The definition of a wound is a break in the continuity of the tissues of the body, either internal or external. An internal wound is one in which the skin has not been broken, but internal tissues have been damaged (example: a bruise or fracture). An external wound is where the outer layer of skin, the epidermis, has been broken. There are basically six different types of open wounds: abrasions, incisions, lacerations, punctures, avulsions, and amputations. There are many types of internal wounds, examples of which are contusions (bruises), sprains/strains, fractures, and internal organ injuries. These injuries can occur internally, but most commonly are both internal and external.
Wounds are caused by the exertion of some outside force such as a motor vehicle collision, fall, mishandling or assaults with sharp objects or firearms, tools, machinery, etc. All of these forces can cause both types of wounds. “Blunt” trauma, is an external force that doesn’t break skin tissue but causes internal wounds (getting hit with a baseball bat, falling a great distance, a large object falling on the patient are examples).
Definitions and Treatments
Abrasion- The outer layer of skin, the epidermis, is damaged. It appears rubbed or scraped away. These wounds are very painful, but bleeding is minimal. There is limited danger of contamination and infection. Wound should be washed with soap and water, irrigated with hydrogen peroxide ONLY IF Sterile Saline is not available, then antibiotic ointment applied. A Band-Aid or sterile dressing may be applied for the first 12 – 24 hours to protect the damaged area, but then removed to allow air flow to reach the wound and promote healing.
Incisions- An incision is similar to a laceration except the wound is cut cleanly, meaning precisely. The bleeding may be moderate to severe and deeper cuts may involve muscles, tendons, or nerves.
Lacerations-A lacerated wound is similar to an incision except the edges of the wound are jagged and uneven. Bleeding may be moderate to severe and muscles, tendons and nerves may be involved. The destruction of tissue is greater with a laceration than an incision. Both have great possibility of becoming deeply infected.
Treatment for incisions and lacerations is the same. First find a clean dry dressing (a traumedic bandage, ABD pad or other gauze type pad) and cover the wound and press firmly on the wound with your hand. This is called applying direct pressure. Continue to hold direct pressure for several minutes. Do not keep peeking under the dressing to see if the bleeding has stopped. This will continually tear away the clots that have begun to form. If the dressing becomes saturated, apply another ON TOP of the old one and hold pressure over both. When adding more dressings you may remove all but the original. Use a roll of gauze called Kerlix or Kling (I like Kerlix better-it’s stretchier), to hold the dressing in place. When bandaging start closest to the heart and work down. This is called wrapping from the proximal to distal side of the wound. Example, if the cut is on the patient’s forearm, you would begin wrapping at the elbow and work to the wrist and hand. If on the thigh, work from the groin to the knee, etc. Wrap tightly but not to the point of constriction. You should be able to feel a pulse below the wound (radial=wrist, pedal=top of foot). After dressing and bandaging the area, if possible, elevate the injured area above the heart. If the bleeding still has not subsided, the next step is to use pressure points try to stop it. This means finding a pulse point above (proximal) the wound and using the opposite hand of the one holding direct pressure, to compress the pulse point. This may help reduce the flow of blood to the injury, but not to the entire extremity. Maintain this treatment and transport the patient to your team medic for suturing. NOTE: if the patient has bled copiously, signs of shock may appear and will need to be treated appropriately.
Punctures-A puncture when an object pierces the skin and can either remain impaled in the skin or come out. For purposes of this discussion we will not discuss penetrating chest or abdominal trauma, but focus on less serious injuries such as a nail in the foot or a fish hook in the hand. With a puncture external bleeding is usually minimal and this is bad. When a wound bleeds the body is trying to cleanse itself of the foreign particles that have invaded it. A puncture will not bleed freely on it’s own. First make sure the penetrating object has been removed from the wound. If it is still impaled, remove it…REMEMBER, we’re NOT talking about chest or abdominal trauma, the procedure with that is totally different. Now you want to make it bleed. Sound odd? Not really. You don’t want to bleed them down a liter or two, after all this isn’t the Eleventh century when the so called doctors and healers cut gaping holes into their patients trying to bleed the disease out of them. You simply want to squeeze the fatty tissue around the wound to try to get it to bleed a little. Then vigorously clean the wound with soap and water, irrigate and scrub with peroxide then iodine or betadine. Apply antibiotic ointment and cover with a Band-Aid for 12-24 hours. Continue to monitor the area for signs of infection. If the edges of the wound become red, puffy, feel fevered and or seep pus, the wound has become infected and oral antibiotics are necessary along with continued cleaning of the wound.
Avulsions-These are wounds where a piece of skin has been partially ripped from the body. Usually it is a hunk of soft tissue from any area and is still attached by a small area of skin. Bleeding is usually heavy and depending on how deep the wound is, hard to control. The dressing and bandaging will be the same as above, except first flap the piece of skin back down where it should be. After bleeding has been controlled, the decision will have to be made on whether or not to cut away (called debride pronounced debreed) the flap of avulsed skin. In a survival situation, this will be the most likely choice. If the area is small, the skin flap will necrose (die) and rot off anyway. With larger flaps, it has to be cut away before it rots, because it takes longer and the risk of infection is greater. To cut off the skin flap, some local anesthetic may be necessary. Then using a pair of forceps in your weak hand and a pair of sharp surgical scissors in your dominant hand, cut away the flap, in and oblong shape leaving about an inch of skin. Irrigate the area with sterile water or saline, then with betadine. The area will be very raw and tender. If the avulsion was shallow the bleeding will stop without sutures. If it was deep, the sides of the wound may have to be pulled together to sew up the wound. A nasty scar will result, but hell, we aren’t going to be contestants in the Miss America pageant! If no suturing was required, dress and bandage the wound in a sterile dry dressing. In 12 hours change the dressing and in 24 change again but this time add antibiotic ointment (the wound won’t be as raw and open therefore less susceptible to infection). Keep the wound dressed and bandaged until it is scabbed then remove dressings and allow it to heal. If the wound is on a bending place like the knee or elbow, every effort must be made to keep the joint straight to prevent the scab from tearing. If suturing was necessary, apply antibiotic ointment to sutures, cover with sterile dressing for 12-24 hours, then leave uncovered, but still apply antibiotic ointment once or twice a day. In 7-10 days, if the wound appears closed and is not seeping or bleeding, remove the sutures.
Amputation-This is when a part of the body, usually a digit or extremity, is severed from the body. In a survival situation, the amputated part will not be able to be sewn back on. Using a clean sterile dressing, cover the stump and hold direct pressure. If it is a digit that has been severed, use the same techniques as you would for a laceration. For an extremity, apply a pressure dressing using an ACE bandaged wrapped tightly around the stump. If possible elevate the stump and continue to hold pressure. Transport to the team medic ASAP. If the medic is unavailable, irrigate and debride the stump, then the excess tissue may have to be cut away to aid in sewing the stump up. Large blood vessels will have to be sutured closed or if available, cauterized. This will be a very tricky procedure to do and risk of infection is extremely high. Oral antibiotics will be necessary prophelactically to decrease the risk of infection.
Contusions-a fancy name for a bruise, which is simply a cluster of broken capillaries caused by a blunt blow to the skin.
Hematoma-commonly referred to as a “goose-egg”, this will appear as a large lump on the skin, as if an egg were under the skin. The lump may appear discolored and may have abrasions or a laceration on or near it. It is caused by the tearing of a vein under the skin. The blood pooling under the skin causes the lump. Ice packs may be applied to reduce swelling. A hematoma will disappear, leaving a bruise in 5-7 days.
Sprains/Strains-A common question is what is the difference? A sprain is an injury to a ligament or tendon in the area of a joint. Usually the ligament or tendon becomes stretched or even torn causing swelling, pain, immobility, inability to bear weight if a lower extremity, or inability to lift or grasp if an upper extremity. A Strain is an injury to a muscle that results from over extending. The symptoms are the same as a strain except a strain can happen to any muscle, not just those around joints; also usually with a strain the patient can bear limited weight on lower extremities and will be able to lift and grasp with upper extremities though weakly. The treatment for both is the same. Remember the acronym ICIE, Immobilization, Compression, Ice, Elevation. Immobilization is keeping the injured area still. Compression is wrapping snuggly with an ACE wrap. Ice is, well, applying ice!! Elevation is elevating the injured area above the heart to help reduce swelling. Ibuprofen may also be given if the patient is not allergic to it. Ibuprofen is a better choice for pain than Acetaminophen because it has not only pain relievers, but also works as an anti-inflammatory. If the person is an adult, 400-mg every 6 hours may be given. DO NOT use aspirin. It thins the bloods and may worsen the swelling and bruising.
Dislocations-This is a displacement of a bone from a joint. It can happen with any joint, but is most common with ankles, knees, hips, shoulders, elbows, and digits. They can result from a fall, direct blow, or can accompany a fracture. They are very painful and can impede or cut off blood flow distally. Signs and symptoms are pain, swelling, gross deformity, discoloration, limited or loss of range of motion, numbness and tingling, and possibly absence of a distal pulse. The treatment for a dislocation is called reduction. The bone has to be guided back into the socket and the process is fairly simple. First assess the distal pulse, or the major pulse point below the injury. For hips or legs use the pedal pulse which is on top of the foot about two inches below the ankle and between the metatarsals of big toe and second toe. For arms and shoulders, use the radial pulse on the bottom side of the wrist under the thumb. When you find a pulse use a ballpoint pen to make an “X” over the pulse point. This way you won’t have to find it again. If you cannot find it, and the area is turning dark purple or cyanotic (bluish), the blood flow is being impeded. Two people are necessary to efficiently perform a reduction. One person holds the extremity above the injury and their job is to simply hold tight and prevent movement. The second person, firmly hold the area below the injury and pulls the area out straight, not bending or rotating the area. Usually you can feel the ball go back into the socket. If this is performed correctly, the patient will feel immediate relief. Now reassess the distal pulse by placing you fingers on the “X” or if it was initially absent, finding it. The patient should have full sensation but may still have limited range of motion. Once blood flow is returned, use the ICIE acronym (Immobilization, Compression, Ice, and Elevation) and transport the patient to your team medic.
Fractures- this is a break in the continuity of the bone mass. Any type of trauma can cause it. With out x-ray, diagnosing and treating fractures will be difficult. There are several different types of fractures, but for survival purposes the only types are simple and compound. A simple fracture is a break in the bone with no bone fragments protruding through the skin. A compound fracture is break with fragments protruding through the skin. Fractures are painful and present with the same signs and symptoms as a dislocation, except a fracture can happen anywhere there is bone and not just at joints. As with a dislocation, assessing the distal pulse is of utmost importance to determine if a piece of the bone is compressing a blood vessel.
Usually if the area is grossly deformed, such as bending where it shouldn’t, there is a chance of a diminished pulse. If the pulse is absent, gently try to straighten the extremity, aligning it with uninjured area. Reassess pulse. Try to get area in normal alignment, while frequently checking the pulse. Once the fracture has been returned to its normal position, and a pulse is present, use ICIE, and keep the area still. In the field and during a survival situation, perfect healing of fractures will be impossible. The distal pulse is a key point in insuring proper blood flow to the area below the fracture. Without x-rays, re-aligning the bone will be a combination of skill, knowledge, and just plain luck. A compound fracture will be extremely difficult to realign and the risk of infection is dangerously high. If you don’t have advanced medical skills, and none are available, you’ll have to do the best you can with what you’ve got. The procedure is the same, except before attempting to realign, irrigate the wound and bone frags with sterile water or saline. Pulling down (like reducing) to get the bones back into the skin will be tough and the possibility of further damage, including lacerating blood vessels is great. IF there is a skilled medic available, let them do it. They may be able to surgically open the area and realign the bones without causing too much damage. Regardless, this will be a serious emergency and infection and deformity may occur. Once you have the bones realigned as best you can, follow the same procedures for a simple fracture and give oral antibiotics as well as use a topical antibiotic on the wound site. Keep the site clean and dry and allow the wound to heal.
Internal Organ Injuries-Injuries such as these will be a mortally serious concern. Without a doctor on your team, there is little you can do. If the patient is bleeding internally, and signs of shock are present, keep the patient as comfortable as possible and soothe them as best you can. In a survival situation, this will most likely be a terminal event.
In a nutshell, those are the basics of wound identification and management. I hope this was helpful to those of you who have little or no medical training. When treating any injuries, use your common sense and do the best you can. In a survival situation, there may not be anyone else to count on for medical advice or treatment, so learn what you can while you can.