish, oysters, clams, or other crustaceans.
• Most commonly occurs on the hands, typically in the web space and dorsum of the hand between the thumb and 2nd finger. 
• A well demarcated area of erythema, with burning, itching, pain, and swelling. 
• The area of erythema will expand approximately 2 - 3cm per day. 
• As the cellulitis progresses, the patient can develop fever, joint stiffness, lymphangina and lymphadenopathy.

Treatment:

• Clean the area of the wound well with soap and water.
• Soak in non-scalding hot water with Epsom Salts, 3 - 4 times per day.
• Oral antibiotic: 
  penicillin VK 500mg po qid x 7 days,
  or cephalexin (Keflex) 500mg po qid x 7 days,
  or Ciprofloxacin (Cipro) 500mg po id x 7 days.
• Make sure they are up-to-date for tetanus prophylaxis.

For more details on this an other ocean-related toxins see the July/August 2006 edition of the Wilderness Medicine Newsletter.

This blog is powered by the Wilderness Medicine Newsletter, now celebrating 20 years of publication. The WMN is published and distributed online six times each year by TMC Books, and subscriptions cost as little as $10 per year. To find out more, or to subscribe online, click here.