Wound management: control, clean, close
A crewmember cuts his hand while splicing a line. What should you do? Basic wound management begins with controlling bleeding, cleaning the wound to prevent infection, and closing or bandaging it to promote healing and permit continued function.
Most bleeding can be stopped by applying firm pressure directly over the bleeding site. Use any clean material initially, and later use sterile gauze. If the wound is on an extremity, try to elevate it above the level of the heart. Protect yourself from blood-borne pathogens, such as the hepatitis and AIDS viruses, by wearing barrier gloves. Gloves can leak, so be sure to wash your hands or wipe them with an antiseptic towelette after removing them. Dispose of bloody materials by securing them in a waterproof bag.
Seawater is a rich broth of infectious microorganisms. Treat all wounds, even minor cuts and scrapes, as contaminated and potentially serious; careful cleansing can prevent infection. Clean superficial cuts and scrapes with soap and water (galley water is fine) or use commercial antiseptic wipes containing BZK. Cover small injuries with a liquid antiseptic bandage or a coating of antibiotic ointment together with a waterproof adhesive bandage.
Larger, deeper lacerations are best cleaned using a 10- to 20-ml syringe with an 18-gauge catheter tip to create a high-pressure irrigation stream. Squirt the solution directly into the wound; the pressure will be forceful enough to flush out germs and debris without harming tissues.
Disinfect water for irrigation by adding 10 ml of Betadine (10 percent povidone-iodine) solution to a half-quart of fresh water from the boat’s tanks. Alternatively, reserve a quart of commercial bottled drinking water specifically for wound irrigation. Eyewash solution is another option. It is sterile, non-irritating and is excellent for irrigating wounds. Full strength Betadine, hydrogen peroxide and alcohol can damage tissue and shouldn’t be poured directly into wounds. Remember, “The solution to pollution is dilution.” Be generous with the irrigation.
Many lacerations can be safely closed at sea. The “golden period” for safely closing most wounds is within eight hours after the injury occurs; beyond this period, the risk of infection increases. Closing minor soft tissue wounds is desirable to reduce the risk of infection and achieve a better cosmetic result; however, wound closure is never necessary.
Some wounds always carry a high risk of infection — for example, wounds inflicted by animals or marine creatures (seals, sharks, eels, fish teeth, spines), puncture wounds, deep wounds on the hands or feet, and those that contain a great deal of crushed or damaged tissue. Wounds containing imbedded foreign material (coral debris, sand, sea urchin spines) should be left open to drain.
As a rule, any soft-tissue wound that penetrates beyond the yellow layer of fat is likely to involve the fascia — the tough, shiny white layer — and the tissue beneath it (muscle, tendons, bone or joint). If you see white or red tissue in the wound, it is a deep wound. These should never be closed, because of the high risk of infection by entrapped bacteria. If in doubt, do not close.
High-risk wounds, and those that have aged beyond the golden period, are best left open to drain. Pack them daily with 4-by-4 gauze dressings moistened with disinfecting solution, and bandage them. Puncture wounds are difficult to clean. It’s best to use hot soaks with fresh, clean water four times daily for 15 minutes. You can boil galley water and let it cool until it is comfortable. Seek medical consultation when treating any of these wounds; they require antibiotic therapy and careful follow-up.
There are various materials for closing wounds: sutures, staples, tissue glue, butterfly bandages, adhesive closure strips, even duct or sail tape. Your choice depends on your experience, medical supplies and comfort level. Wound closure strips are easy to apply and are a preferred way to close a deep cut in the marine environment. They also are easy to remove, should that become necessary.
Dressing the wound
Allowing a wound to dry out and form a scab delays healing. To prevent this, apply an antibiotic ointment and non-adherent dressing to the wound, then place an absorbent gauze dressing over the non-adherent one. Hold these both in place with a conforming roller bandage. Change the dressing whenever it becomes wet or dirty, and check daily for the following signs of infection:
• increasing pain, redness or swelling
• pus or greenish drainage from the wound
• red streaks on the skin adjacent to or “upstream” from the wound
If signs of infection develop, remove the tape, open the wound to allow drainage, pack it with moist gauze, and seek medical consultation. Do not be intimidated by wound management. Knowing a few simple principles increases self-reliance and can make the difference between returning to port or continuing your trip with confidence.
Closing the wound
1. Use scissors to clip off hair near the wound so that the strips (tape) will adhere better. Do not shave the skin directly over the wound.
2. Apply a thin layer of tincture of benzoin on the skin along both sides of the wound. Benzoin’s stickiness helps keep the tape in place.
3. After the benzoin dries (about 30 seconds), place the tape on one side of the wound and pull the wound closed; the edges should just touch. Attach the other end of the tape to the skin to keep the wound edges together. Leave about a half-inch between strips.
4. Place pieces of tape crossways (perpendicular to the other strips) over the ends of the existing strips to keep the ends of the tape from curling.
5. Leave the tape in place for a week.
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This story first appeared in the January 2009 issue.