Advanced Wound Care TCCC First 1 Stop Bleeding

Advanced Wound Care

TCCC First 1. Stop Bleeding Early a. Tourniquets can be converted or reduced later b. Wound Packing 2. Resuscitate with warm fresh whole blood if possible 3. Early antibiotics buy time a. Ertapenam

Convert or Reduce Tourniquets to Save Tissue • Jan 2016 Afghanistan 3 rd SFG Team with National Gaurd Flight Medic • • • SF Soldier single gunshot to lower extremity Tourniquet applied after signs of hemorrhagic shock MEDEVAC Helicopter stuck on objective Active firefight too hot for another pickup 19 hours until role 2

Lessons Learned From Marjah 1. Get tourniquets on early to prevent blood loss a. 90% survive when tourniquet applied prior to shock 2. Soldier’s life saved by blood products from helo(2 units PRBCs) a. 90% die when tourniquet applied after shock 3. Soldier’s leg saved by 6 attempts to reduce tourniquet to pressure dressing a. Noted pulse was present when tourniquet was removed despite bleeding b. No arterial involvement 4. Ran out of pain meds 5. Extra equipment a. monitor on the helo 6. Extra training and experience a. Flight medic is also an ER nurse when not activated

Early Irrigation Can Buy Time Copious Low pressure Irrigation Only • High pressure pushes bad bacteria further into wound a. Saline b. Sterile H 20 c. Clean H 20 d. NEVER SEA WATER (Vibrio and other bacterial contamination)

Surgical Debridement is Definitive Care for Combat Wounds 1. Hemostasis a. Major and minor vessels 2. Relieve Tension a. Compartments and skin 3. Remove devitalized tissue a. 4 Cs i. Color ii. Consistency, iii. Contractility, iv. Capillary Bleeding

Make and Sterilize Pack Complete Slide show available in -Tactical Medicine Collective Google Drive -Surgery Folder: https: //drive. google. com/open? id=0 B 7 OAVQu. Gtbz. Aejl. TLUFEVmxqc. F U

Pre-Surgical Checklist q Resuscitated and stable o Vitals normalized o Hematocrit > 21 o Normal UOP q Antibiotics 2 g Ancef IV q TXA prior to cutting q Prepare for Monitored Anesthesia Care (MAC) with MSMAID o o o Machine or Drip Suction Monitor Airway IV/IO Drugs

Prep and Drape q q q q q Gross decontamination of entire limb with chlorihexidine scrub Irrigate and Dry Don hat, mask and boot covers Prep pack, gown and gloves Apply tourniquet at this time if needed Scrub in Don gown and gloves Open packs and create sterile working space Paint everything with Povidone Iodine Drape 3 layers 1. Air barrier 2. Waterproof steri drape layer 3. Outer working surface

Debridement q Elongate wound edges and trim devitalized skin with scalpel o No more than 3 mm beyond necrotic tissue o Undermine skin as little as necessary to visualize tissue q Find and ligate or transfix known vessels with absorbable suture q Release all compartment tension with Mayo scissors o Extend ruptured compartments o Perform fasciotomy on all compartments in the affected extremity q Begin excising necrotic tissue with Mayo scissors o Work systematically from one muscle group to the next o Clamp and ligate bleeders after all devitalized tissue is cut away o DO NOT BACK TRACK as the healthy tissue will turn dark in color after a few minutes

Dressing the wound q Irrigate 1 -3 liters until fluid is clear o NO DAKINS SOLUTION for Delayed Primary Closure Even very weak solution cures muscle to jerky if left for 4 -7 days q Pack and dry wound o Count gauze in or use single roll q Loosely apply gauze matrix to wick exudate away from wound o Must touch all tissue q Build bulky dressing and cover with compression bandage or stocking o Check distal pulses q Use wet to dry dressings only if bone, tendon, nerves or vessels exposed

Delayed Primary Closure q Attempt surgical Closure 4 -7 days after initial wound q Anesthetize o Rip bandage off • should bleed but not profusely o No bad smell o o • Ammonia = good • Fruity = Pseudomonas infection(bad) • Other bad smells that fill a room indicate infection Collagen ok, just scrape it out with back of instrument Undermine skin no more than 5 cm Irrigate until clear and Dry Suture closed • Infections caused by closing under tension o Bacitracin not recommended on suture line

Nursing care q Surgical Drain only indicated for voids larger than a fist q Bacitracin not recommended due to skin maceration o If bacitracin is used, it must be changed daily q Keep wound covered until sutures/staples come out q Splint in extension to prevent contractures q Immobilize for first 24 hours to prevent rebleeding o Get up and moving around after 24 q Daily physical and visual exam o Palpate to make sure there is no collection of fluid q If signs of infection present you must open and surgically redebride

Infected Wounds 1. Re-debride all infected tissue 2. Closure by allowing to heal by secondary intent 3. Sugar or Honey Dressings 4. High pressure pulse irrigation to break up biofilm 5. Medical Maggot therapy when all else fails

Sugar or Honey Dressings q Re-debride devitalized and necrotic tissue q Remove any contaminants or fragments q Irrigate and Disrupt all biofilm q Dry as before q Fill void with regular sugar or honey q Cover with Tagoderm or occlusive dressing q Change every 24 hours

Maggot Therapy 1. Put animal or fish guts outside 2. harvest tiny white eggs 3. Place on 2 x 2 and put on wound 4. cover with silk tea sack and tape edges 5. Remove in 48 hours 6. Reapply more if needed