Precisely.



Potentially, but totally organ dependent and of questionable reliability, particularly with the lay provider. The difficult part in medicine is often not identifying what it is, but rather what it is not. With most issues at the heart (No pun intended) of this issue there will be an exceedingly long list of differentials.



Honestly, this is one of the primary concerns with suturing in the field by lay providers who have minimal skills or equipment to properly close and then prevent or treat infection. As I've said before, a wound closed is a wound that cannot be effectively monitored for infection. Steri-strips are your friend. I would not recommend placing a straw in any partially closed wound.



It's a better option than using dirty rags, but certainly not ideal. Boiling will destroy most, but not all, organisms. Again though, lacking a better option this might be your best. Make sure they're clean, boil them effectively, and use as low a lint count as possible to avoid additional contamination.




I've never seen or heard evidence as to the effects of water temperature at the time of irrigation. That said, it would stand to reason that one should avoid either hot or cold and stick as close to tepid or room temperature as possible. This would be to avoid additional tissue damage caused by heat, but also (and primarly) for patient comfort. As far as water out of the stream goes, no. While tap water has been shown in multiple studies to be an acceptable irrigant, absence of contaminants must be ensured to the best of your abilities to prevent infection. My preference would be filtration followed by boiling and allowing to cool.




Patient presentation. Altered level of consciousness, fever, anorexia, decreased urine output, increased WBC count if available, an increase in both heart rate and respiratory rate, and eventually, signs of hemodynamic instability are all indications of systemic infection. These will vary based on the extent of the infection, obviously.

G-

Okay, so this might be a stupid question... but IF you get a wound infection and there's just not much else you can besides trying to keep it clean and you have no antibiotics, will the patient ever get better?

When I was 10 years old, I ripped the back of my right hand open. I thought it'd get better just like every other scrape and boo-boo I'd ever had up to my life at that point. My parents cleaned it up, topical antibiotic ointment, etc. and ice for swelling. It sort of did, but stayed swollen and after 1.5 months, it began to ache and I had red streaks going up my arm. I was in Japan and we went to a doctor at month 2. He freaked out, had some orderlies come into hold me down, did a local anesthetic injection around the wound site in 3 places. I still scars from the injection spots. The scar is about 2.2" long and 0.25" wide. When it originally happened, I thought I had broken a bone(s) and could see sections of the bone. During the 2 months I was hoping it would get better, my hand strength gradually declined to about 30%. Today, I would guess that my right hand is about 90% the strength of my left.



After the anesthetic, they cut the wound open with a scalpel and squeezed and squeezed. It hurt like nothing I have ever felt before or since. As Apache noted, epinephrine in a wound stops bleeding and at this point, I realize that the Japanese doctor did this and then took swabs and began scraping around under the skin into the wound, squirted a bunch of water in it, redid the anesthetic injections, and then did it all over again. Rinse and repeat. 45 minutes later after another rinse and repeat, they painted my hand and wound with iodine, wrapped my hand up, and sent me home with piles of antibiotics. After that, within 1 month my hand was getting stronger and I had to start practicing making fists to stretch the scar out. They said they weren't going to stitch it up because it'd prevent me from being able to make a fist.

Since coming back to the US, every doctor has asked me about it and wondered why the scarring is so bad and they didn't stitch it up. PAW... it'll be worse scarring, but what are the odds that an infected wound heals on its own?

Almost all wounds would heel on their own. By stitching things we speed it up and improve the cosmetic outcome.

EricinMaryland - sounds like you got infection established in your wound, this would be common.

So, Apache... had I not gone into a doctor, you think this would have eventually healed up on its own?

Probably not. Red streaks are incredibly Bad News.They indicate that blood poisoning is setting in, and (in my very limited understanding) mean that you either need cleaning and heavy antibiotics very quickly, or an amputation, or a handy burial plot.

Wait.

They used lidocaine with Epi in your hand? WTF over?

Ea Ea! Wakarimasen
That's interesting. I don't get it, I wouldn't have done it. But its interesting.


With any infection, one of of two things happens.

Your leukocytes man up and woop that ass. (The infection goes away)
Or they don't. (The infection gets worse)

If they don't the infection will either spread, or it will stay as big and nasty as it currently is in kind of a WBC stalemate.

If it gets big enough bad things

sore kara, nihongo de hanashiteirunoka? boku mo wakaranai sono koto.

It's one of those things that when I look back on it, I often wonder how it would have played out here in the US. Cruching, grinding, being poked, getting stuck, slipping... anything that triggers an infection AND YOU DO NOT have medical care or antibiotics or anything, really all you can do is pack the wound, keep it clean, clean it often, dress it, and hope for the best. All of it seems applicable to PAW, and in this thread so far, if you have surgically do anything at all, you're basically creating a deep wound.

Low Key is running a story thread about chopping your foot and/or hand with an ax. In my case, my hand got caught in the middle of my sister falling out of a closet onto the edge of a chair back and the wound was caused by the back of a chair. Fun stuff. In PAW, we'll be around all this debris that will be awful. And don't let Low Key near you with any scenario-based accident in waiting.

And we have a new volunteer for a FA story thread. Thank you Eric, readers here and future generations will thank you for your sacrifice to PAW medical science.

It's a relative contraindication. It gets done plenty of times when your going to be sewing for awhile and want to minimize blood on the field, and there are generally no negative effects on PTs that have decent circulation. Think of the vasoconstriction issue as the suturing myth equivalent to "if you put a TQ on 'em, their arm is going to die off!" Occasionally true, but also mostly false.

What he said.

In regards to whether or not all wounds will heal on their own, I would argue that in a healthy, young individual, odds are most minor infections will heal on their own. That does not mean that all infections will heal on their own, not by stretch. All we have to do is look at the post-injury mortality rates that occurred in any conflict prior to the advent of penicillin and sulfanamides to see the truth in this.

G-

Tell it to the malpractice attorney? =)

Organ damage that's serious enough to worry about will show dire signs sooner or later (probably sooner). Most of the organs are well-perfused (meaning, they have a very good blood supply), particularly the kidneys, spleen, and liver, so surgical intervention is required to stop the bleeding. Direct pressure to an organ is not really practical, and is contraindicated.

Organs aren't ennervated the same way as the skin, so symptoms of damage won't always be as obvious or specific. Your patient won't say, "ow, my spleen!", but will complain of abdominal pain that can usually (but not always) be narrowed down to one of the four quadrants of the abdomen, which increases the likelihood of identifying which organ is affected. Signs of uncontrolled bleeding from an organ laceration are the same as for any other cause of severe bleeding (hypovolemic shock: mental status changes, rapid but weak pulse, cold clammy skin, blood pressure dropping, etc), but there won't necessarily be any visible bleeding since most or all of the blood will be just collecting in a body cavity.

If the liver is damaged but not fatally, you may see some jaundice in the skin over a longer period, but the liver has pretty good regenerative capability, and as long as the blood supply from the portal vein isn't dumping out of a laceration, they might be alright with supportive care.

The classic signs of appendicitis are right-lower quadrant abdominal pain, and often "rebound tenderness" (press down and it doesn't really hurt, but hurts when pressure is released) occurs in another abdominal quadrant. As mentioned, though, "classic" does not mean "always". There are LOTS of things that can cause abdominal pain: recent history of trauma, of course. In females of child-bearing age, ectopic pregnancy must always be considered and ruled out (urine pregnancy tests aren't generally considered to be sensitive enough for testing for an ectopic pregnancy). Or, the patient could just be full of shit (constipated), etc.

Surgeons used to install a "Penrose drain", which is just a short piece of soft rubber tubing to allow the wound to drain, and secured to the outside of the wound with a suture. These have recently fallen out of favor, as they are a two-way street: leaving an open-ended tube exposes the wound to invasion. However, in less than ideal conditions a Penrose drain could be used. A much more ideal wound drainage setup is a JP section bulb or a Hemovac. Both work under the same principle: a tube is secured in the wound, with a bulb on the other end. When the bulb has the air squeezed out and is recapped, it is a now wound drainage tube with a small amount of passive suction on the end of it.

In my experience, patients roll over and pull these wound drains out about 1/3 of the time. We don't put them back in when this occurs (it's more of a surgical procedure), but you can expect more swelling and discomfort at the site without a drain in place.

Packing accomplishes the same thing as a wound drain, as well as providing a debriding effect, but requires more maintenance and daily repacking. Quarter-inch or half-inch packing gauze is ideal for this. We get ours packed loosely in a sterile plastic jar, and it's a tighter weave than kling gauze so it doesn't leave a bunch of fibers in the wound.

I would not re-use gauze if I could at all avoid it, but as was mentioned you CAN clean and sterilize used gauze if you have to. In a pinch, any cloth can be cut into strips and sterilized for wound packing, but the fewer fibers it leaves behind the better.

Malpractice makes malperfect...

Actually the long standing contraindication for the use of epi for digital blocks has long been abandoned by the medical community due to extensive clinical findings that have shown that concerns regarding ischemic necrosis complications due to vascoconstriction in digits is completely without merit. Although the pharmacokinetics seem quite plausible, a quick search in google will provide you with more clinical studies than you will likely ever care to read.

Here's a few links that have been cited before, although not all of them may not work for you:

http://www.pubmedcentral.nih.gov/articl ... id=2526033

http://www.aafp.org/fpr/20011200/8.html

http://www.caep.ca/CMS/temp/pg245.pdf

http://www3.interscience.wiley.com/jour ... 1&SRETRY=0

Jim

Painiac, thanks for the organ info... I didn't realize that the appendix test was more about letting up on the pain. Fortunately, I've never had it. The quadrants thing makes some sense.

Is it pretty safe to say that if you get any trauma damage, that rips open or punctures an intestine (either one) or the stomach, that the person is pretty much screwed?

Yes

Vets still use penrose drains occasionally

Thanks Para, ill have to go through these in more detail.

However,

That's from the http://www.aafp.org/fpr/20011200/8.html you linked

This article states Lido with Epi isn't the end of the world but still isn't the cocktail of choice.
Which was kind of my understanding, the risk is there however small.

Very much so.
Digestive enzymes alone spilled into a body cavity are a very bad thing. Outside the parts of the organs that are specifically protected by excreted mucus, these enzymes start to digest you just like they do the things you eat. Obviously, this is agonizing (see peritonitis, pancreatitis, gallstones, etc. for similar pathology).

Not much aside from the bacteria H.Pylori (the cause of bacterial stomach ulcers) can survive an extended period in the stomach, but the intestines are loaded with bacteria. The interesting thing to remember about the gastrointestinal tract is that its contents are not technically INSIDE the body: the entire digestive system is a permeable tube, with the body actually arranged around it. Bacteria live harmlessly in your intestines, but if something allows them into your body itself, this quickly becomes a serious problem.

Bowel perforations are severely dangerous even with immediate expert surgical intervention and strong antibiotics. Outside of these ideal conditions, death is probably inevitable.