Advanced Wound Care

1. Advanced Wound Care

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

3. Convert or Reduce Tourniquets to Save Tissue • Jan 2016 Afghanistan 3rd 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

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

5. Early Irrigation Can Buy Time Copious Low pressure Irrigation Only • High pressure pushes bad bacteria further into wound • Saline • Sterile H20 • Clean H20 • NEVER SEA WATER (Vibrio and other bacterial contamination)

6. Surgical Debridement is Definitive Care for Combat Wounds • Hemostasis • Major and minor vessels • Relieve Tension • Compartments and skin • Remove devitalized tissue • 4 Cs • Color • Consistency, • Contractility, • Capillary Bleeding

7. Make and Sterilize Pack Complete Slide show available in -Tactical Medicine Collective Google Drive -Surgery Folder: https://drive.google.com/open?id=0B7OAVQuGtbzAejlTLUFEVmxqcFU

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

9. Prep and Drape • 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 • Air barrier • Waterproof steri drape layer • Outer working surface

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

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

12. Delayed Primary Closure • Attempt surgical Closure 4-7 days after initial wound • Anesthetize • Rip bandage off • should bleed but not profusely • No bad smell • 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 5cm • Irrigate until clear and Dry • Suture closed • Infections caused by closing under tension • Bacitracin not recommended on suture line

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

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

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

16. Maggot Therapy • Put animal or fish guts outside • harvest tiny white eggs • Place on 2x2 and put on wound • cover with silk tea sack and tape edges • Remove in 48 hours • Reapply more if needed