Post-TEOTWAWKI Wound Care – Part 2

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    by M.V., Survival Blog:

    (Continued from Part 1. This concludes the article.)

    Another type of abscess which might be encountered would be a perianal or perirectal abscess. Though hygiene can play a role it is typically caused by an infection in the perianal crypts which extends into the subcutaneous space. Pain and swelling typically occur as in all abscesses and prompt drainage is necessary. The longer that these progress; the more extensive that they become, so time is of the essence. Drainage is as previously described and your incision should be radially away from the anus as if the anus was a hub on a wheel and the incision is the spoke. You are looking for the softest spot on the swollen area which is typically away from the muscles which you do not want to cut. A generous incision is made with ellipse of skin and care as described previously. Most times you will not need oral antibiotics if you catch these early.

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    We can probably ignore the treatment of diabetic ulcers and venous and arterial ulcers and wounds because these patients will likely not have the required care and medications necessary remain stable for an extended period of time. Let us now discuss large wounds with significant tissue loss and necrosis. These can occur if a simple abscess is allowed to progress significantly as well as with traumatic injuries. The body’s response to large wounds is the same as with small, just on a grander scale. Modalities which we would employ in the here and now such as rotation flaps, skin grafts, wound vacuum devices will not be available. The biologic substances that are also available and quite expensive will also not be available.

    One of the biggest issues with large wounds is control of infection. There are issues of fluid losses but we are not going to discuss wounds that are that large since the likelihood of survival in a post-collapse world with that type of wound will be an act of God.

    Infection control starts with debridement of the wound of necrotic tissue, which in laymen’s terms is cutting away all the dead looking stuff. Bacteria love rotting flesh so its removal is necessary. First clean the wound with sterile water or saline to remove dirt and particulates. You can also put some iodine or betadine in the irrigant prior to scrubbing the wound out. One would typically cut away dead tissue with a scalpel or some other type of clean sharp blade. How do you know when you reach good tissue? It will bleed. Most times you cannot remove all of the dead tissue and that is when we rely on our dressing changes to do the rest. An easy technique is what is called wet to dry changes. This is typically done with saline fluid but if all you have is clean sterile water that will do also.

    Homemade saline solution requires boiling 1 liter of water covered (or 4 cups which is a reasonable approximation) for 20 minutes, let cool and add 2 teaspoons of non iodized table salt (8 grams). Sterile water is also fine. You moisten gauze or whatever dressing you have (the more porous the dressing the better) and put it into the wound. The dressing is not supposed to be soaking wet, just moist. Then a dry dressing is placed on top. The goal is for the moist dressing to dry out which will stick to the decaying particles that are present. When you removed the once wet now dry dressing the stuck particles come with it cleaning the wound. That is the reason for the porous or what I call holey gauze. Decaying particles get trapped in the pores and get pulled away. If you use “no stick gauze” it will defeat the purpose of the dressing changes.

    Control of bacterial concentrations in the wound can be achieved with a simple solution that you can make with available supplies. Dakin’s solution has been in use for decades and is quite effective. It is extremely simple to make and also quite inexpensive.

    Making the Solution:
    1. Wash your hands well with soap and water.
    2. Gather your supplies.
    3. Measure out 32 ounces (4 cups) of tap water. Pour into the clean pan.
    4. Boil water for 15 minutes with the lid on the pan. Remove from heat.
    5. Using a sterile measuring spoon, add 1⁄2 teaspoonful of baking soda to the boiled water.
    6. Your doctor may prescribe one of several strengths. Measure bleach according to the chart and add to the water also: Use sodium hypochlorite solution 5.25% (Clorox® or similar household bleach).
    Bleach products that are more concentrated and thicker are not recommended. Be sure to purchase unscented bleach.
    7. Place the solution in a sterile jar. Close it tightly with the sterile lid. Cover the entire jar with aluminum foil to protect it from light.
    8. Throw away any unused portion 48 hours after opening. Unopened jars can be stored for one month after you have prepared them.

    A useful reference: Making Dakin’s Solution.

    It will be okay if the bottle is not covered and also it will last way longer than 48 hrs. It is better practice to pour the solution on to the gauze rather than dipping the gauze into the bottle since you would like to keep the solution as sterile as possible for as long as possible. There have been various studies of the concentration of Dakin’s and its bacteriocidal properties and rate of injury to new growing tissue. The concentrations above are 0.5/ 0.25/ 0.125%. Some studies suggest control of bacteria can be achieved with as low as 0.025%. I typically use 0.25% because that is what has worked best for me over the years. Treatment with Dakin’s is simple. It is a wet to dry dressing change but instead of just plain water or saline you use the Dakin’s to moisten the gauze. Dressing changes are two to three times per day and should continue until you reach the proliferative phase of healing. How do we know when that time has occurred? When the wound stops looking so soupy and gross and becomes red and beefy (transition from inflammatory to proliferative phase) you can typically stop using Dakin’s and just go back to wet to dry or to dry dressings.

    Some wounds will have a difficult time finishing the healing process. They just kind of stall and linger and will not completely close. This typically occurs due to a new bacteria in the wound which needs to be treated with antibiotics. It would be most beneficial to have a culture to find out what kind of bacteria and then treat it with the appropriate antibiotic. This situation can arise in any wound, even one initially treated with Dakin’s. You can try peroxide into the wound but this typically does not work at this point. You will most commonly see a thin film on the beefy red tissue (granulation tissue) and this coincides with the cease in the progression of healing. At this point my thoughts are it is best to re-excise the superficial aspect of the wound to get rid of the film and the tissue just underneath. This sometimes gets rid of the bacterial load and restarts the healing process.

    There is a product called MediHoney, which is honey based, that has been used with good results. It is insanely expensive and I do not know if a small amount of regular honey would work as well. My gut feeling is that it might but there is no way I am going to try this now for medical legal issues. There is enough data to know that honey based wound dressings do work but those studies are not taking Food Lion brand honey and pouring it into a wound.

    Some extremity wounds can also be slow to heal especially if the injury to the extremity caused a significant amount of swelling. There is a dressing called an Unna boot (traditionally used for venous stasis disease) which is a compression dressing that protects the skin and helps keep the edema out of the extremity which aides in healing. It can be made by applying zinc oxide and calamine lotion to a gauze roll which is wrapped around the extremity, covering the wound, typically from mid-foot to just below the knee. Obviously, the wound should be between the starting and ending points of the wrap. The compression dressing is called Coban wrap which is a self-adhesive dressing that is placed over the impregnated gauze wrap. It can be left on for a few days or up to a week and is replaced with the extremity elevated as to keep the swelling in check. This dressing is not for a grossly contaminated wound. The wraps come pre-made but it should be easy enough to soak a roll of gauze in calamine and spread some zinc oxide on it to recreate it.

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