Saturday, December 1, 2012
Wound Care (from scrapes to sutures)
By George E. Dvorchak Jr. M.A., M.D.
SKIN, which covers our body, has the important function of protecting the
internal organs and tissues from the environment and physical objects.
Technically, this protective covering is also our largest body organ
and the first line of defense from in juries and bacteria. With injury,
the outer layer of skin, the epidermis, is either scraped away or
opened-up to permit bacteria and materials to enter. In a more severe
wound, the next layer downward, the dermis is penetrated. This
contains connective tissue, sweat glands, hair follicles, nerves, lymph
and blood vessels. Generally speaking, the deeper the wound, the
more serious the consequences it can have for the body.
As survivalists, you want to be prepared for about anything at any
time. Therefore, the best approach to a presentation on wound care is to
cover everything from the simple closed wound to more serious injuries.
In these, the skin has been compromised and the wound is therefore
referred to as open.
CLOSED WOUND TO THE SKIN: This is the common BRUISE or CONTUSION which
is caused by a blunt object impacting upon the body. The result is that
blood will begin to leak from the injured vessel under the skin which
then causes that area to change color to a black or blue. The good thing
with this injury is that because the skin has not been broken, infection
is not a great possibility. Therefore, the immediate first aid treatment is
to apply ice for about 10 minutes and then throughout the day.
Even though the skin was not broken, this could still be a serious
problem, one depending on what was injured beneath the skin and the
amount of force that originally caused the injury. If an internal organ
in the abdominal area was severely injured, bleeding could be taking
place internally without evidence externally.
When traveling or hunting with horses, an injury could happen by simply
stopping to adjust a load on a pack horse. If he gets spooked and you
kicked, an internal injury could result. A hard kick to the abdomen when
days from medical care could cause internal bleeding that may be fatal.
Not all is obvious at all times!
OPEN WOUNDS TO THE SKIN: It is in this category where everything from a
band-aid to sutures are necessary along with special considerations
and concerns. In beginning with the least serious of six major
categories of open wounds, we have the ABRASION. This is where the outer
surface of skin has been scraped away as from a scratch or rope burn.
There is usually some minor oozing of blood and serum.
Depending on how the injury was obtained, there is usually dirt or
foreign matter ground into it. This problem brings to light another
player against wound healing, infection. The treatment now goes beyond
the application of ice. To treat an abrasion as a scraped knee, the wound
must first be cleansed with soap, water and if available, hydrogen
peroxide. This will remove dirt that will cause an infection and therefore
impair healing.
Once cleaned, the wound should be blotted dry with a clean cloth or
preferably a sterile gauze. It now would also be a good idea to apply
pressure over the injured site for a few minutes for the purpose of
slowing down and hopefully stopping any bleeding. The application of a
first aid or antibiotic cream to the abrasion could help to prevent
infection and keep the bandage that you will apply from sticking to the
raw wound. For the best protection, the bandage should cover an inch
beyond the wound. An ice pack over the final bandage can serve to reduce
swelling and some of the discomfort. The next category of wounds is the
INCISION. This is made from a sharp knife-like object that leaves a
clean cut. To keep this one separated from the next, think of a surgical
incision where the cut edges are smooth.
The third is the LACERATION which is similar but with jagged edges
due to a tear. Because these go beyond the outer layer of skin and into
the deeper layers that contain blood vessels, there is a lot of bleeding.
If you were deep enough or unlucky enough to cut an artery, blood will
squirt out with each heart beat due to the high pressure in these
vessels. The best approach here is to apply a pressure dressing and get
to medical care where sutures will usually be needed to fully or
partially close the wound, depending on if it was dirty or clean.
Because suturing is a common medical procedure, I will later outline some
information on what is involved to better inform you of your doctor's
options.
The next wound is the PUNCTURE. As its name implies, this is when a
foreign object is pushed into the skin. This could be a splinter that
only penetrates the superficial layers of skin or a nail, sharp stick or
fishing hook that penetrates deeper. With this you usually will not see
much external blood which does not mean that there is little internal
bleeding. To treat something such as a puncture wound to the foot from a
nail, all you can do is to put ice on it along with a pressure wrapping
and get to medical care. This is critical since if you are not
already protected against tetanus, you will need to get an injection for
such protection. If you are in the outdoors a lot, it pays to keep
your immunizations updated.
The next skin wound is the AVULSION. This is where skin is pulled
or torn off. As with an AMPUTATION, the severed tissue should be saved
and taken with you to the hospital. If a finger, a pressure dressing
over the stump or if skin, again a pressure dressing over the wound is
about all one can do until medical facilities are reached. One other
point should be addressed concerning "serious wound" dressings. That
is, once a dressing is applied, leave it alone and do not take it off
every 20 minutes to check the wound. If unnecessarily disturbed, all you
will be doing is to undo the positive measures already applied.
WOUND MANAGEMENT SUMMARY: The first concern with any wound is to control
bleeding. On the first aid level, this usually means through the use
of a pressure bandage. The next concern is to prevent wound
contamination which refers to cleaning the wound and applying a sterile
bandage and possibly an antibiotic ointment. Lastly, immobilization of
the inured part along with rest and if severe, medical intervention, are
all wise procedures.
The Mystery Of Sutures - Many of us while growing up had to be sewn
back together. My father, a small town GP who did it all put six in my leg
and another six or seven in my chin all before the age of 12. If you
were like me, you just wanted to get it over with and therefore could
not have cared about details. In the following, I will give a general
summary of what suturing encompasses. Hopefully, this will help to lift
some of that curtain of mystery concerning this common procedure.
THE SUTURE ITSELF: The thread like material attached to a curved
needle or used on a straight one is absorbable and used internally or
nonabsorbable and used internally and externally as in holding skin
together. Some of the materials used in the non-absorbables and that
which we are concerned with are made from silk, cotton, nylon, dermal
and stainless steel. One of the reasons for all of the different
materials concerns tissue reaction to something foreign to the body even
though it is serving a purpose. All the body knows is that there is a
foreign substance within it that was not there before. The body can
then react against this invader and you will get a tissue reaction.
The reason stainless steel is popular in surgery by some surgeons is
that of all the suture materials, it evokes the least tissue
reaction.
Suture size is also important since different materials and weights
of thread are matched to the task and tissue. Generally speaking, suture
material should not be stronger than the tissues it is expected to hold
together. Of all the sutures, those of silk or nylon are most widely
used in holding skin together. The size is designated as 2-0 or 00, 3-0
or 000, etc. The smaller the number, the stronger the material. To hold
skin together, a 000 or 0000 is generally used. Needles attached to the
thread can either be straight or curved with those curved most commonly
used in your doctor's office. With ones curved, a needle holder or
hemostat is required to use it.
A friend of mine who is an orthopedic surgeon told me that he would
recommend a straight needle for use in the outdoors to close the skin
since a needle holder is not needed. When using a continuous suture
with a straight needle, this would be the quickest way to close a
skin wound. If you are heading into remote areas and feel that you
would like to know how to do this, I would recommend that you ask your
family doctor for advice since he best knows you and would be the one
to advise you on this. Yet, for most lacerations, a pressure dressing
over the wound would be the preferred procedure until medical care
would be available.
Another consideration your doctor will have to be careful about is that
after skin has been sutured back together, edema or swelling of the
tissues usually enters into the picture. If the suture was originally
tight, with swelling, it will soon be too tight. Therefore, proper
tension the first time the job was done is critical to good healing.
The purpose of suturing is to pull the tissue together just enough
so that there will be no dead spaces below the skin where blood and
fluid can accumulate. If there is, it will eventually be a breeding
ground for an infection. In staying with how sutures are put in, it is
also important that the same amount of tissue be included on each side
of the suture.
If the suture includes more tissue on one side than the other and/or the
needle is inserted deeper on one side than the other, when tied together,
the skin edges can overlap causing poor wound healing and/or a scar. All
your doctor wants to do is to put the severed edges back like they were
before the accident so that the body can complete the job of healing.
Because a medical emergency as a laceration can happen anywhere with
the worst place being when medical care is not readily available, I
would highly recommend a Red Cross first aid course. Once this is
completed, I would then recommend that you take advanced courses and
hopefully get certified as an Emergency Medical Technician. Also, if
you go on outfitted back country hunts, one of the questions you should
ask of the outfitter/guide is if he or she is certified in first aid. In
the event that your guide would get inured, it would also be to everyone's
advantage if you were qualified to help him.
A rule of good medicine is to do no harm to your patient.
Therefore, take a first aid course and learn how to help yourself and if
the situation presents itself someone else.
(This article was optically scanned from :American Survival Guide January
1992
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