Episode 68 S2-33
Treating Deep Lacerations and Crush Wounds
Without Land Ch 33
Dr. Joe Alton a.k.a. Dr. Bones
As a first responder reacting to this type of injury, major bleeding must be addressed first. Make certain that major arteries are not broken. Hemorrhage is the biggest reason people with a deep laceration would die in a survival situation. In our current practices we tend to check the airway, breathing and circulation (ABC) but in a survival situation you want to check the circulation first. Then check the airway and breathing. You have a certain amount of time for most injuries called "The Golden Hour" but if you have an injury to your femoral artery they call it "The Platinum Five Minutes," meaning you only have five minutes to secure that injury.
There are some simple ways to treat bleeding. The first thing you should do is create a barrier. Take a dressing, t-shirt or any suitable cloth and jam it into the wound. Apply direct deep pressure to get that bleeding stopped immediately. Lift the patient's legs and injured extremity (if not the leg) about twelve inches above the heart. This is called the "Shock Position" and it helps stop bleeding and keep the blood pumping to the heart and brain. Tourniquets have had a love/hate reputation in the past. Dr. Alton says, "the truth is tourniquets work." There are many brands available including SOFTT, C-A-T, and SWAT (Stretch, Wrap, and Tuck). They are available at www.DoomandBloom.net as well as other online retailers and you can learn more about their application in Dr. Alton's article, Choosing a Tourniquet. You should also invest in a homeostatic agent like Celox or Quick Clot. These are granules that stop bleeding and are also useful for burns. One study found that it only takes ninety seconds for Celox to work and when the dressing was removed and applied to another wound, the first wound stayed closed and the bandage closed the second one as well. You should also wrap the affected area with a pressure dressing. It is essential that you have a bleeding control kit to take care of these types of injuries.
There are two types of crush injuries. Minor crush injuries, like slamming your fingers in the car door, usually have bruising, lacerations and pain but are not life threatening. Major crush injuries can have some serious damage below the skin. These injuries may cut off the flow of blood in the damaged limb. This can lead to muscle and tissue damage. There is also a good chance infection will set in if the skin is broken. In a crush situation, like the one described in Without Land, where you have to pull a victim out there is also a possibility of "de-gloving the individual," where the skin is actually pulled away from the bone and muscle. Another symptom that may develop is called "compartment syndrome." This happens when swelling causes muscles and tissues to be deprived of circulation. Compartment syndrome can cause serious nerve damage and muscles may die. When compartment syndrome is present the skin is tight, bruised and there is severe pain, Dr. Alton says it is more pain than you would expect from this injury. It will feel like pins and needles pain. Then numbness will set in and the pulse will fade. The treatment options are limited. It is controversial but the skin may need to be opened up to release the pressure. It is not very likely that this patient will make a full recovery and expectations may need to be tempered.
There are a few additional considerations for this type of injury. Any shattered bones would need to be amputated and this procedure will be dangerous and difficult. When closing this type of injury you need to tie off the vessels first. Then you proceed with stitching the layers of muscle and then skin after that. Dr. Alton cautions against closing this dirty wound though. He says that closing the wound may close in infection and you could die from that. He sited a case where necrotizing fasciitis, a bacteria that can travel from limb to limb, was closed into a leg injury and the young lady lost her injured leg, half the other leg, and both arms.
To be prepared to treat injuries like this you can do a few things. First, take a first responder class, available at most community colleges. Visit websites like DoomandBloom.com and study their material. Get lots of bandages. Buy way more than you would ever think you would possibly need because they go really fast. Have your homeostatic agents on hand. Have Israeli Battle Dressings. Stock up on antibiotics while you still can. Dr. Alton states that medicines in pill or capsule form will actually last a lot longer with 100% potency than the expiration date indicates on the packaging.
Featured Quote From Today's Chapter:
"God knew we were too strong for a simple life."
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50 Person Multiperson Trauma Medical Unit
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