Linda Laskowski Jones, MS, RN, ACNS-BC, CEN, FAWM

Linda Laskowski Jones, MS, RN, ACNS-BC, CEN, FAWM Explain wound care priorities in an austere or wilderness environment. Describe management considerations pertinent to animal bites. Develop strategies for wilderness emergency preparedness. Identify wound type Achieve hemostasis Evaluate extent of injury Prevent infection Consider treatment options Consider the need for rapid evacuation Principle: In the wilderness, you do the best that you can with what you have! 1

Many causes of wounds in the wilderness! Blisters Abrasions Lacerations Puncture wounds Amputations Open fractures Burns Animal & insect bites Firm, direct pressure Layer dressings Elevation / pressure points Hemostatic dressing Tourniquet: for lifethreatening hemorrhage Shock management 2

Hemorrhage control Shock management Wrap body part in dry, sterile dressing material Place wrapped part in plastic bag if available Place bag with part in an ice slurry Do not allow part to get wet or freeze Transport body part with patient to hospital 3

Fully expose injured area Assess wound: Location Dimensions (width, length, depth) Severity of contamination Presence or absence of foreign body Bone, tendon, joint & nerve involvement Assess distal neurovascular & nerve function Typical contaminants: Skin flora: S. aureus (including methicillinresistant species) Soil: Clostridium & Pseudomonas species Oral flora from bites: Pasteurella, Eikenella & Streptococcus Irrigate wound: use cleanest water available; use water purification devices / tablets Remove visible foreign material / contaminants Up-to-date on tetanus prophylaxis? 4

Factors Time elapsed since injury Injury location Extent of contamination Injury severity & degree of underlying tissue involvement Injury mechanism / forces Immune competence of patient Leave wound open or close? Judgment call based on degree of contamination & potential for infection High risk wounds: Leave open Pack with saline or water-moistened gauze & dress; change packing daily; oral antibiotics Wound closure: Anesthesia available? Probably not but, if so: LET: topical lidocaine, epinephrine & tetracaine; massaged over wound for 20-30 min (associated with slight increase in wound infection rate) 1% lidocaine for local infiltration (need supplies) Ice 5

Methods to re-approximate edges: wound edges should touch but not be tightly pulled together Tape Wound closure strip or micropore tape / benzoin Duct tape with perforations made with a safety pin toward sticky side for wound drainage Tie hair together using pieces of dental floss to knot & pull edges closed for scalp lacerations Skin adhesives / glue (no topical antimicrobials if a cyanoacrylate product is used; will dissolve glue) Staples consider if available & wound will remain clean; never use on the face Suture not usually feasible unless in clinic setting Commercial non-adherent pads and/or dressing materials Cleanest available improvised materials (e.g., bandana, T-shirt) Wounds involving joints: consider splinting area to decrease risk of wound re-opening Topical antibiotics if no skin glue is applied: bacitracin best; neomycin OK but more allergies Honey also acts as a topical antimicrobial Change dressings at least once daily Indications for prophylaxis: Complex or mutilating wounds Gross wound contamination / penetrating debris Extensive ear & cartilage lacerations Animal bites Bone, joint or tendon penetration Immunosupressed patients or those with valvular heart disease Indications for treatment: Wounds with signs of infection 6

Prophylaxis: 3-5 day course First generation cephalosporin Amoxicillin-clavulanate Clindamycin For suspicion of MRSA: Trimethoprim/sulfamethoxazole Clindamycin Doxycycline Infection: 7-10 day course Tailor to suspected organisms & local resistance patterns Stop the burning process Remove clothing & jewelry in area 1 st degree: apply aloe vera gel Large blisters: consider draining & debriding Apply antibiotic ointment (Silvadene, bacitracin) or honey Cover burn with dry, sterile dressing Splint burned extremities in position of function Prevent hypothermia / Evacuate Reverse triage / CPR for any victim in cardiac arrest Trauma management Burn Injury: Range from superficial to full thickness, linear charring or contact burns from overlying metal objects Lichtenberg figures or keraunographic markings appear as branching or ferning marks on skin (erythematous arborization) 7

DO NOT: Apply lotions, salves, or greasy substances Apply ice to burns Disrupt blisters if they are small Native to all states except Maine, Alaska & Hawaii Bite ~ 4,700 people / year Pit vipers are venomous at birth Snake bite-related deaths: 2 to 5 deaths per year More common in children & elderly No antivenin, inadequate or late dose Usually occur 18-32 hours after envenomation, but may occur earlier 8

Young, adult males > age 20 Children < 10 years of age Persons under the influence of drugs or alcohol Use of snakes in religious rituals or sport Rattlesnakes, Cottonmouths & Copperheads Heat sensitive pit between each eye & nostril; enables snake to locate warm-blooded prey Triangular head due to presence of venom glands; venom immobilizes & digests prey Two curved, canalized fangs--retract when mouth closed 3 pairs replacement fangs (fang replacement occurs throughout snake s life) Snake regulates venom quantity based on size of prey; can inject from one or both fangs Amount of venom injected variable in defensive bites 9

Recognition: Venomous or Harmless? Applicable to North American Pit Vipers Venomous Triangle-shaped head Elliptical pupil Pit Fangs Rattle--rattlesnakes Non-venomous Rounded head Round pupil No pit No fangs / small teeth No Envenomation ( Dry Bite) Fang marks without local or systemic reaction Minimal Envenomation Fang marks, local swelling, pain Rubbery, minty or metallic taste in mouth No significant systemic effects Moderate Envenomation Fang marks with local & systemic effects: pain, nausea, vomiting, paresthesias, fasciculations, swelling beyond bite site, mild coagulopathy Severe Envenomation Fang marks with severe swelling / local response, severe systemic manifestations, including hypotension & seizures Marked coagulopathy 10

Severe Envenomation Emergency Interventions in the Field: Move victim to safe area away from snake Advise rest (exertion speeds venom effect) Remove jewelry & tight clothing Splint & immobilize bite area at heart level Evacuate to hospital ASAP Emergency Intervention DO NOT! Apply ice Apply a tourniquet Incise or suck wound Capture / handle snake Note: even DEAD or decapitated snakes can inflict a bite -- take a digital photo instead! 11

Poison Control Center Prophylactic fasciotomy not recommended; swelling from myonecrosis typically resolves with adequate antivenom administration Radiographic imaging to identify embedded teeth or fangs in bite wound Consider antivenom (CroFab): Enhanced safety profile: no skin testing; administer within 6 hours if possible Tetanus prophylaxis / wound care; antibiotic prophylaxis not routinely indicated Don t molest snakes use common sense! Don t keep venomous snakes as pets Stay out of striking distance Use caution in snake-infested areas: rocks, tall grass, caves & heavy underbrush Don t put hands & feet where eyes can t see Wear boots & protective clothing 12

Severity varies: depends upon animal & reason for attack; most do not attack unless provoked Most attacks occur far from definitive care Initial wound care similar to domestic animal bites Blunt trauma / crush injury common Antibiotic coverage is same as for domestic animals Wounds are tetanus-prone & generally left open Consider need for rabies prophylaxis Top speeds up to 40 mph Attacks more common in summer Brown Bears: higher rate of attack than black bears Sudden close encounter Mother with cubs Most dangerous: bears that view humans as prey 13

Make noise; be cautious Avoid common bear areas Pepper spray may be useful: Must be used within 30 feet right into bear s face Do not use on skin or clothes Should not be sprayed in camp as a deterrent Consider carrying a marine / road flare Never feed a bear Keep campsite free of garbage Store food in approved containers & out of reach (hung at least 10ft up in tree or on pole) Never keep food / scented items in your tent Remember the 100m triangle: Assure 100m between the campsite, the food storage & cooking areas Never approach a mother bear with her cub Do not look directly into the bear s eyes Do not run or make sudden movements Do not act aggressively Stand your ground; back up slowly Backpack may offer some protection If attacked, get into fetal position, cover head & play dead Bears can climb trees 14

If an attack is immanent: Yell & throw things Look big Act aggressively toward bear; black bears tend to retreat If attacked: kick & fight aggressively as that bear has no fear of humans & may want to eat you! Becoming more common Frequently stalk, pounce & break the cervical spine May be scared off by aggressive behavior Look big; cluster with hiking partners Keep backpack on for protection Fight back with any object available Do NOT run away Scene safety: Mountain lion may still be in area Manage ABC s: control massive hemorrhage Remove debris & foreign objects, including teeth Assess for fractures Evacuate for definitive care 15

Rabies All mammals can be infected, esp. bats, raccoons, skunks, foxes Transmission: Scratch or bite from infected animal; saliva contact with open wounds, eyes, nose or mouth, inhalation of aerosolized virus Animal may exhibit behavior change! 20 to 60 day incubation, but may be 9 days to > 1 year for human rabies Common cause of human death in developing countries Treatment: No effective treatment for symptomatic disease; nearly always fatal! If animal isn t available, victim must start postexposure prophylaxis Post-exposure Prophylaxis: #1 Immediate wound cleansing soap & water! #2 - Human Rabies Immune Globulin RIG: injected into bite site & IM for passive immunity #3 - Rabies vaccine 1 ml Deltoid IM for active immunity (Days 0, 3, 7, 14 --new CDC 4-dose regime) --Immunosuppressed patients: 5 th dose day 28 16

Medium size, light brown with fiddle-shaped mark on back ( fiddleback or violin spider) Live in dark, secluded areas Venom has cytotoxic effects on tissue; bites cause ulcerative lesions Bite may be painless, stinging to sharp & painful Intense aching & pruritus in minutes to hours Central bite site: bleb or vesicle surrounded by expanding erythema; later becomes dark & necrotic with eschar Systemic effects rare, but occur Differential diagnosis: MRSA Interventions: Apply cold compress intermittently for first 4 days after bite Do NOT apply heat--will increase enzyme activity of venom & worsen wound! Rest & elevate affected area Supportive care: topical antiseptic & sterile dressing; antibiotics if infected May need debridement & skin grafting 17

Don t place hands & feet where eyes can t see Inspect clothing & shoes Inspect bedding Wear protective clothing & gloves when in areas that harbor spiders Tentacles have barbed, venomcharged nematocysts that fire stinging cells Toxins injected into skin & enter victim s circulation Reaction to toxin may cause collapse in water & drowning Mild Reaction: Rash with stinging, itching, tingling, burning & intense throbbing pain Red-brown-purple tentacle prints or welts Skin infection can occur Moderate to Severe Reaction: Multiple, body-wide effects including muscle spasms, nausea, vomiting diarrhea, stomach pain, severe pain at sting site Anaphylaxis Organ failure, coma & death 18

Prevent firing of nematocysts: Wash area with sea water (not freshwater) Hot water or topical lidocaine best for pain Do not rub or compress Avoid vinegar: widely advocated but increases pain after stings of most jellyfish species Remove tentacles with tweezers or gloved hand Shave area with shaving cream or baking soda paste to remove nematocysts Pain control (ibuprofen, acetaminophen), diphenhydramine, tetanus immunization Etiology: Skin exposure to below-freezing temperatures with ice crystal formation Increased risk: Inadequate or wet clothing, fatigue, poor nutrition, smoking, alcohol & drug use, impaired circulation Occurs most in extremities, with higher incidence in feet than hands First Degree Pale, white & numb while frozen Edema & hyperemia after rewarming Second Degree Area is pale, white & numb while frozen After rewarming, redness, edema & clear to white fluid-filled blisters 19

Complete tissue freezing; pale, white & numb Pain, redness & edema with rewarming Blisters contain dark, hemorrhagic fluid; surrounding skin is red or blue & may not blanch Involves skin, muscles, tendons & bone Area is pale, white & numb while frozen Chunk of wood consistency Mottled skin with bluish discoloration forms deep, dry, black-crusted lesion; gangrene develops Splint to minimize motion, pad between fingers / toes & elevate Before thawing, give ibuprofen 400 mg q 12h (inhibits inflammatory cascade) Re-warm rapidly in 40 C water bath (104 108F hot tub temp) Note: Slow rewarming increases thromboxane & prostaglandin production; causes secondary damage Pain control! Tetanus prophylaxis 20

DO NOT: Use dry heat Thaw if part can refreeze Rub or massage area when frozen Rub frostbitten area with snow Note: If evacuation delay is expected, do not rewarm! Better to have victim walk out on frostbitten foot. Synthetic base layer (Cotton kills!) Wool / down / synthetic insulating layers Waterproof / wind-proof outer layers Hat / face protection (balaclava) Gloves (mittens are warmer) & glove liners Wool / synthetic socks (1 pair) Sun glasses or goggles Adequate nutrition Adequate fluid intake Avoidance of alcohol Tetanus prophylaxis up-to-date Consider medical supplies based upon type of austere / wilderness environment / excursion, trip duration, risks & personal skills / training Medications: broad-spectrum antibiotics Communications: emergency contacts & travel insurance Rabies prophylaxis? Know when to evacuate 21

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