WWYD for the First Aid section: Rusty Nail.

Discussions of the best (or worst) equipment to have on hand for use in the event of an injury during an emergency.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by shrapnel » Wed Jul 24, 2013 2:36 pm

Silly but serious question- I know you aren't supposed to feed infants honey, because botulism. Is botulism only bad when you ingest it, or could the spores getting into a wound be Bad News on their own? I mean, given the option between impending sepsis, and maybe later wound botulism, I know which I'd choose, but if you aren't using medical grade honey, is it a thing that one should consider?
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Re: WWYD for the First Aid section: Rusty Nail.

Post by Browning 35 » Wed Jul 24, 2013 3:38 pm

Veritas wrote:Just to dispel a myth I keep seeing on here, you don't need to pack or drain a wound that is not infected. Packing/drains/any foreign body does not prevent infection. You place these things in wounds/abscesses that require draining of pus, not to prevent a fluid collection prophylactically.
Great comments in the post above this one, I'm only quoting this to point out that in the OP the wound is already infected that is red with pus coming out.
You are awaked by throbbing pain and heat in your left foot at 4am, and look down to see it is swollen and red, with a yellow discharge seeping from both sides of the wound.
The time to do something would have been immediately after reaching home where your medical supplies are. Not the next day.
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Re: WWYD for the First Aid section: Rusty Nail.

Post by okiebill » Wed Jul 24, 2013 3:57 pm

You do not have to pack a deep wound that is not infected BUT...

Packing the wound with moist Gauze or the like and changing frequently will keep the wound from drying out ( inhibiting new tissue growth). It will also prevent the wound from healing unevenly or forming a pocket ( Deep ones should heal from the bottom up). Changing the packing will also let you monitor for infection ( Your nose will tell you) and monitor the healing process...

The moral of the story is go ahead and pack it as it will do you nothing but good :D

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Re: WWYD for the First Aid section: Rusty Nail.

Post by painiac » Thu Jul 25, 2013 7:29 pm

shrapnel wrote:Silly but serious question- I know you aren't supposed to feed infants honey, because botulism. Is botulism only bad when you ingest it, or could the spores getting into a wound be Bad News on their own? I mean, given the option between impending sepsis, and maybe later wound botulism, I know which I'd choose, but if you aren't using medical grade honey, is it a thing that one should consider?
Excellent question! Answering it requires a brief primer. Botulin is the most potent toxin known, with a dose of only 0.05 micrograms being potentially fatal. It is a neurotoxin that causes temporary muscular paralysis, with death usually occurring from paralysis of the musculature of the respiratory system. Botulin is produced by the bacteria Clostridium botulinum. The bacteria produces spores, which can contaminate improperly canned foods, or canned foods that have been breached. The bacteria requires an anaerobic environment to grow.

There are actually several ways to get botulism (botulin poisoning).

1) Ingesting food that has been contaminated is the one most people think of: even just a taste of such food can contain enough toxin to be potentially fatal.

2) As you know, babies being given honey is an associated vector, because their immature digestive system is an anaerobic environment with a higher pH than an adult's. An adult's stomach has a pH of around 2 or 3, so the spores are neutralized. A baby's digestive system is a more friendly environment in which the bacteria can grow and release its toxin.

3) Surprise! Soil contamination in a wound is another possible vector. Remember how I said it requires an anaerobic environment? A wound is just such an environment.

So why doesn't everyone who packs wounds with honey get botulism? If honey were a neutral substance that contained botulinum spores, that's exactly what would happen. Fortunately, honey is a harsh environment to any bacteria because of its high sugar content. Such a high concentration of sugar destroys bacterial cells by hyperosmosis. The downside to this is that if you apply honey to a wound once and then leave it alone, the tonicity of the wound will equalize from your own cells' water, and all you'd have accomplished would be to have provided any surviving bacteria with a ready source of food. That's why honey packing must be done at least a couple times a day, depending on how quickly it's becoming diluted. Properly packed, Clostridium botulinum cannot survive in such an environment any better than any other bacteria.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by Jorian » Thu Jul 25, 2013 9:57 pm

How 'bout chlorhexidine gluconate? We usually have some mouthwash around with that stuff in it. Would whatever else is in the mouthwash (flavoring? Not much - it tastes terrible) constitute a risk?

Where's Jim? I think he told us once that they have wound treatments in Europe based on it...

Chlorhexidine a biguanide antiseptic, is prob-
ably the most widely used biocide in antiseptic
products, in particular, in hand washing and
oral products but also as a disinfectant and
preservative (9,17). It is produced in two forms:
a 0.05% dilution for wound cleansing and a 4%
solution for use as a surgical skin preparation
and hand scrub. Recently 2% solutions have
been made available for surgical skin prepa-
ration (10,12). Chlorhexidine gluconate (CHG)
has been used for more than 30 years in the
clinical setting. It has a high level of antimi-
crobial activity, low toxicity and strong affinity
for binding to the skin and mucous mem-
branes (12). It seems to impart its antimicrobial
activity at the membrane level, damaging both
outer and inner bacterial membranes, causing
leakage and possibly disrupting membrane
potentials critical for ATP generation (9,17).
It disrupts the microbial cell membrane and
precipitates the cell contents.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by painiac » Fri Jul 26, 2013 1:36 am

Jorian wrote:How 'bout chlorhexidine gluconate? We usually have some mouthwash around with that stuff in it. Would whatever else is in the mouthwash (flavoring? Not much - it tastes terrible) constitute a risk?
No antiseptics have any reasonable place in wound cleansing.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by Jorian » Fri Jul 26, 2013 6:52 am

painiac wrote:
Jorian wrote:How 'bout chlorhexidine gluconate? We usually have some mouthwash around with that stuff in it. Would whatever else is in the mouthwash (flavoring? Not much - it tastes terrible) constitute a risk?
No antiseptics have any reasonable place in wound cleansing.
From Medscape:

"Chlorhexidine has been commonly used in disinfectant and antiseptic solutions. Chlorhexidine antiseptic solutions are used mainly in urology, gynecology, dentistry, and in the treatment of wounds. It is highly bactericidal.

Several animal studies have tested the efficacy and safety of chlorhexidine on wounds ( Table 5 ). It has been found to have mild inhibitory effects on wound healing in guinea pigs.[87] Chlorhexidine diacetate was found to accelerate wound healing in full-thickness wounds in beagles.[88] Chlorhexidine was also found to be relatively safe for use as a surgical wound irrigation solution, since only the higher concentrations tested (0.05%) caused slight tissue toxicity in rats.[89] Lower concentrations (0.02%) are recommended for wound irrigation. In other studies, it was found to cause inhibition of granulation tissue in guinea pigs[57] and decreased tensile strength of wounds in rats.[90] However, Brennan, et al., found no decrease in collagen production in a rat model,[91] and Shahan, et al., also in a rat model, found decreased tensile strength 48 hours after the treatment and significantly increased strength at 96 hours, since chlorhexidine decreased the healing time.[92]

In human studies, chlorhexidine rinses were shown effective in reducing microbial complications when used perioperatively in patients that received dental implants.[93] Conversely, in another study, it was found to be ineffective to reduce wound sepsis rate and length of hospital stay in patients that had undergone appendicectomy.[94] The authors speculate that reinfection from within as an explanation for the lack of chlorhexidine efficiency.

Chlorhexidine appears to be relatively safe with little effect on the wound healing process, and its use may favor healing of open wounds in risk for infection. However, the results from studies to date are insufficient to draw conclusions about the use of chlorhexidine on open wounds. More human trials need be performed to assess its efficacy and safety."


Sounds like good old clean water might be the best bet. Great thread Crypto - so many of the "WWYD" threads are about stuff that rarely (or never) happens.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by medic photog » Fri Jul 26, 2013 8:12 am

I'd start with getting in there and opening it up followed by a couple 2,000 liter saline bags to flush it out. I would guess the administration set would work well at getting the fluid into and out of the wound and you can always use a pressure infuser or b/p cuff to up the pressure if needed. I've seen a lot of negative pressure wound treatment therapies lately and over pressure high oxygen concentration stuff too. Bottom line is, this needs to be opened and flushed. Anybody else here besides me work any of the "recent" disaster ie 9-11 Katrina, Sandy, Haiti? It's the "little things" that always seem to be the biggest issues. I treated more foreign body eye issues. simple scrapes. lacerations, sprains, blisters than other things. One of the first things you loose in these is potable water, then any sanitation so expect everything to be dirty, contaminated, nasty. You can then add the location's prior health and sanitation issues to the formula and the problem becomes huge in a lot of instances.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by sigma42 » Fri Jul 26, 2013 9:33 pm

BY DALLAS
I forgot to mention. Unless you are up to date on your tetanus, you have a good chance of not making it no matter what antibiotics you have stashed away in that scenario.
ditto, and

BY TACAIR
Remove boot and sock. Prepare a betadine (povidone-iodine) solution in an emesis basin (or SS salad bowl) with warm water. Use enough of the PVPI solution to darkly color the water.

Soak the foot for at least 20 minutes, if the bleeding isn't copious, let the wound bleed.

Rinse the foot and dry using care around wound site. Apply an antibiotic paste to top and bottom of foot, dress and bandage. Check twice daily.

If signs of an infection appear, start with warm salt water soaks, dry and loosely bandage. Seek medical help.


I was bitten by a cat on my hand, and this combo was the only thing that saved my arm from being whacked off.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by Doc8404 » Fri Jul 26, 2013 11:56 pm

Sorry to jump in, I only read the first page and caught glimpses of this page. So I apologize if I'm repeating anyone or going all over the place like I am now lol. Plus, I am not as good as I once was, sooo my bad. :words: I'm also talking as if I'd have my BOB web gear on me or if I had packed it with me, which I would had if I was taking a ferry somewhere.

Definitely irrigate it copiously with NS using a syringe I have with a plastic catheter attached, I've heard of adding salt to the NS but I don't remember the amount to add per liter. Since my foot is showing definite signs of infection I'd irrigate like crazy lol. I'm assuming the wound site is about a 1/4 inch at the openings and since the wound may have closed up some from swelling, if not or even if it has swollen, although after I had gotten the injury I would have already had used some sterile gauze to place it into the wound to prevent the abscess cavity from forming and allowed my foot to drain more and get more bacteria out. But if in your scenario I hadn't and I covered the wound, which I wouldn't have done on a puncture wound I'd be downing my bottle of erythromycin immediately.

Since the foot is already infected, after irrigation and taking some antibiotics, hopefully I wouldn't come down with a fever :lol: shit in one hand, right? I'd apply a warm compress using disinfected water to the wound at least 3 or 4 times daily, When I dressed the wound without, hopefully, bringing the edges of the puncture site closer together, using a good absorbent sterile and DRY bandage. Other then that I guess cross your fingers and hope there are no feeling of "rice crispies" around the wound site and no gray fluid which would indicate I'm about to amputate my foot or die of gangrene. That's all I got.


Edit: I wouldn't have worn my web gear and I wouldn't have had my rifle on me though.
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Re: WWYD for the First Aid section: Rusty Nail.

Post by GhostlyKarliion » Sun Jul 28, 2013 1:22 pm

dallas wrote:
Braxton wrote:Spray the puncture liberally with carb and choke cleaner*. Use the little tube they give you to get deep into the wound. This will flush out all the crap left in from the nail.

Now that you have it clean and filled with a flammable substance, light that shit on fire. Fire kills all, and stops the bleeding.

I am 100% serious.

I have done this before.

ZS people ( including a MD) have watched me do this to myself.

I an't dead yet.

*In a pinch Brake Cleaner can also be used. But it does not burn as well.
So, you go from a simple penetrating wound to one with chemical and thermal burns. Nothing like killing cells and scrambling their DNA with carcinogenic substances to speed healing.
When I saw this banter, this was the only thing I could think of:

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ETA: I am not doubting that either procedure works (the HIV treatment was surprisingly successful, as I am sure the "thermal irrigation" of the wound with growth inhibiting chemicals would be), but I wonder if the risks of the proscribed treatment outweigh the potential gains.
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Re: WWYD for the First Aid section: Rusty Nail.

Post by Veritas » Sun Jul 28, 2013 11:26 pm

okiebill wrote:You do not have to pack a deep wound that is not infected BUT...

Packing the wound with moist Gauze or the like and changing frequently will keep the wound from drying out ( inhibiting new tissue growth). It will also prevent the wound from healing unevenly or forming a pocket ( Deep ones should heal from the bottom up). Changing the packing will also let you monitor for infection ( Your nose will tell you) and monitor the healing process...

The moral of the story is go ahead and pack it as it will do you nothing but good :D
I'm not sure I agree with that. Most texts do not recommend packing routinely, even for abscesses, most EM literature seems to state that packing only increases pain and discomfort, and if it is already draining then there is obviously not a reason to worry about an enclosed pocket that cannot drain, which is why you place a drain in the first place. Deep wounds do not necessarily need to heal by secondary intention. It sounds like this may need to be opened up, explored, irrigated, etc. Then wet-to-dry dressings may be appropriate, but routinely packing wounds (esp simply to monitor for infection, or promote healing by secondary intention) truly is a bad idea, unless you are aware of new research indicating it is not.
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Re: WWYD for the First Aid section: Rusty Nail.

Post by duodecima » Mon Jul 29, 2013 12:52 am

Great thread!

I realize that the wound is already infected in this, but copious (lots and lots anf then some more) irrigation with water. I would also be trying to rinse thru that tunnel. Myself, I'd be using a 1 1/2" needle on the syringe, probably. Or, as suggested, just insert the tip of the syringe and if water comes out the other side of the foot, be happy!!

Once it's infected, I'd use heat and elevation. I would consider taking a sterile blade and opening the tract for better drainage - and I would irrigate if I could, to make sure the pus was getting out. There are arteries and nerves and tendons and shit in there, so slicing your foot open further is not to be done lightly, obviously. I would try opening it with a clean (preferibly sterile) long blunt object first, before cutting. Ironically, boiling another long nail might be the best bet. (My instant- read kitchen thermometer probe also comes to mind.) Either way doing it is going to hurt like a mother fucking bitch, btw.

If the bugger kept trying to close up when it needed to drain, I would absolutely try to pack it open, the ribbon gauze (iodoform or not) would be great - but any clean wicking material that would stick together so it could be pulled out and not leave bits of itself behind would work. Boiling a shoelace or a cloth ribbon comes to mind (altho I personally do have ribbon gauze.)

Crypto, I don't think this is a scenario where the only useful thing is antibiotics. Hell, depending on how agressive this is, no oral antibiotic may be good enough, if it's going septic in just a few hours. +10,000 to the previous poster who emphasized using your comms to use any official or unofficial resource to get yourself off the island and to hospital care - THAT is the single most important thing in this wwyd. Second most important thing seems like clean water, for prevention and treatment. Good wound care might prevent, or at least buy you time. Even the most kill-em-bugs-ded IV antibiotic cannot take the place of proper wound care. That said, antibiotics are sometimes life saving, but for a bunch of those times, we're talking IV, not anything we can practically keep in our BOBs.
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Re: WWYD for the First Aid section: Rusty Nail.

Post by JackBauer » Mon Jul 29, 2013 6:10 pm

duodecima wrote: ... +10,000 to the previous poster who emphasized using your comms to use any official or unofficial resource to get yourself off the island and to hospital care - THAT is the single most important thing in this wwyd. Second most important thing seems like clean water, for prevention and treatment. Good wound care might prevent, or at least buy you time. Even the most kill-em-bugs-ded IV antibiotic cannot take the place of proper wound care. That said, antibiotics are sometimes life saving, but for a bunch of those times, we're talking IV, not anything we can practically keep in our BOBs.
Duo, thanks! I believe thats the first + 10, 000 ive gotten on the internet!
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Re: WWYD for the First Aid section: Rusty Nail.

Post by okiebill » Mon Jul 29, 2013 8:15 pm

Veritas wrote:
okiebill wrote:You do not have to pack a deep wound that is not infected BUT...

Packing the wound with moist Gauze or the like and changing frequently will keep the wound from drying out ( inhibiting new tissue growth). It will also prevent the wound from healing unevenly or forming a pocket ( Deep ones should heal from the bottom up). Changing the packing will also let you monitor for infection ( Your nose will tell you) and monitor the healing process...

The moral of the story is go ahead and pack it as it will do you nothing but good :D
I'm not sure I agree with that. Most texts do not recommend packing routinely, even for abscesses, most EM literature seems to state that packing only increases pain and discomfort, and if it is already draining then there is obviously not a reason to worry about an enclosed pocket that cannot drain, which is why you place a drain in the first place. Deep wounds do not necessarily need to heal by secondary intention. It sounds like this may need to be opened up, explored, irrigated, etc. Then wet-to-dry dressings may be appropriate, but routinely packing wounds (esp simply to monitor for infection, or promote healing by secondary intention) truly is a bad idea, unless you are aware of new research indicating it is not.

Veritas, I was referring to packing an infected puncture wound that was opened for cleaning / necrotic tissue removal only and did not mean to imply that someone should pack anything they can stick gauze in :oops:

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Re: WWYD for the First Aid section: Rusty Nail.

Post by greenbeetle » Tue Jul 30, 2013 7:12 am

abelru wrote:Two words to consider;
1) Pseudomonas
2) auriginosa

Four other words to consider;
1) Foot
2) infections
3) suck
4) balls

Puncture wounds through sweaty, nasty, fetid footwear are known to carry an increased risk of resultant P auriginosa infection. So much so that prophylactic coverage with fluoroquinolones (or a suitable alternative) is standard of care for just such an injury.

Considering this (and assuming the unavailability of antibiotics), I would explore the puncture site and consider debridemont of any questionable tissue, and evacuation of all purulence followed by aggressive soaks with a hypertonic solution or a betadine solution. Would consider concomitant fasciotomy if swelling is significant since I'm already cutting my own foot.

But also considering the fact that normal/first world treatments are unavailable, would also consider early amputation if entire foot is erythematous with pus expressing from the puncture site(s). Especially if I am beginning to demonstrate signs of systemic response/sepsis.
Although, as I think about it, a partial amp or disarctic of my own foot sounds like a fucking nightmare.

Really. A fucking nightmare.

+1. Through and through puncture wound to foot from rusty nail that is already purulent = antibiotics +/- debridement and drain to keep wound from closing. If the infection is not a deep tissue one already it will be soon without treatment. The idea of treating this without antibiotics is extremely dangerous. Understood OP acknowledges this. In the scenario presented, if no antibiotics or healthcare available and signs of advancing infection occur over a day or two, I also would consider amputation as a last ditch life-saving effort.

A fasciotomy of an infected limb without antibiotics is fruitless. Besides requiring a surgeon it is excruciatingly painful and results in a useless limb that must be frequently dressed, changed, oozes large amounts of fluid / blood and must be kept sterile. Outside of a hospital setting an effective fasciotomy is 1. not possible 2.excruciatingly painful 3. likely to result in hypovolemic shock 4. take a quinolone and go to the hospital before you die of sepsis
Last edited by greenbeetle on Wed Jul 31, 2013 1:40 pm, edited 1 time in total.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by Veritas » Wed Jul 31, 2013 12:31 pm

okiebill wrote:Veritas, I was referring to packing an infected puncture wound that was opened for cleaning / necrotic tissue removal only and did not mean to imply that someone should pack anything they can stick gauze in :oops:
No worries, packing vs no packing changes all the time. Personally I think if a wound is draining it doesn't need packing but that's an "art of medicine" call and not necessarily dogma. Nothing wrong with doing packing for debridement purposes.
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Re: WWYD for the First Aid section: Rusty Nail.

Post by dallas » Wed Jul 31, 2013 9:00 pm

GhostlyKarliion wrote:
dallas wrote:
Braxton wrote:Spray the puncture liberally with carb and choke cleaner*. Use the little tube they give you to get deep into the wound. This will flush out all the crap left in from the nail.

Now that you have it clean and filled with a flammable substance, light that shit on fire. Fire kills all, and stops the bleeding.

I am 100% serious.

I have done this before.

ZS people ( including a MD) have watched me do this to myself.

I an't dead yet.

*In a pinch Brake Cleaner can also be used. But it does not burn as well.
So, you go from a simple penetrating wound to one with chemical and thermal burns. Nothing like killing cells and scrambling their DNA with carcinogenic substances to speed healing.
When I saw this banter, this was the only thing I could think of:

Image

ETA: I am not doubting that either procedure works (the HIV treatment was surprisingly successful, as I am sure the "thermal irrigation" of the wound with growth inhibiting chemicals would be), but I wonder if the risks of the proscribed treatment outweigh the potential gains.
:lol: That's it. Genetic modification. Brilliant

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Re: WWYD for the First Aid section: Rusty Nail.

Post by dallas » Wed Jul 31, 2013 9:03 pm

Veritas wrote:
okiebill wrote:You do not have to pack a deep wound that is not infected BUT...

Packing the wound with moist Gauze or the like and changing frequently will keep the wound from drying out ( inhibiting new tissue growth). It will also prevent the wound from healing unevenly or forming a pocket ( Deep ones should heal from the bottom up). Changing the packing will also let you monitor for infection ( Your nose will tell you) and monitor the healing process...

The moral of the story is go ahead and pack it as it will do you nothing but good :D
I'm not sure I agree with that. Most texts do not recommend packing routinely, even for abscesses, most EM literature seems to state that packing only increases pain and discomfort, and if it is already draining then there is obviously not a reason to worry about an enclosed pocket that cannot drain, which is why you place a drain in the first place. Deep wounds do not necessarily need to heal by secondary intention. It sounds like this may need to be opened up, explored, irrigated, etc. Then wet-to-dry dressings may be appropriate, but routinely packing wounds (esp simply to monitor for infection, or promote healing by secondary intention) truly is a bad idea, unless you are aware of new research indicating it is not.
I can tell you from first hand experience from a wound on my hand that you do pack wounds. You pull it out every morning, put it in the whirlpool, scrub it, then repack with xeroform gauze. A truly pleasant experience :gonk: for a couple of months, but it healed really well for secondary intention.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by Veritas » Thu Aug 01, 2013 10:41 am

dallas wrote:
I can tell you from first hand experience from a wound on my hand that you do pack wounds. You pull it out every morning, put it in the whirlpool, scrub it, then repack with xeroform gauze. A truly pleasant experience :gonk: for a couple of months, but it healed really well for secondary intention.
It's not really about first hand experience. It's about what's best for most people, most of the time, in most situations. Of course nothing is 100%, that's why we don't use anecdotal evidence to form practice patterns. Hopefully you are using evidence based medicine. If not, that's your choice, but honestly it makes more sense than just doing what worked last time hoping it will work again.

http://www.ncbi.nlm.nih.gov/pubmed/19388915" onclick="window.open(this.href);return false;

http://www.ncbi.nlm.nih.gov/pubmed/22653459" onclick="window.open(this.href);return false;

Two sources after a 5 sec PubMed search. Packing is really not supported by any kind of evidence, but it's so pervasive in people's minds that physicians often feel obligated to pack a wound even if it doesn't need it. Of course there are situations when you should pack a wound for debridement or to heal be secondary intention, but to routinely pack is unnecessary.
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Re: WWYD for the First Aid section: Rusty Nail.

Post by duodecima » Thu Aug 01, 2013 1:39 pm

Veritas wrote:
dallas wrote:
I can tell you from first hand experience from a wound on my hand that you do pack wounds. You pull it out every morning, put it in the whirlpool, scrub it, then repack with xeroform gauze. A truly pleasant experience :gonk: for a couple of months, but it healed really well for secondary intention.
It's not really about first hand experience. It's about what's best for most people, most of the time, in most situations. Of course nothing is 100%, that's why we don't use anecdotal evidence to form practice patterns. Hopefully you are using evidence based medicine. If not, that's your choice, but honestly it makes more sense than just doing what worked last time hoping it will work again.

http://www.ncbi.nlm.nih.gov/pubmed/19388915" onclick="window.open(this.href);return false;

http://www.ncbi.nlm.nih.gov/pubmed/22653459" onclick="window.open(this.href);return false;

Two sources after a 5 sec PubMed search. Packing is really not supported by any kind of evidence, but it's so pervasive in people's minds that physicians often feel obligated to pack a wound even if it doesn't need it. Of course there are situations when you should pack a wound for debridement or to heal be secondary intention, but to routinely pack is unnecessary.
I'm a happy evidence based medicine fiend - but you do have to look to the limits of the evidence. Routinely packing a drained abscess looks like a grey zone at the moment. These are both relatively small studies. Direct quote from second study: "Larger studies are needed to better validate the equivalency of these 2 strategies." It's absolutely necessary that we remember to look for evidence on practices that became standard before EBM was routinely used. Iodoform gauze vs plain is another case in point, for this. But at the moment, packing a drained abscess isn't wrong. (And drained abcesses are not necessarily the same as a deep puncture.)

And that's not counting to stuff you're packing for debridement purposes, which is different.
"When someone shows you who they are believe them" M. Angelou

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Re: WWYD for the First Aid section: Rusty Nail.

Post by dallas » Thu Aug 01, 2013 2:08 pm

Veritas wrote:
dallas wrote: Of course there are situations when you should pack a wound for debridement or to heal be secondary intention, but to routinely pack is unnecessary.
BINGO. You get the prize. That was my experience on MY hand. That is why I said "first hand experience". Pun intended. Now you know why I am a poor doc instead of a rich comedian.

I had a multi-drug resistant infection in a wound. I got debridement with wound packing and whirlpool for secondary intention. You can barely see the scar now; however, the daily wound therapy was something else. The PT honestly told me on the first day: "We have ways of making you talk here". He then said he wished he could say it would not hurt much, but it would hurt like he!!. He was right. Scrubbing exposed nerves is something else, but I can say he never broke me. I did not talk. :clap:

Thank God for IV antibiotics. I would not be here without them. There are some cases where you are gone without antibiotics.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by Figs and Bacon » Tue Nov 12, 2013 12:11 am

Veritas wrote:First, you have picked a unique problem. As has been mentioned, penetrating wounds to the sole of the foot, especially through a shoe, are a special type of injury specifically. This would be totally different scenario if you cut a bare foot on broken glass, or grabbed a rusty nail with a gloved hand.

To speak specifically to the scenario, I would not introduce anything into the wound that could potentially fuel a bacterial infection. I know honey was touted as a good antiseptic, but the studies I have read deal more with chronic wounds, and superficial ulcerations, not deep wounds or puncture wounds. Definitely do not use sugar water, and betadine solutions have little to no role in irrigation, which would be the key here and in any traumatic wound scenario. Betadine has to dry to kill bacteria, and likely you will not dry out a puncture wound. Alcohol, corrosive chemicals, cautery, are all absolutely ridiculous, and even though a physician may have laughed at you, I doubt he would be reaching for brake cleaner if you saw him in the office.

As the surgeons say, the solution to pollution is dilution. You need to irrigate the wound with a lot of water. You need to make sure it gets in the wound, and then out. Hand surgeons will occasionally core out cat bites and other puncture wounds prone to high bacterial counts to get good wound irrigation. You don't need antibiotics if the wound is clean enough that your body can fight the infection on it's own. I don't normally suggest cutting open a wound, but you would likely need to in this instance as you have no way of getting an Xray or ultrasound to look for a foreign body. You must remove any potential foreign body, and if you need to open the wound up to do it, so be it.

You could certainly soak it, but honestly once you irrigate it, explore it, remove any foreign body, it's just basic wound care. Don't pack it, just keep topical antibiotic ointment, change dressings, and you'll probably be okay as long as you don't have diabetes.
Nurse here. This is the correct answer. Irrigate the wound as best you can. Don't bother trying to cram honey, sugar, antiseptics, brake fluid, Grandma Jimson's Olde Tyme Fever Tonic, or anything else into the wound.

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Re: WWYD for the First Aid section: Rusty Nail.

Post by royalflush » Tue Nov 12, 2013 11:06 am

The way i treat wounds, especially ones that are purulent (infected):
all of these supplies are easy enough to keep. they are all in my first aid kit that takes up the front pocket of my bookbag (reluctant to call it a BOB), and is ALWAYS in my car. so preparedness is the name of the game. DONT shove honey in the wound- very dumb.
1) always keep in mind that this SOB is going to hurt. if you are at the point that it is pouring out yellow discharge, there is a pretty good amount of inflammation- so go ahead and take an NSAID for sure! it will help a little, the ealier its taken the better for you. I would only take them if you were able to do at least some of the following antimicrobial steps (see below)
2) I will use lidocaine if available in patients with abscesses, and it's not atypical that by the time it's "oozing" it needs to be opened up and some tissue might be debrided. (assuming the wound has already abscessed) if you have it- use it, if not, it'd going to hurt.
3) Saline first, plenty of irrigation, under pressure if the patient can handle it. rinse, rinse, rinse as much of the purulent material as possible
4) my favorite antimicrobial scrub is Chlorhexidine, this or iodine are typically what wounds are cleaned with in hospitals in preparation for debridment (don't attempt unless lidocaine or sedation). this stuff IS NOT HARD to get and is FANTASTIC scrubs everything you can with cotton balls soaked in chlorhex scrub, then rinse with alcohol on cotton balls. not a big fan of soaking in alcohol or irrigating wounds with alcohol unless its the only antimicrobial you have.
5) let the surgical scrub sit for a while, they spray down with iodine and let that hang out on the wound for a while.
6) triple antibiotic ointment and STERILE non-adhesive pads. (dont cram) wrap foot and REST (will drastically decrease recovery time).
7)this entire process may need to be repeated 3 times over a 48 hr period and about once a day for a week, then the wound should start healing up microbial free
8) antibiotics are your friend- take some penicillin for this one, and it should kill the staph's and streps that enter the wound, but realize that there could have been anything on the ground, soaking in the water (since you said hurricane sewers will be running above ground), including some of these nasty gram negatives like clostridium etc.. these are the ones that will cause sepsis and gangrene. if you can get your hands on clindamycin it will help with this.

If YOU HAVE NOTHING AT ALL (SUPPLY WISE)
Your best bet will be frequent irrigation with clean water. if you can find some salt, add some to the water. keep clean, and rest it! if you don't keep it clean, the tissue may start to heal up and the infection will continue and you'll have a nasty abscess if you didn't already have one. if you can find nsaids- realize you taking them will reduce your fever and limit your bodies natural defenses against infection- so if you can fight through the pain, might be a decent idea.

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