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Introduction
Unfortunately, wounds are all too common on outdoor trips, with abrasions and full-thickness lacerations leading the list; that said, deeper wounds are not unheard of. The goal of wound care is to prevent infection and promote healing. Expedition settings bring challenges to wound management that are relatively rare in an urban environment and require a deeper understanding of the healing process and available dressing technology. Patients with a high risk for infection, especially with damage to tendons, ligaments, joints, or bones, should be evacuated for physician assessment and treatment. Clean wounds without damage to underlying structures can often be treated in the field with the right materials and constant monitoring.
The Healing Process
The wound healing process has five continuous and overlapping phases: 
Individual characteristics that inhibit healing include:
Wound attributes that inhibit healing include:
Dressings
Characteristics of Ideal Expedition Dressings
Six categories of wound dressings are discussed below. Recommendations for field use are based on the ideal characteristics discussed above for healthy individuals with no local or systemic wound infection and appear in the highlighted boxes. Infected wounds and those slow to heal should be evacuated for assessment and treatment by a physician or wound care specialist.
Transparent Micro-thin Film Dressings Transparent micro-thin film dressings are permeable to water vapor but not liquids. They help maintain a moist environment for full-thickness wounds with little exudate and abrasions. Because they are transparent, you can watch the wound heal through them. If clear fluid [serious exudide] builds under the film, switch to a foam dressing to prevent skin maceration. Alternatively, add a non-adherent gauze dressing ± additional gauze under the film to absorb excess fluid. You can also add a antimicrobial directly to the wound bed or dressing if the wound is at risk for infection. Transparent film dressings are often the best choice for wet expedition environments and can be layered with other dressings to manage exudate. Paint the surrounding skin with Tincture of Benzoin to aid in adhesion.
Transparent micro-thin film dressings [we carry Tegaderm®] are recommended:
Foam Dressings Foam dressings are effective for all wound types. They adhere to the wound’s surface and absorb excess exudate while maintaining a warm, moist wound bed; they can be left in place for multiple days. Generally, the thicker the foam, the more exudate it can absorb and hold. Some foam dressings come with a perimeter adhesive, while others require fixation. Foam dressings without perimeter adhesive can be cut to size but need a transparent film dressing or flexible medical tape [we carry Mefix®] to hold them in place. If the wound is at risk for a local infection, you can apply an antibacterial ointment under the foam. Foam dressings can also degrade moist slough on the wound surface.
Foam dressings [we carry Melpilex®] without a perimeter adhesive are recommended for low to medium exudate wounds during the proliferation and epithelialization phases to prevent maceration; they should be secured in place with a transparent film dressing or flexible medical tape [we carry Mefix®]. Flexible medical tape permits moisture to evaporate through the dressing and is water-resistant; it is preferable to transparent film dressings unless the wound will be directly exposed to water.
Dry Gauze Dressings While dry gauze dressings should never be used directly on a wound bed before the wound has completely closed, they can be impregnated with medical honey or Vaseline to create a moist environment to promote healing. Dry gauze can added as a secondary dressing to hold excess exudate or provide protective padding. Vaseline-impregnated gauze dressings are inexpensive and work well for dry or low exudate wounds; they can be held in place using a non-adhering bandage, flexible medical tape, or a transparent film dressing. For maximum flexibility and to minimize micro trash, carry roller gauze instead of individually wrapped gauze pads.
Vaseline-impregnated gauze dressings are recommended as the initial dressing for most wounds in healthy individuals during. Secure in place using a self-adhering bandage [we carry Cohere®] during the inflammatory phase when you need to change dressings during the day. [With care, self-adhering bandages can be reused multiple times.] Once exudate is under control — during the proliferation and epithelialization phases — you can secure with transparent film dressing or flexible medical tape — and leave in place for multiple days.
Dry gauze can be used as a secondary dressing to capture excess exudate the inflammatory, proliferation, and epithelialization phases or as padding to protect fully closed wounds during the maturation phase. Hydrogel Dressings Hydrogel dressings are primarily used for dry wounds or wounds with minimal exudate. They reduce pain, promote healing, and can be used with infected wounds. Once the lid has been removed, they are commonly used to relieve pain and promote healing with friction blisters. They can also degrade slough on the wound surface.
While hydrogel dressings work well for treating friction blisters [we carry Nextcare hydrogel dressings and ENGO patches], HYDROGEL DRESSINGS are NOT RECOMMENDED for full-thickness wounds in an expedition setting because foam dressings are more versatile.
Hydrocolloid Dressings Hydrocolloid dressings use gel to create an impenetrable protective barrier that prevents bacteria from entering the wound bed and maintains a moist environment. Like hydrogel dressings, they are used with dry wounds or wounds with minimal exudate; however, they should not be used with infected wounds or wounds at risk of infection because they are occlusive and can trap bacteria.
Hydrocolloid dressings are NOT RECOMMENDED in an expedition setting because foam dressings are more versatile.
Calcium Alginate Dressings Calcium alginate dressings are used with wounds with substantial exudate. They form a soft gel when in contact with exudate and conform to the contours of the wound to provide a micro-environment that helps break down dead tissue and encourage new skin cell growth. They can be used to pack deep wounds. They require a secondary dressing and fixation.
Calcium alginate dressings are NOT RECOMMENDED in an expedition setting because foam dressings are more versatile and easier to use, and medical honey can be used to fill a deep wound and promote healing.
Antimicrobials Recommendations for antimicrobials used in treating wounds in a remote setting are for healthy individuals and designed to prevent a local or systemic wound infection. Infected wounds and those slow to heal should be evacuated for assessment and treatment by a physician or wound care specialist. Povidone-iodine Solution & Chlorhexidine Use soap and water to gently wash the wound bed and surrounding skin and pat dry at each dressing change. Apply chlorhexidine or povidone-iodine solution to the skin surrounding the wound to reduce the chance of bacteria reaching the wound bed. If the risk or consequences of local infection are high, dilute a 10% povidone-iodine solution to less than 1% and wash the wound before applying the primary dressing.
10% povidone-iodine solution [we carry 10% povidone solution] is recommended over chlorhexidine because it can be used full-strength to clean skin around the wound. While chlorhexidine is faster and better than povidone-iodine in reducing bacterial migration, due to its toxicity CHLORHEXIDINE SHOULD NOT BE USED in deep wounds.
When diluted to less than 1%, it is recommended for flushing and packing high-risk wounds, cleansing a high-risk wound bed, or saturating a gauze dressing to treat or prevent a local infection. [we carry 10% povidone iodine solution in a variety of Nalgene® bottles to prevent leakage while in your first aid kit. Medical Honey Medical honey has proven more effective than antibacterial ointments in preventing infection and promoting healing. It can be used to fill a deep wound, applied to the wound’s surface, or impregnated into a gauze dressing. It can be left in or on a wound for up to seven days.
Medical honey [we carry Medihoney®] is recommended for the prevention of local infections and the treatment of biofilms.
Antibacterial Ointments & Creams Antibacterial ointments & creams — e.g., Bacitracin, Neosporin, Polysporin, or mupirocin — to prevent wound infection are controversial.
Antimicrobial ointments and creames are NOT RECOMMENDED for treating or preventing local infection infections in an expedition setting because medical honey is more effective and versatile in promoting healing and does not lead to allergic dermatitis or bacterial resistance.
Refer to the graphic on the below for a summary of wound care guidelines throughout the healing process. Download a pdf copy
Click graphic to download as a pdf file
Bottom Line
There's a ton of information in this post. Bottom line, here's what you need to know:
Severe bleeding is rare in an expedition environment; partial- and full-thickness wounds are not. Barring a life-threatening bleed, you need to be able to clean, dress, bandage, and care for a wound until it heals or you have successfully evacuated the patient to more advanced care. If you are working with or around machinery, chainsaws, axes, other cutting tools, etc., we recommend carrying:
To clean a wound, we recommend carrying:
To dress a clean, low to moderate risk wound during the inflammatory phase:
To pack and dress a deep wound, we recommend carrying:
If you are on an afternoon, day, weekend, or even a long-weekend trip and get a partial or full-thickness wound, you're not out long enough to get past the inflammatory phase of wound healing, and will not need to carry a foam dressing; for longer trips you will. To dress a wound with low to moderate exudate, a wound at risk of infection, or a wound with increasing slough in the proliferation and epithelialization phases, we recommend carrying: To protect a wound in a wet expedition environment, we recommend carrying:
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
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Fleas, mosquitoes, lice, assassin bugs, sand flies, chiggers, ticks and other biting insects may be carriers of an infectious disease. With the advent of global warming, insects and insect-borne infectious diseases are spreading to new areas. To protect yourself against contracting an insect-borne infectious disease, the Centers for Disease Control and Prevention (CDC) recommends using the following insect repellents and insecticides; they have been shown to be safe and effective, even in pregnant and breastfeeding women. Clothing, tents, and mosquito netting are ideal for first order of protection and sleeping, especially when saturated with Permethrin (which kills insects on contact). To protect against chiggers and ticks, wear light-colored or white long pants, long-sleeved shirts, and socks so ticks can be more easily seen; pull socks over pant cuffs. Wear a hat and place petroleum jelly around hairline to keep ticks from crawling into hair (where they will be very difficult to find). Do a thorough tick check each morning & evening before entering and leaving your tent. The CDC does not recommend other insect repellents and products as they have not been shown to be effective despite manufacturers claims. These include natural plant oils, (such as citronella oil, cedar oil, geranium oil (or geraniol), and lemongrass oil), repellents containing vitamin B1 or garlic, and wristbands and ultrasonic devices. Application
DEET
Picaridin
IR3535
Lemon Eucalyptus Oil
Permethrin
Interested in learning first aid? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available. In 1979, the U.S. Food and Drug Administration (FDA) began requiring an expiration date on prescription and over-the counter medicines so it’s not surprising that the FDA strongly recommends disposing of all expired drugs. That said, in 1985 the FDA began testing medications for the Department of Defense under the Shelf Life Extension Program (SLEP) to see if it was safe for the military to stockpile medications. Continual testing shows that many Rx and OTC drugs retain full potency years beyond their expiration dates. And, current data also shows that no drugs currently in production have been shown to be toxic past their shelf life. Excluding nitroglycerin, insulin, and liquid antibiotics, most medications are as long-lasting as the ones tested by the military. That said, it’s difficult for an individual consumer to know how long a specific drug will remain active beyond it’s expiration date as it’s ingredients, type and presence of any preservatives, and storage conditions can dramatically affect the drug's potency and life expectancy. Obviously we have control of what we put into our own first aid kit but how do we, as expedition leaders and medical officers make decisions about drug use once in the field and faced with someone else’s first aid kit that contains expired medications? Below are some practical guidelines:
Over the counter (OTC) acetaminophen, ibuprofen, and naproxen are commonly used to treat pain and fever. Because they are labeled and packaged for OTC use most people consider them safe. This is not true. In addition, many people also believe that more is better. This is also not true. In fact all three medications have the potential for serious side effects. Aging further increases the risk of serious side effects as older people, especially those over the age of 65, often have a decrease in liver and kidney function and are mildly dehydrated.
In addition to its therapeutic effects, acetaminophen is a dose-dependent liver toxin; patient who take acetaminophen with alcohol or while fasting-due to illness, anorexia, or malnutrition-are at serious risk for liver failure. Even if taken at the current OTC recommended dose (not to exceed 4 g/day), the drug can be toxic. The FDA expert panel recommends lowering the standard dose from 1,000 mg to 650 mg and the maximum dose/day to 3 g/day. Accidental overdose send roughly 80,000 people to the emergency department each year; at least 500 are fatal. Part of the problem is that acetaminophen is found in more than 600 OTC medications including cold, flu, sinus, and in Rx codeine-based medications (Vicodin® or Percocet®). Patients unaware of the potential for serious complications often mix and match drugs containing acetaminophen and easily exceed the maximum daily dose. Forewarned is forearmed. Ibuprofen and naproxen also have serious side effects. Chronic use of both, including aspirin, may cause indigestion, gastric or duodenal ulcers, and fluid retention. In addition, ibuprofen use slightly increases the risk of a heart attack or stroke. Renal damage is also possible and significantly increases if the patient is dehydrated (as is often the case in an outdoor setting). Not surprisingly the risk of adverse effects increases substantially with dose and course. Note that while many athletes take ibuprofen or naproxen for general muscle soreness, neither drug has been shown to be effective. Remember that the GI side effects of both drugs increase if the drug is not taken with food and the renal effects increase if the patient or athlete is dehydrated. Follow the following simple guidelines greatly reduces your chance of adverse effects:
Interested in learning first aid? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course. Looking for a reliable field reference? Consider consider purchasing one of our print or digital handbooks; our digital handbook apps are available in English, Spanish, and Japanese. Updates are free for life. A digital SOAP note app is also available.
Padded Aluminum Splints may be purchased at our online store and fit into the outside zippered pockets on our Guide and Expedition first aid packs.
Introduction
Whether you are traveling alone, taking part in an expedition, or responding as a member of a search & rescue (SAR) team, you will need a first aid kit. What you should take and how you should package it depends on many things. There is no generic first aid kit. Below are a few basic concepts that you will need to know in order to begin building a kit that meets your needs.
As the size of the expedition group gets bigger or the trip longer, you will need to carry more of the basic first aid kit contents and additional drugs to treat medical problems that typically don't arise on shorter trips due to the one to three week, or longer, incubation period required for most infectious diseases. Our Expedition Pack can typically hold enough supplies for a group of 8-12 people for up to three weeks, more with resupplies. The needs of larger groups (typically found on commercial raft trips) can be met by using multiple packs.
A good guide has excellent self- and situational awareness, a complete understanding of the terrain and environmental hazards they may encounter and strategies for mitigating their associated risk, together with a reasonable assessment of their clients skills. Despite their training and skill, risk cannot be completely eliminated, and injuries and illnesses can occur. The prudent guide will carry supplies to address both common and unlikely, but possible, scenarios. As the terrain increases in difficulty, the potential for both stable and unstable musculoskeletal injuries increases; and, it makes good sense to add a padded aluminum splint, self-adhering bandages, and perhaps kinesiology tape to the contents of the basic first aid kit. In conjunction with a cloth roll cut from a T-shirt, a padded aluminum splint can be used to stabilize most common extremity fractures—forearm, wrist, knee, and ankle. Self adhering bandages may be used in lieu of a cloth roll to secure the splint or by itself, to support a strain or sprain or hold a dressing in place. Kinesiology tape is a specialized tape with an adhesive backing, and when combined with with Tincture of Benzoin, can also be used to protect against or support a strain or sprain. Maxi-pads can be added as emergency trauma dressings and OTC medications to treat common medical problems like diarrhea, constipation, sinus congestion, acid stomach, etc.
Statistically, playing in the backcountry is pretty safe; life-threatening injuries and illnesses are rare. Most traumatic injuries are simple cuts, scrapes, and blisters. Environmental injuries, like dehydration, heat exhaustion, sunburn, and cold, are common, uncomfortable, and typically easily treated (and preventable). Since wilderness travelers are healthy, medical problems are minimal and tend to focus on headaches and general aches & pains. Problems in longer trips tend to be related to poor hygiene.
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