What would you do here? Simple Skin Avulsion [WARNING: POST CONTAINS GRAPHIC IMAGES]

[El Solis]

Here is a simple skin avulsion, something that could easily happen on a trip. What would you do? How would you address the wound? What supplies would you need to properly care for this wound? Do you carry enough supplies to care for this wound for more than one day?



In this case I just washed the wound with soap and water, patted it dry and then was able to lay the skin out where it belonged and apply a skin glue. If this was in the backcountry, I would do the following:

1. Get my Basecamp First Aid Kit (FAK) and put on my Personal Protective Gear of at least gloves. Probably don’t need a mask or eye protection.
2. Wash the wound with water and soap. Drinking water is fine, you do not need sterile water. Please do not wash these wounds with hydrogen peroxide as it will damage the healthy tissue as well. Just plan water or soap and water is sufficient.
3. I wound then lay the skin out where it is supposed to be using tweezers.
4. If you don’t have skin glue, and no…crazy glue is not the same, I would then lay down a non-stick pad (a brand name is Telfa or you could use Xeroform which is gauze with vasoline) and then tape it down.
5. Keep an eye on it. You want to watch for infection which is usually present when the following are found: redness in the area but there can be red streaks that move away from the area, warmth, pus, increasing pain, increasing swelling.
6. For this wound I would leave the dressing in place for at least 48-72 hours and try to keep it dry to allow the skin to “reattach”. The odds are that the skin that is lost will eventually die but it will be a protective barrier.

If you have any questions or suggestions for topics please let me know!

Chris

 

[emt.micah]

Concur. And realize that this must be cleaned and dressed well to prevent infection. An infection in the hand like this can easily cause more problems in a hurry. Also, depending on the mechanism of injury, RICE it.

 

[slomatt]

Are there any alternative dressings you would recommend if a non-stick pad is not available? I'm assuming a standard gauze dressing would not be ideal since it would stick to the wound and be difficult to remove. Trying to determine if it makes sense to add non-stick pads to my first aid kit.

Thanks as always for posting these scenarios.

 

[El Solis]

A non-stick would be the best but in a pinch you could use regular gauze but when you remove it you would want to soak it with water first to help keep it from sticking. It wouldn’t be the end of the world if the skin came off a few days later. This wound did well and the skin survived but I had expected it to die. If you did a good job cleaning it you could leave the dressing on for 48-72 hours before changing it (of course checking for infection). This gives the wound time to start to lay down the matrix for new skin and secure the flap.

Another option is to cover a piece of gauze with vasoline and the put that on the wound. Commercially it is called Xeroform. A similar product is called Adaptic.

Another option, and I’m only throwing this out there so people can see there are many right ways to do things, is to use the butterfly bandage or steristrip tape to hold the wound down. If you did this you would leave them in place and let them fall off on their own. I don’t carry butterfly bandages and I might have a pack of steristrips. Non-stick gauze is really something you should have in your boo boo and basecamp first aid kit.

Chris


PS: if there’s a topic anyone would like addressed please just ask! I’m happy to answer any questions related to trauma, first aid, medical care, general health care issues, etc.

 

[Jedi]

Trying to determine if it makes sense to add non-stick pads to my first aid kit.

I recommend throwing some Tefla pads in there. The non-stick capability is nice to have for anything that bleeds and needs to be covered.

 

[The other Sean]

Your mention of using Vaseline, is there any worry about causing infection from using an already opened tube or tub?

When my son was born and when they sent us home just after he was circumcised, they had us put a dab of Vaseline on a gauze and put it over the area so it wouldn't stick to his diaper until it healed. it worked quite well. The hospital sent us home with two tubes of Vaseline that had a fancy name on it.

Also, the more topics you are posting, the more I realize I know very little. The bit about not using peroxide on it is something I didn't realize.

 

[El Solis]

Vasoline is pretty safe from an infection standpoint. Not much will grow in it.

Was the tube of stuff “petroleum jelly”? Or something else?

You can get single shot tubes of vasoline but I don’t think you need to. For most people here we aren’t off the grid for weeks at a time. If you got hurt day one you’d be back to civilization in a day or so.

As for the knowledge part, shoot me some topics you’d like to know about and I’ll get some videos or post out. We are working on a formal training program for OB so keep an eye out for that as well.

 

[The other Sean]

It was petroleum jelly (finally remembered to look for the extra tubes before little guy went to sleep, 4 months old now). I figure if it works on a 4 day Old's sensitive area like that, it must be ok for other things similar? I remember it did work well keeping the dressing off his wound until it healed up a few days later.

As far as topics, there are many scenarios many of us would never think of that are somewhat common out of doors, so I wouldn't know where to start as far as ideas.

 

[Stewart (Stu) Pirie]

Could you do a write up on puncture wounds (Ive seen someone who fell on a stick whilst winching and penetrated the thigh) and perhaps larger bleed wounds like a chainsaw cut?

Ive had some training in regards to these both in a medi training course as part of my Anti poaching unit, but its always good to keep the brain topped up on info.

 

[El Solis]

I’ve done a simple chainsaw cut, here’s the link: What would you do here? Chainsaw Injury [WARNING: GRAPHIC IMAGE IN THE POST]
https://www.overlandbound.com/forums/index.php?threads/What-would-you-do-here?-Chainsaw-Injury-[WARNING:-GRAPHIC-IMAGE-IN-THE-POST].20129/

I’m planning an “On Call With Chris” video about puncture wounds and snake bites. Hoping to shoot that when I can get five minutes.

 

[MunsterGeo Overland]

Could Cling Film ( as we call it over here in Ireland and the UK and what you probably call Saran wrap) be used as a non-stick material in this senario and overwrapped with a typical bandage or tape? Assuming the area had been adequately cleaned of course.

 

[El Solis]

Technically it could but the cling wrap doesn’t breath and that might cause issues with healing. Really the goal is to reposition the skin and then hold it in place as best as possible. There are lots of improvised ways to accomplish this.

 

[MunsterGeo Overland]

Brilliant, thanks for taking the time to reply and explain.

I asked as for a camp situation we would have Saran wrap in our camp First Aid kit for burn treatment and was curious when I seen your interesting scenario post.

On the hills and mountains here in Ireland the injury you used here is very possible as there are many areas with loose shale. Lower leg and lower arm injuries of this sort would be most likely on the descent in sunny weather as a lot of casual hillwalkers switch to shorts and tee-shirts..... You can imagine the rest....

 

[HOT-ROD]

Hey question, what’s your thoughts on bacitracin on the trails? I use it all the time for wounds and stuff.

 

[El Solis]

Bacitracin is one of those it doesn’t really hurt to use it, probably not needed if the wound is cleaned and kept clean. Better for road rash, scrapes and shallow cuts. I don’t routinely use it but I carry it.

 

[Rogue7]

Xeroform is considered an occlusive dressing. As infection is a primary concern with a wound of this type, an occlusive dressing is not suggested. A telfa or gauze dressing and frequent dressing changes would be best.
To close the skin, steri-strips or thin tape strips are best.

As a last resort, use Duct Tape. Every adventurer caries it!

 

[cookiedough]

avulsion - yikes. It's just amazing to me all the good things washing with soap (soap or really a detergent?) and water can do. In the case of this injury, what's a good OTC anesthetic to use preferably before irrigation? I guess in my mind shock is the issue to contain (me - I just pass out at the sight of needles) and the pain and sight of washing my own injuries (you know, mountain biker = blood donor) is enough to give me the woosies.

 

[El Solis]

Good OTC meds are ibuprofen and Tylenol. Can take both together and each does something a little different. We are moving away from opioids and going back to these two for post op pain control.

 

[USStrongman]

Interesting reads. My thoughts on this:

While Xeroform is an excellent occlusive dressing used extensively in burn, trauma and plastics, in an ideal environment it should be changed daily. While it does contain 3% Bismuth Tribromophenate, research shows that Xeroform itself is not an effective antimicrobial. Enter Aquacel Ag. Original Aquacel had a typical silver amalgamate the same as Silvadene, but in a completely different medium. Aquacel Ag changed that by replacing certain ions in the silver chain, giving it 99.9% effective kill rate. More importantly the half life for kill is 12-14 days as opposed to the 4-6 hours of Silvadene. MSSA, MRSA, e Coli, Staph and more were no longer of major concern. It absorbs 23x its weight in exudate and often, unless copiously soaked in exudate, does not need changing. Only the outer dressings do.

The only issue with this scenario above, is the patients age, and assumed ability to fight infection combined with inadequate blood perfusion. Getting that patient proper medical care is more time sensitive than a younger person.

In addition, skin glue should only be used in two scenarios.

1. You have thoroughly cleaned it with a true antimicrobial product. Staph has become more resistant in the past 30 years and a skin glue is asking for potential sepsis if left untreated, especially in an older patient.

2. It can be visualized every day and not used in combination with a true non-antimicrobial dressing. Bacteria love warm, moist dark places... and occlusive dressings without proper antimicrobial prep are asking for trouble... again, especially in older people.

I always carry two antibiotics on trips. Flagyl for GI issues and Keflex for skin and potential staph (like above), especially when traveling outside the US.