Wound Care

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Facilitator:
Patients:
Time: 35 mins; 1505-1540
Actual time:
Learning Objectives:
Materials: Fake blood, St Johns Wort oil; pencil, duct tape, gauze for impaled object

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Note to trainers

Students learn better (and you save time in the first aid sections) if you find ways to let them see mock injuries and first-aid responses.

The cup o'blood demonstration is an example. Another one is actually applying well aimed direct pressure and elevation to someone when teaching it, squirting water on a volunteer's arm when talking about flushing a wound, squirting St Johnswort oil on a leg we imagine is bruised and letting them rub it in, and "impaling" an object in someone's arm or hand by stabilizing a stick or something with duct tape so it sticks out, then demonstrating how to truly stabilize it with roller gauzes and bulky stuff.

Be creative! Whenever you can find time, let students practice every skill possible. Think of this like a cooking class instead of a philosophy class.

Cup of blood demonstration

Have one trainer pour 1/2 cup of fake blood on another

• Blood is very dramatic and often looks like a lot more than it is.

• That being said, take it seriously

What is it?

Analogous to head injuries.

Internal

Can be especially dangerous because you don't see it, and can be fatal

• Caused by blow to part of body, either directly disrupting blood vessels under the skin or deep in the body, or causing other injuries that disrupt the vessels (like a broken hip or thigh bone). often does not break the skin

• Major internal bleeding usually caused by major trauma, such as car accidents, falls

• bleeding into the thigh, abdomen and pelvis

• Minor internal bleeding (bruises) caused by falls, rubber bullets, wooden projectiles, batons (these can all also causes external bleeding)

• on the skin, and deep in the tissue

• Can decrease risk by wearing good shoes, body armor

External

Can see, sometimes seems more dramatic than it is, can be fatal if serious.

Can decrease risk by having all skin covered, not running, being aware of location of fences and barbed wire

Lacerations

Cut with clean edges -- can be from broken bone, a knife, anything sharp

Abrasions

Superficial such as scrape or road rash

Some cuts are a combination of lacerations and abrasions, with lots of deep cuts and general scraping of skin around.

Avulsion

A flap of skin that is attached to the body on only side

Amputation

A part of the body that is no longer attached -- most often fingers, toes

Puncture wound

Impaled object

A puncture wound, in which the cause is still attached

Animal bites

Red Flags

• Major internal bleeding

• Major external bleeding that doesn't stop within 5 minutes

• Amputations

• Impaled objects

• For any major bleeding, think shock

Assessment and first aid

Make sure you do a complete initial assessment, and watch out for signs of shock. Large bleeding wounds can distract from other injuries

Many people are frightened or upset at the sight of blood, especially their own. Calm, comfort and reassure essential here

Bleeding can be hard to find in folks who have lots of clothing on (cold weather, padded block)

Internal Bleeding

Major Internal Bleeding

• Person may have signs of decreased circulation

• May also have abdomen or leg that is larger than usual, growing, with skin tense. can be very painful

• GET HELP, put in shock position, be vigilant for person getting worse

Less major internal bleeding: bruises

• Apply direct pressure to area (might stop the bleeding)

• Apply cool cloths or ice wrapped in cloth to decrease inflammation

• First 24 hours: use infused arnica flower (Arnica montana) oil to decrease pain and swelling and speed healing of bruises. Apply to wherever it hurts, is discolored, or is swollen; do not put on open skin; do not give Arnica tincture by mouth unless you have consulted with an herbalist

• After first 24 hours: use infused St. Johns Wort flower (Hypericum perforatum) oil to decrease pain and swelling and speed healing of bruises. Good for burns, nerve injury (handcuff compression injury), general wound/bruise/sprain healing (after 24 hours). Apply to wherever it hurts, is discolored, or is swollen; do not give St Johns Wort tincture by mouth unless you have consulted with an herbalist

External Bleeding

First aid for external bleeding

lacerations and abrasions (Special circumstances below)

Stop the bleeding

The body stops bleeding by forming a clot (which we help with direct pressure) and by having the vessels contract (which happens over time)

• Remove large foreign bodies (non-impaled sticks, dirt, gravel, etc)

• Apply well-aimed, direct pressure (a 4x4 between your glove and the bleed gives you better grip and the gauze mesh gives the blood more to grab onto when forming a clot)

• Elevate above heart if possible

• Hold until bleeding has stopped, and then for a few minutes more (you don't want to disturb forming clot, and want to give time for vessels to contract and close off)

• Do not lift up bandage, unless you think you are on the wrong spot

If bleeding doesn't stop within 5 minutes, get help

DO NOT use tourniquet: it cuts off all circulation to limb, causing cell death and total loss of limb

You can apply a pressure bandage for transport:¹ if person needs a pressure bandage, she needs to get more care for injury

• Do not remove gauze already placed over cut

• Assess for normal circulation and sensation in location "beyond" injury (further from heart): press on nail beds until they are pale, then let go -- if nailbeds do not fill within time to say "nailbed filling" then circulation is not good; ask if person can feel you touching their skin; ask if she has numbness or tingling there

• Wrap rolled gauze around site, can criss-cross over site of injury/bleeding to increase pressure

• Tie off with knot over the injury to both indicate where it is and to apply one last bit of extra pressure

• At end: assess for normal circulation and sensation in hand/foot area "beyond" injury to make sure the pressure bandage isn't too tight. If it is too tight, unwrap slowly until normal circulation or sensation returns, then rewrap more loosely; usually do not need to remove entire bandage.

• Write your initials and the date and time dressing was applied on the dressing or on a piece of tape placed on the dressing. When that thing shows up in the first aid station next week, the clinicians will want to know

Remedies

² These help stop bleeding and limit infection risk -- apply directly on the wound as an adjunct to first aid (none of these remedies replace first aid). For serious bleeding, dump in the remedy then slap down the dressing on top so it doesn't just get washed out by the blood. (Remember: Don't lift the dressing once you start applying pressure.)

• Cayenne powder (stimulates blood vessels to spasm shut and maintain blood pressure) -- put it on the wound or bruise, apply pressure, and take by mouth (in water) if desired

• Cinnamon can be used similarly on the wound or bruise and large amounts by mouth, especially for internal bleeding (nothing by mouth for shock signs)

• Yarrow (Achillea millifolia) leaf powder or fresh yarrow leaf (similar to cayenne and cinnamon in principle and topical/oral dosage instructions) and tincture of yarrow can be taken internally (nothing by mouth for shock signs or altered mental status)

• Yunnan Pai Yao powder (Chinese patent medicine remedy) -- use like cayenne or cinnamon for wounds or bruises

• Spider webs or burnt hair ashes (contain chemicals that increase clot formation) -- apply directly to wound under pressure. Takes a LOT of spiderwebs or cobwebs or hair, not so practical most places

• Slippery elm bark powder (lots of fibers for clot to grab onto) -- apply to wound under pressure

NOTE: we are not teaching pressure points. it takes a lot of time, and isn't particularly useful at this level of training

If minimal bleeding, or if bleeding stops within minutes

Wound care principles:

1. Keep it clean

2. Help it heal faster

3. Keep the dressing from sticking

Clean out anything that might cause infection and apply dressing: aggressive cleaning can restart bleeding, so only clean small cuts and scrapes in the field -- everything bigger or really dirty goes on to clinicians

• Rinse it really well with tap water (bathroom sink is much better than a water bottle for this). Soap and water is an even better idea, with a little scrubbing with a 4x4

• Hydrogen peroxide, isopropyl alcohol, and other antiseptics are bad ideas in the street. They slow down the healing of cuts because they kill EVERYTHING -- bacteria AND new growing cells; they're heavy as shit to lug around, and cost money -- water comes out of bathroom sinks for free; if they get donated to the medics, just throw them out

• If you can't get the wound completely clean, put on a dressing and send for more advanced care

• Pat dry

Optional: put on a salve/ointment/poultice; cover with bandaid or sterile gauze dressing

• Antibiotic ointment may help a little, but the effect is pretty small according to medical research. Biggest effect seems to come from keeping the dressing from sticking to the clot

• Honey does pretty much the same things antibiotic ointment does, and can improve healing time (grab honey packets from restaurants and coffee shops)³

• Herbal wound healing salves⁴ may protect the wound, fight infection, and improve wound healing. They may include a lot of different ingredients, including: Calendula flower -- Calendula officinalis: general wound and burn healing; especially good for blisters.

  • St Johns Wort flower -- Hypericum perforatum: speeds recovery from burns, nerve injury (handcuff compression injury), general wound/bruise/sprain healing

  • Comfrey -- Symphytum officinale: good for wound healing (ONLY for shallow cuts: comfrey can stimulate such speedy wound healing that the skin closes over the top of the wound, trapping germs and other badness inside)

• Make a poultice of field plantain (Plantago major): patient chews fresh leaves and applies directly to wound. helpful in drawing out venom, dirt and other wound contaminants

Educate about tetanus precautions and stitches if appropriate

Tetanus -- about it:

• The tetanus bacteria causes life-threatening infection: 25% of people die from it. it is a horrible death. those who survive usually have serious nerve damage

• Easily prevented

• Transmitted by bacteria in soil, feces

• Anyone with a burn or cut that is or could be contaminated should be considered at risk for tetanus

Tetanus -- current recommendations:

• Anyone who has a wound with high possibility of tetanus and has not had full series AND a booster within 5 - 7 years should be seen by health care provider ASAP to be considered for both the immunization and the immunoglobin

• Anyone with a more minor wound, who has not had the vaccine in 5-7 years should be seen within 72 hours to get the shot

• Everyone should get a booster every 10 years

Any of the following may need stitches (help the patient locate and get to clinical care)

• Deep laceration (more than 1/2 inch), long laceration

• Cut over a joint

• Cut where person cares about cosmetics

• Animal bites (especially human)

• Jagged edges

Special circumstances (Trainer note: don't get lost here. Say it, show it; move on)

In all these cases, take special care to educate about tetanus precautions

1. Anyone with immune compromise (from cancer treatment, chronic steroid use, HIV/AIDS, etc) or chronic medical conditions (such as diabetes) may need antibiotics for even minor injuries, so may need to get more care

2. Avulsion -- skin that is only attached on one side: "the lonely peninsula"

3. Re-approximate skin, bandage

4. Consider sending for more care

5. Peninsula part of skin will have poor blood supply, so may slowly die

6. High risk of infection if this happens

7. Amputation -- part of body no longer attached. CALL FOR HELP. CALL 911. For everything EXCEPT teeth:

8. Do not wash or otherwise mess with the unattached body part or the place where it was cut off, as this might make it more difficult to reattach

9. Wrap amputated part and place where it was cut off in sterile gauze

10. Put amputated part in ziploc bag, with person's name and time of injury

11. Put on ice if possible (but never allow ice to directly touch amputated part)

12. Give to EMS when they arrive or to person if EMS has not been called

FOR TEETH: rinse with gentle stream of water

• Place back in tooth socket

• Place gauze between teeth

• Have person bite down

• Get them to EMS, hospital or dentist

• Puncture

• Often deeper and more serious than they appear

• High risk for infection

• Flush especially well

• Recommend that they get further care, or give good aftercare instructions on signs of infection

• Impaled object -- puncture wound, sometimes all the way through, with object still in place

Trainer notes: you can have a co-trainer use duct tape to make a stick or something stand up like it is impaled another co-trainer's hand or arm; stabilize it with bulky objects and roller gauze as you narrate

• DO NOT remove the object; it may be blocking damaged blood vessels, and decreasing bleeding; it may cause more damage coming out. If a person is impaled on the fence, they move the fence with the person

• Place sterile dressing as first layer

• Then place bandaging around the impaled object, so that it does not move (donut bandage can be useful)

• If possible, pile up bandaging until it is up to the highest point in the impaled object, place bandage over object, then wrap entire area with rolled gauze

• Transport to hospital or wellness center.

• Animal bites (human and non-human)

• Very high risk of infection, especially human bites

• Almost always need antibiotics to prevent serious infection.

• In some cases, it is recommended that folks with animal bites get rabies shots

• If at all possible, get animal that did the biting (it will be quarantined)

Aftercare for bleeding injuries

• Watch for signs of infection: increasing redness, swelling, pain. pus (after first 24 hours), fever, red streaks going up arm

• Keep covered any time it may get re-injured or dirty, until the wound has a scab or is healed over

• Consider leaving it uncovered when it won't get dirty or reinjured, so it can dry out

• Nutrition is very important: for wound healing the body needs a good supply of vitamin C and zinc. vitamins A, E, the entire B vitamin family, calcium and magnesium also may help with healing from wounds and burns, so eat well

• Give "care of cuts and scrapes" aftercare sheet