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:
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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
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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While mountain biking down a steep single track your friend catches his front wheel and is thrown forward with his bike. During the fall the handlebars smash into the left side of his chest. Asa has difficulty sitting up and catching his breath, and appears to have injured his left wrist. After assisting him to a sitting position and coaching him to breathe with his abdomen, his respiratory distress appears to resolve. During your physical exam, he reports a sharp pain (7) in the ribs on his lower left chest when he tries to take a deep breath. While his left wrist hurts (4) and has a slightly decreased ROM with good distal CSM, it appears weak: Asa is unable to easily hold and lift a full 1-liter water bottle. His helmet is cracked, he reports feeling a bit woozy, and has a headache (4); the remainder of his physical exam is unremarkable. With abdominal breathing, the pain in his ribs is manageable (3). 20 minutes after his accident his pulse is 94 and regular and his respiratory rate is 22 and remarkably easy; he reports his normal pulse rate is in the mid-60's and he doesn't know his normal respiratory rate. While awake, he still feels a bit "out of it." A focused spine assessment reveals cervical pain and tenderness at C-7 with no shooting pain and normal motor and sensory exams. What is wrong with Asa and what should you do? Click here to find out. Don't know where to begin or what to do? 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. You are on a multi-day backpacking trip in the southwestern canyons with a friend and her partner. You haven't seen your friend Janey for a number of years, and this is the first time you spent any time with her partner, Jon. The temperatures on the trip have been in the mid 70s until today when they unexpectedly climbed to over 90º F by noon. You are in a fairly open part of the canyon and exposed to the direct sun. Everyone is sweating heavily and looking forward to reaching camp and water. By mid-afternoon Jon is noticeably tired and feeling nauseated. You are almost out of water, but camp is within a half mile. You stop, pull out a SOAP note and complete a full patient assessment. During your SAMPLE history, Jon tells you he just started taking lithium for a mild bipolar disorder; the last time he urinated was before lunch. The remainder of his history is unremarkable; however, both his pulse and respiratory rates are a little higher than normal. What do you think is wrong with Jon and what should you do? Click here to find out. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
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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. You are part of a hotshot crew responding to a wildfire in northern California. Temperatures are well into the triple digits close to the handline they were tasked with holding. James, one of the crew members, is complaining of the heat and it's difficult to keep him cool. During your patient assessment, you find that he has recently started taking Benadryl® for a newly developed allergy to juniper pollen. What do your think is wrong with James and what should you do? Click here to find out. Don't know where to begin or what to do? Take one of our wilderness medicine courses. Guides and expedition leaders should consider taking our Wilderness First Responder course.
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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. You are leading a father/son day hike for a local camp. The father's ages range between 35 and 54 with various levels of fitness; their sons are 11 or 12 years old. The hike is a point-to-point hike covering a total of five miles. You are currently a hiking up a rather steep grade to a prominent overlook; there is only a few hundred feet to the top and just over a mile remaining to your pick-up spot. The day is sunny and hot with an ambient temperature of 88º F. One father, Bill, an overweight man in his early 50s, repeatedly stops to catch his breath on the hill. After his second rest stop you move him to the front of the group in an effort to keep the group together and slow the pace. Upon reaching the top at 3 PM he is clearly exhausted, slightly pale, sweating heavily, and complaining of the heat; the slight breeze at the overlook is clearly welcome. While resting, he admits he "is more out of shape than he thought" and relates that he is otherwise healthy with no personal or family history of heart disease; although, his physician has been trying to get him to start statins to lower his cholesterol. He can't remember the last time he urinated or the color of his urine at the time; he thinks it was when he woke up this morning. He reports drinking about a quart of water on the hike thus far but not snacking; he is very thirsty now. His color returns and after 10 minutes, his pulse is 86 and regular, his respirations are 20 and easy, and his oral temperature is 102º F.
What do you think is wrong and what can you do about it? Click here to find out. Don't know where to begin or what to do? 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. You are leading an interpretive day hike down the Bright Angel Trail of Grand Canyon National Park for a local concessionaire. People sign up for the hike online or at the concessionaire's Flagstaff office; they do not complete a medical form. It is a 9-mile out-and-back hike; water, shade and bathrooms are available at Indian Garden, which is the turn-around point. There is also water and a resthouse at 1.5 and 3 miles. It's mid-August and the temperature is expected to reach triple digits by early afternoon; the hike is scheduled to leave the Backcountry Information Center at 7 am. Participants are asked to arrive at 6:30 am with a day pack that includes snacks, lunch, water (at least two liters, one bottle should be frozen), and sunscreen. They are also instructed to wear light-colored clothing, a wide-brimmed hat, and sun glasses. During your pre-hike safety talk, no one responds when you ask if anyone has any medical conditions you should be aware of. The day heats up quickly and it's close to 90º F by 10 am and travel has been slower than expected. You are close—a quarter mile—from Indian Garden when one client, a 62-year-old man, begins to complain of the heat. You stop, cool him off using a combination of mist from your spray bottle and fanning. Once he is cool, you continue to Indian Garden, where once again, he complains about the heat. You break out the spray bottle as he sits in the shade. Once he is cool, you take out a SOAP note and do a full patient assessment. During your SAMPLE history you discover that he was hospitalized four years ago for a heart attack and currently taking a beta blocker and a diuretic to help prevent a second heart attack. The client, Tyrone, reports that he has been athletic with no health issues for the past two years. What do you think is wrong with Tyrone and what should you do? Click here to find out. Don't know where to begin or what to do? 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. |
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