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Linda Laskowski Jones, MS, RN, ACNS-BC, CEN, FAWM

Explain wound care priorities in an austere or

wilderness environment.

Describe management considerations pertinent

to animal bites.

Develop strategies for wilderness emergency

preparedness.

Identify wound type

Achieve hemostasis

Evaluate extent of injury

Prevent infection

Consider treatment options

Consider the need for rapid evacuation

Principle: In the wilderness, you do the best that you can with what you have!

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Many causes of wounds in the wilderness!

Blisters

Abrasions

Lacerations

Puncture wounds

Amputations

Open fractures

Burns

Animal & insect bites

Firm, direct pressure

Layer dressings

Elevation / pressure

points

Hemostatic dressing

Tourniquet: for life-

threatening hemorrhage

Shock management

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Hemorrhage control

Shock management

Wrap body part in dry, sterile dressing material

Place wrapped part in plastic bag if available

Place bag with part in an ice slurry

Do not allow part to get wet or freeze

Transport body part with patient to hospital

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Fully expose injured area

Assess wound:

Location

Dimensions (width, length, depth)

Severity of contamination

Presence or absence of foreign body

Bone, tendon, joint & nerve involvement

Assess distal neurovascular & nerve function

Typical contaminants:

Skin flora: S. aureus (including methicillin-

resistant species)

Soil: Clostridium & Pseudomonas species

Oral flora from bites: Pasteurella, Eikenella &

Streptococcus

Irrigate wound: use cleanest water available;

use water purification devices / tablets

Remove visible foreign material / contaminants

Up-to-date on tetanus prophylaxis?

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Factors

Time elapsed since injury

Injury location

Extent of contamination

Injury severity & degree of

underlying tissue involvement

Injury mechanism / forces

Immune competence of patient

Leave wound open or close? Judgment call – based

on degree of contamination & potential for infection

High risk wounds: Leave open

Pack with saline or water-moistened gauze &

dress; change packing daily; oral antibiotics

Wound closure:

Anesthesia available? Probably not…but, if so:

LET: topical lidocaine, epinephrine & tetracaine;

massaged over wound for 20-30 min (associated

with slight increase in wound infection rate)

1% lidocaine for local infiltration (need supplies)

Ice

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Methods to re-approximate edges: wound edges should touch but not be tightly pulled together

Tape

Wound closure strip or micropore tape / benzoin

Duct tape with perforations made with a safety pin toward sticky side for wound drainage

Tie hair together using pieces of dental floss to knot & pull edges closed for scalp lacerations

Skin adhesives / glue (no topical antimicrobials if a cyanoacrylate product is used; will dissolve glue)

Staples – consider if available & wound will remain clean; never use on the face

Suture – not usually feasible unless in clinic setting

Commercial non-adherent pads and/or dressing

materials

Cleanest available improvised materials (e.g.,

bandana, T-shirt)

Wounds involving joints: consider splinting area to

decrease risk of wound re-opening

Topical antibiotics if no skin glue is applied:

bacitracin best; neomycin OK but more allergies

Honey also acts as a topical antimicrobial

Change dressings at least once daily

Indications for prophylaxis:

Complex or mutilating wounds

Gross wound contamination / penetrating debris

Extensive ear & cartilage lacerations

Animal bites

Bone, joint or tendon penetration

Immunosupressed patients or those with

valvular heart disease

Indications for treatment:

Wounds with signs of infection

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Prophylaxis: 3-5 day course

First generation cephalosporin

Amoxicillin-clavulanate Clindamycin

For suspicion of MRSA:

Trimethoprim/sulfamethoxazole Clindamycin

Doxycycline

Infection: 7-10 day course

Tailor to suspected organisms & local resistance patterns

Stop the burning process

Remove clothing & jewelry in area

1st degree: apply aloe vera gel

Large blisters: consider draining &

debriding

Apply antibiotic ointment

(Silvadene, bacitracin) or honey

Cover burn with dry, sterile dressing

Splint burned extremities in position

of function

Prevent hypothermia / Evacuate

Reverse triage / CPR for any

victim in cardiac arrest

Trauma management

Burn Injury:

Range from superficial to full thickness, linear

charring or contact burns from overlying metal

objects

Lichtenberg figures or keraunographic

markings appear as branching or ferning

marks on skin (erythematous arborization)

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DO NOT:

Apply lotions, salves, or greasy

substances

Apply ice to burns

Disrupt blisters if they are small

Native to all states except

Maine, Alaska & Hawaii

Bite ~ 4,700 people / year

Pit vipers are venomous at birth

Snake bite-related deaths:

2 to 5 deaths per year

More common in children & elderly

No antivenin, inadequate or late dose

Usually occur 18 - 32 hours after envenomation,

but may occur earlier

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Young, adult males > age 20

Children < 10 years of age

Persons under the influence of drugs or alcohol

Use of snakes in religious rituals or “sport”

Rattlesnakes, Cottonmouths & Copperheads

Heat sensitive pit between each eye & nostril;

enables snake to locate warm-blooded prey

Triangular head due to presence of venom

glands; venom immobilizes & digests prey

Two curved, canalized fangs--retract when mouth closed

3 pairs replacement fangs (fang replacement occurs throughout snake’s life)

Snake regulates venom quantity based on size of prey; can inject from one or both fangs

Amount of venom injected variable in defensive bites

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Recognition: Venomous or Harmless?

Applicable to North American Pit Vipers

Venomous

• Triangle-shaped

head

• Elliptical pupil

• Pit

• Fangs

• Rattle--rattlesnakes

Non-venomous

• Rounded head

• Round pupil

• No pit

• No fangs /

small teeth

No Envenomation (“Dry” Bite)

Fang marks without local or

systemic reaction

Minimal Envenomation

Fang marks, local swelling, pain

Rubbery, minty or metallic

taste in mouth

No significant systemic effects

Moderate Envenomation

Fang marks with local & systemic effects: pain,

nausea, vomiting, paresthesias, fasciculations,

swelling beyond bite site, mild coagulopathy

Severe Envenomation

Fang marks with severe swelling / local

response, severe systemic manifestations,

including hypotension & seizures

Marked coagulopathy

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Severe Envenomation

Emergency Interventions in the Field:

Move victim to safe area away from snake

Advise rest (exertion speeds venom effect)

Remove jewelry & tight clothing

Splint & immobilize bite area at heart level

Evacuate to hospital ASAP

Emergency Intervention

DO NOT!

Apply ice

Apply a tourniquet

Incise or suck wound

Capture / handle snake

Note: even DEAD or

decapitated snakes can

inflict a bite -- take a digital

photo instead!

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Poison Control Center

Prophylactic fasciotomy not recommended;

swelling from myonecrosis typically resolves with

adequate antivenom administration

Radiographic imaging to identify embedded teeth

or fangs in bite wound

Consider antivenom (CroFab): Enhanced safety

profile: no skin testing; administer within 6 hours if

possible

Tetanus prophylaxis / wound care; antibiotic

prophylaxis not routinely indicated

Don’t molest snakes – use common sense!

Don’t keep venomous snakes as pets

Stay out of striking distance

Use caution in snake-infested areas: rocks, tall

grass, caves & heavy underbrush

Don’t put hands & feet where eyes can’t see

Wear boots & protective clothing

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Severity varies: depends upon animal &

reason for attack; most do not attack unless

provoked Most attacks occur far from definitive care Initial wound care similar to domestic animal

bites Blunt trauma / crush injury common Antibiotic coverage is same as for domestic

animals Wounds are tetanus-prone & generally left

open Consider need for rabies prophylaxis

Top speeds up to 40 mph

Attacks more common in

summer

Brown Bears: higher rate

of attack than black

bears

Sudden close encounter

Mother with cubs

Most dangerous: bears

that view humans as prey

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Make noise; be cautious

Avoid common bear areas

Pepper spray may be useful:

Must be used within 30 feet right into

bear’s face

Do not use on skin or clothes

Should not be sprayed in camp as a deterrent

Consider carrying a marine / road flare

Never feed a bear

Keep campsite free of garbage

Store food in approved containers & out of reach (hung at least 10ft up in tree or on pole)

Never keep food / scented items in your tent

Remember the 100m triangle: Assure 100m between the campsite, the food storage & cooking areas

Never approach a mother bear with her cub

Do not look directly into the bear’s eyes

Do not run or make sudden movements

Do not act aggressively

Stand your ground; back up slowly

Backpack may offer some

protection

If attacked, get into fetal position,

cover head & play dead

Bears can climb trees

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If an attack is immanent:

Yell & throw things

Look big

Act aggressively toward

bear; black bears tend to

retreat

If attacked: kick & fight

aggressively as that bear

has no fear of humans &

may want to eat you!

Becoming more common

Frequently stalk, pounce &

break the cervical spine

May be scared off by

aggressive behavior

Look big; cluster with hiking

partners

Keep backpack on for protection

Fight back with any object

available

Do NOT run away

Scene safety: Mountain lion

may still be in area

Manage ABC’s: control

massive hemorrhage

Remove debris & foreign

objects, including teeth

Assess for fractures

Evacuate for definitive care

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Rabies

•All mammals can be infected,

esp. bats, raccoons, skunks, foxes

•Transmission:

• Scratch or bite from infected animal; saliva

contact with open wounds, eyes, nose or

mouth, inhalation of aerosolized virus

•Animal may exhibit behavior change!

•20 to 60 day incubation, but may be 9 days to > 1

year for human rabies

•Common cause of human death in developing

countries

• Treatment: No effective treatment for symptomatic disease; nearly always fatal!

• If animal isn’t available, victim must start post-exposure prophylaxis Post-exposure Prophylaxis:

#1 – Immediate wound cleansing – soap & water!

#2 - Human Rabies Immune Globulin—RIG: injected into bite site & IM for passive immunity

#3 - Rabies vaccine 1 ml Deltoid IM for active immunity (Days 0, 3, 7, 14 --new CDC 4-dose regime) --Immunosuppressed patients: 5th dose day 28

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Medium size, light brown with fiddle-shaped mark

on back (“fiddleback” or violin spider)

Live in dark, secluded areas

Venom has cytotoxic effects on tissue; bites

cause ulcerative lesions

Bite may be painless, stinging to sharp & painful

Intense aching & pruritus in minutes to hours

Central bite site: bleb or vesicle surrounded by

expanding erythema; later becomes dark &

necrotic with eschar

Systemic effects rare, but occur

Differential diagnosis: MRSA

Interventions:

Apply cold compress intermittently for first

4 days after bite

Do NOT apply heat--will increase enzyme

activity of venom & worsen wound!

Rest & elevate affected area

Supportive care: topical antiseptic & sterile

dressing; antibiotics if infected

May need debridement & skin grafting

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Don’t place hands & feet where

eyes can’t see

Inspect clothing & shoes

Inspect bedding

Wear protective clothing &

gloves when in areas

that harbor spiders

Tentacles have

barbed, venom-

charged nematocysts

that fire stinging cells

Toxins injected into

skin & enter victim’s

circulation

Reaction to toxin may

cause collapse in

water & drowning

Mild Reaction:

Rash with stinging, itching, tingling, burning & intense throbbing pain

Red-brown-purple tentacle prints or welts Skin infection can occur

Moderate to Severe Reaction: Multiple, body-wide effects including muscle

spasms, nausea, vomiting diarrhea, stomach pain, severe pain at sting site

Anaphylaxis

Organ failure, coma & death

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Prevent firing of nematocysts:

Wash area with sea water (not freshwater)

Hot water or topical lidocaine best for pain Do not rub or compress

Avoid vinegar: widely advocated but increases pain after stings of most jellyfish species

Remove tentacles with tweezers or gloved hand Shave area with shaving cream or baking soda

paste to remove nematocysts

Pain control (ibuprofen, acetaminophen), diphenhydramine, tetanus immunization

Etiology: Skin exposure to below-freezing

temperatures with ice crystal formation

Increased risk: Inadequate or wet clothing,

fatigue, poor nutrition, smoking, alcohol & drug

use, impaired circulation

Occurs most in extremities, with higher incidence

in feet than hands

First Degree

Pale, white & numb while frozen

Edema & hyperemia after rewarming

Area is pale, white & numb while frozen

After rewarming, redness, edema & clear to white fluid-filled blisters

Second Degree

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Complete tissue freezing; pale, white & numb

Pain, redness & edema with rewarming

Blisters contain dark, hemorrhagic fluid; surrounding skin is red or blue & may not blanch

Involves skin, muscles, tendons & bone

Area is pale, white & numb while frozen

“Chunk of wood” consistency

Mottled skin with bluish discoloration forms deep, dry, black-crusted lesion; gangrene develops

Splint to minimize motion, pad between fingers

/ toes & elevate

Before thawing, give ibuprofen 400 mg q 12h

(inhibits inflammatory cascade)

Re-warm rapidly in 40 C water bath (104 –

108F hot tub temp)

Note: Slow rewarming increases thromboxane

& prostaglandin production; causes secondary

damage

Pain control!

Tetanus prophylaxis

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DO NOT: Use dry heat Thaw if part can refreeze Rub or massage area when frozen Rub frostbitten area with snow

Note: If evacuation delay is expected,

do not rewarm! Better to have victim walk out on frostbitten foot.

Synthetic base layer (Cotton kills!)

Wool / down / synthetic insulating layers

Waterproof / wind-proof outer layers

Hat / face protection (balaclava)

Gloves (mittens are warmer) & glove liners

Wool / synthetic socks (1 pair)

Sun glasses or goggles

Adequate nutrition

Adequate fluid intake

Avoidance of alcohol

Tetanus prophylaxis up-to-date

Consider medical supplies based upon type of

austere / wilderness environment / excursion, trip

duration, risks & personal skills / training

Medications: broad-spectrum antibiotics

Communications: emergency contacts & travel

insurance

Rabies prophylaxis?

Know when to evacuate

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