Begin here if patient has a wound (injury with broken skin), including serious injury, such as:1. Begin emergency care
Seal a sucking chest wound NOW (p293).
1.2 Control severe bleeding.
1.3 If possible head, neck, or back injury, splint neck and back to prevent movement (p243).
1.4 Position: Keep patient lying down, to prevent fainting or shock.
1.5 Check vital signs: P,R, BP. if shock (weak, fast pulse, low BP), now go to p7.
If history of severe bleeding, check P & BP with patient lying down, then sitting up.
Treat for shock (p. 7) if, when sitting up, pulse gets higher by more than 20, or systolic BP (top number) gets lower by more than 10.
If serious injury, plan to have helper recheck vital signs at least every 15-30 minutes, until they have been normal for 2 hours.
1.6 Now, for the following injuries, go to the page listed.
Injuries are listed in order of recommended treatment:
Chest injury (p291)
Head Injury (p259)
Eye injury (p101).
2. History 2.1History of present illness
Get a general history of present illness (inside cover).
Also ask the following specific questions:
1. Find out about the accident that caused the injury:
Exactly what happened?
What caused the injury?
Was it related to alcohol or other drugs?
Did patient faint (pass out)? Does patient have other injuries?
If gunshot wound, find out about the gun:
What size (caliber) was used and what kind of bullet (military,hunting,target)?
How close was the gun to the patient when it fired?
If knife wound, find out what size and type of knife was used.
If wound is over the knuckles, suspect a human bite.
Patient may be embarassed to tell you.
If animal bite, find out the following: where is the animal?
Is the animal alive and running loose, alive and tied up, dead?
Was the animal acting strangely?
If a pet, did it have rabies shots? If a wild animal, was it provoked (surprised, fighting back)?
Is rabies common in your area?
2. How much blood does the patient think he lost?
3.Does patient have any other complaints, such as Nausea?
Symptoms of shock:
Feeling weak or tired?
Unable to feel or move his arms or legs?
When did patient last eat?
2.2 Past health history
2. What medicines are patient taking now?
4. When was last TETANUS shot?
3. Exam:If the patient may also have a broken bone, be careful not to move the hurt part as you examine.
3.1 General appearance.
3.2 If needed, do a body survey (p9).
3.3 Examine the injury closely:
Location, Size and shape.
How deep is it?
What type of wound is it (straight cut, puncture wound, other)?
Is it discolored or swollen?
Is it dirty?
Look inside the cut for damage: Nerves and tendons look white (like gristle in an animal).
Cut arteries will pump out blood.
3.4 If wound is on an arm or leg, check beyond (distal to) the injury, and compare both sides of the body.
Damage to a nerve, tendon, or artery often happens when there is a wound of the writs, hand, ankle, or foot.
Check nerves: Can the patient feel your light touch or a poke with a safety pin?
Is his feeling the same as on the good side?
Check tendons: Can he move in all of the normal directions?
Check blood supply: How is the color beyond the cut
Press on the skin.
When you let go, skin color will look white.
Does color return normally, within two seconds (good capillary refill)?
Check pulse beyond the cut: If pulse NOT felt on top of foot (DP), check pulse behind medial ankle bone (PT).
3.5 Bones. Check for tenderness of nearby bones: Start away from the painful area and slowly work towards it.
Feel as much of the bone as you can.
For example, feel along the whole length of the shin bone.
If bone tenderness is present, pick a place where the skin is not injured.
Does the patient have bone pain even when you press the bone over normal skin?
Pain upon pressing the bone may mean that it is broken.
3.6 lab test: Hemoglobin, if patient has lot alot of blood.
Hemoglobin level may be normal at first.
It is important to check it NOW in order to compare it with level after some time has passed.
4. Assessment 4.1 Your assessment should be: Wound.
4.2 Include in your assessment: location and size of wound. Other important information, such as : dirty wound, nerve or tendon injury. 4.3 Make a more specific assessment. Include in your assessment that the wound is one of the following types: Gunshot wound (Plan 5.1) something sticking into body (foreign body) (Plan 5.2) Bite (human or animal) (any break in skin causedby teeth; plan 5.3).
Other wound (such as knife wound, puncture wound, abrasion or other; Plan 5.4).
5. Plan 5.1 Gunshot wound
1. Report NOW to your referral doctor.
Begin the following treatment while someone else contacts the doctor.
Often bullet damage will be inside, where you cannot see it.
2 Special care should include the following:
Look for two wounds (entrance and exit).
Apply a pressure dressing to both wounds.
Now go to plan 5.4 ("general wound care").
Follow parts of that plan which apply.
Be sure to recheck vital signs (P, BP) every 15-30 minutes until they have been normal for at least 2 hours.
5.2 Plan: Something sticking into body (foreign body)
1. Report NOW to your referral doctor. Begin the following treatment while someone else contacts the doctor. If you CANNOT reach a doctor, have someone arrange for transport to hospital as soon as possible.
2. Warnings include the following:
Leave the object in place.
Pulling it out may cause more damage and bleeding.
DO NOT clean or look into this kind of wound.
3. Special care includes the following:
If object is stuck into eye, go to "Serious Eye Injury", p.102.
If object is in arm or leg, apply a splint (p.249).
Cut away clothing (at the seams, if possible).
If there is much chance that the object will be hit or moved, carefully trim object to smaller size.
Put a bulky dressing around object to keep if from moving andto help control bleeding.
Tape the foreign body and dressing in place toprevent movement.
4. Transport patient to hospital as soon as possible. While you are awaiting transport, go to plan 5.4 ("General Wound Care"). Follow parts of that plan which apply.
5.3 Plan: Bite (human or animal)
1. Wash the wound well (p.344).
As soon as possible, scrub the wound well in order to help prevent infection. Wash bites on the face especially well. As you wash, remove all pieces of dirt, clotted blood, and dead or seriously damaged skin.
Irrigate the wound well, with force: use a 10-20cc syringe and a 19-22 gauge needle or I.V. catheter.
Irrigate with at least 1-2 quarts of sterile fluid or boiled, cooled water.
Cover the wound with a dry, sterile dressing.
2. Report NOW to your referral doctor. Also report to your sanitarian if an animal bite. If you CANNOT reach a doctor or sanitatian, follow this plan until you can.
3. Medicine. For certain bites, start an antibiotic in order to preventinfection: If human OR dog bite: Give I.M. shot of PROCAIN PENICILLIN(Wycillin). Repeat the shot every 24 hours for 2-3 days: weight approximate age dose:
Less than 15 lbs. less than 4 months 100mg (4cc)
15-24 lbs 4-17 months 175mg (7cc)
25-49 lbs. 18 months-6 years 250mg (10cc)
50 lbs. or more 7 years or more 250mg (1 capsule)
If allergic to PENICILLIN OR if bite was from sea mammal (such as seal or walrus): Give TETRACYCLINE (250mg capsules or tablets). Tetracycline will stain teeth as they develop. DO NOTgive to: pregnant women. child less than age 8. Dose: 500 mg. (2 capsules or tablets) 4 times a day for 2-3 days.
4. Rabies prevention after an animal bite should include the following:
Transport patient to hospital for possible rabies shots if you can NOT reach a doctor and:
The animal was wild and cannot be found
The animal was acting strangely, attacked without a reason, or died not long after biting patient.
If bite was from a wild animal, tell your local police officer to find it and kill it.
Tell officer NOT to shoot or club it in the head.
The brain must be examined carefully.
If bite was from a pet or sled dog: tell your local police officer to chain or cage the animal so it can not bite other people.
Watch the animal for signs of rabies for 10 days.
Signs of rabies includes:
Irritability (growling more, meaner).
Chewing more than normal.
Walking around without any purpose.
Trouble walking, such as dragging a leg.
Any sudden change in behavior.
If any signs of rabies appear, the animal should probably be killed and examined for rabies.
If you CANNOT reach a sanitarian, call the rabies laboratory yourself to see if the animal should be tested for rabies.
Phone: Monday -Friday 8-5pm: 474-7071. Other times: 452-1166, ask for unit 066.
If the rabies lab accepts the animal for testing, do the following unless advised differently by your sanitarian: if the animal is small (like a fox, cat, or bat), send the whole body. If the animal is large, the head can be removed and sent. The person doing this should: protect themselves by wearing waterproof gloves and avoiding touching the animal's saliva. Leave at least 3-4 inches of neck of the head, so that the salivary glands are included. wrap the head in paper or some other absorbent material. Place in a leak-proof plastic bag, and keep it in a cool place until you send it. Send the animal or its head to:Virology, Rabies Unit Northern Regional Laboratory 233 Arctic HealthBuilding 901 Koyukuk Ave. South Pouch 60230 Fairbanks, AK 99706. label the package: "BIOHAZARD-KEEP REFRIGERATED." tell the airline pilot what is in the package. He should make sure it stays cool and should refrigerate it assoon as possible.
5. Other plan should include the following:
DO NOT close the skin with wound closure strips or sutures unless the doctor tells you to.
Closing the wound will increase the chances of an infection.
When the time is right, talk about prevention of animal bites, including:
Always supervise small children when around dogs.
Have pets vaccinated for rabies.
Avoid wild animals, especially if they are acting strangely.
DO NOT try to make a pet out of a wild animal.
Now go to plan 5.4, which follows ("General Wound Care"). Follow parts of that plan which apply.
5.4 Plan: Other Wound and General Wound Care
1. Report to your referral doctor, unless the wound is minor and he has signed for your to treat minor wounds without contacting him.
Report NOW if:Patient has lost a lot of blood, has a low hemoglobin level, or has signs of shock (weak, fast pulse; low BP).
Wound is large or serious, such as a stab wound or any cut that goes deeper than fat layer (into muscle).
While you are waiting to report, follow this plan.
2. Special care should include the following:
If you think you will need to use instruments that are not already sterile, have a helper start boiling them now, and for at least 20 minutes.
Examples include instruments for:
Picking dirt out of a wound.
If you do not have sterile fluids for rinsing a deep or serious wound, have a helper boil water for 5 minutes and then remove it from heat.
If wound is on a hand or arm, remove jewelry (rings, bracelets) to prevent damage if the hand swells.
Wash your hands well, put on sterile gloves and then clean the wound (p344).
Examine the wound again.Look inside a large cut to see if a nerve, artery, or tendon is cut.If wound is over a bone or joint and you think the bone may bebroken, treat for open fracture.
Go to p238.
3. Decide if you should close the wound, as follows:DO NOT close wound if there is a serious injury underneath or if it may get infected easily.
When in doubt, leave the wound open.
Plan NOT to close the wound in the following cases: Cut goes deeper than fat layer (into muscle).
Nerve, artery, or tendon may be damaged. Bone may be broken underneath.
There is profuse bleeding.
This is a wound that is deeper than it is wide.
It is usually made by something that is sharp and pointed, such as a stab wound, nail or splinter.
Puncture wounds get infected easily.
Human or animal bite.
Happened when working with a sea mammal (such as seal or walrus), fish slime, or rabbit.
Dirty wound. Wound is over 6 hours old.
If you decide you should NOT close the wound, do one if the following:
Arrange for transport to hospital, if needed.
Leave the wound open, and care for it yourself.
If you decide you should close the wound, do one of the following:
use wound closure strips for most wounds that you decide to close.
If wound is easy to close and if there is no space under the skin when closed.
Follow guidelines on p.344.
Suture the wound: If it is a deep cut, through skin and fat.
If wound is in an area where it may easily pull apart with movement.
If wound closure strips will not hold wound edges together.
If you can NOT reach a doctor and the doctor has signed for you to do this when you cannot reach him.
Follow guidelines on p.345.
4. Other plan should include the following:
Cover wound with a dry, sterile dressing.
If abrasion (scrape), use a "non-stick" type of dressing, or apply a small amount of antibiotic ointment to the wound.
If needed, fit patient with a sling, splint, or crutches.
If patient has NOT had a TETANUS booster shot in the past 10 years: Give I.M. booster shot of TETANUS TOXOID and DIPTHERIA (Td). Dose: 0.5cc I.M.
Report to your local police or State Toopers if:
You suspect that a knife or stab wound was the result of an attack.
If needed, for pain: give ACETAMINOPHEN (Tylenol;p.416).
If pain is severe and you CANNOT reach a doctor, give ACTEAMINOPHEN with CODEINE (p.416).
5. Patient education should include information in chart 5.4
chart 5.4 Patient Education WOUND CARE
1. Keep your wound and dressing clean and dry.
Do NOTwash the wound unless your CHA/P tells you to.
If dressing becomes wet, it will need to be changed.
See your CHA/P.
2. Do NOT put medicine, lotion, orointment on the wound unless your CHA/P tells you to.
3. Warning! The wound may get infected.
See your CHA/P for any of the following:
Getting more painful, warm, red, or swollen.
Red streak up arm or leg.
Foulsmell from wound.
Enlarged, tender lymph nodes (lumps; may be neck, armpit,elbow, groin, or behind knee).
Fever or chills.
4. Reduce swelling.
Swellings lows healing and helps to cause other problems, such as infection.
For the first few days: If wound is on arm or hand, raise injured part above the level of your heart: when sleeping, rest arm on pillow.
When sitting, rest elbow on soft, firm support on a table.
When standing, rest hand of injured side on opposite shoulder.
If wound is on leg or foot, raise injured partabove level of your heart: when sitting, rest leg on padded chair. when lying down, rest leg on pillow.
If you have a bruised area, it will help todo the following: for the first 1-2 days, apply cold packs (ice placed inplastic bag and wrapped in a towel).
Apply for 20 minutes.
Repeat as needed.
After 1-2 days, apply moist heat (a warm, wet towel), but do NOTget dressing or broken skin wet.
Apply for 20 minutes, about four times a day.
6. Recheck as follows: Recheck every two days, sooner if serious wound (such as a bite) or if patient is having problems.
If wound was closed with wound closure strips or sutures: do nto removedressing for two days, unless patient has signs of infection.
After two days, examine wound.
If wound is dry and healing well, you may decide toleave dressing off.
Follow guidelines for removing:
-skin closure strips,p.345,
If wound was left open: do not remove dressing for 4 days, unless patient has signs of infection.
After 4 days, examine wound.
If wound is healing well with no signs of infection, your referral doctor may suggest that you close it (delayed closure, after 4-5 days).
If so, follow the guidelines for using skin closure strips (p.344) or suturing (p.345).
If wound happened when working with a sea mammal (such as a sealor walrus), fish slime or rabbit, AND if it is hurting more after 4-5 days,treat as on p.321, "Infected Wound".
If wound is getting infected, (wound getting more tender, warm, red, swollen; pus seen), treat as on p.321,"Infected Wound".
When the time is right, talk about accident prevention.
If problem is related to alcohol or other drug abuse: remind patient kindly of this.
Talk with patient about the alcohol or drug problem.
Follow theplan on p.204.
Cleaning/Washing a wound cleaning/washing is a very important part of wound care.
CLEANING/WASHING A WOUND
For washing, a basin of soapy water: 1 part POVIDONE-IODINE scrub(Betadine) to 10 parts water.
Or, soap and water.
Sterile 4x4's (gauzesponges)
Sterile instruments, if needed (such as forceps toremove dirt)
For irrigating: Sterile fluid: 0.9% SODIUM CHLORIDE (saline).or, LACTATED RINGER'S I.V. fluid. or, water that has been boiled for 5minutes and cooled.
Syringe: for rinsing: large syringe. if needed forirrigating: 10-20cc syringe or larger and 19-22 gauge needle or catheter.
Never put ALCOHOL inside a wound.
Doing this will damage the tissue.
Do the following:
1. Get set up:
Wash your hands well.
Get equipment/suppliesready, so it is easily accessible.
Put on sterile gloves.
2. First, wash around the wound, to keep germs that were on the skin from being washed into the wound:
Cover wound with a sterile 4x4.
Wash skin well around the wound.
3. Trim (cut) hair, if needed, to keep it out of the wound (it causes infection).
Avoid shaving, which may increase infection.
Do NOTtrim an eyebrow.
You need to be able to see the eyebrow on order to matchup the skin edges for good healing.
4. Next, remove the gauze and wash thewound well for 5 minutes: use sterile 4x4's and the soapy water.
If wound fits into the basin, you may decide to wash it there.
Clean out all of the dirt, or it may cause infection.
Lift up and clean under any flaps of skin.
Use instruments to pick out pieces of dirt.
If cleaning the wound is very painful and is still dirty, you may decide to numb the wound with LIDOCAINE(Xylocaine; p.346) and then clean the wound again.
5. Rinse the wound well.
Use a large syringe or clean suction bulb to help wash dirt away.
*Visualaugmentation If the wound is still dirty: it may help to use a mixture of 1part water to 2 parts HYDROGEN PEROXIDE to foam out the dirt.
Next, rinse again.
6. Irrigate certain wounds well.
Irrigate wounds that are likely to get infected:
Wound over bone or joint. bite.
Very dirty wound.
Use a10-20cc syringe and a 19-22 gauge needle or I.V. catheter to flush out any germs.
Irrigate with force.
Use at least 1-2 quarts of sterile fluid orboiled, cooled water.
Use more fluid for a deep or dirty wound.
SOFT TISSUE INJURIES: SKILLS USING SKIN CLOSURE STRIPS
Begin here after you have used the wound care guidelines that start on p. 339.
This means you have already done the following:
Carefully examined and cleaned the wound.
Decided that this is a cut that should be closed with skin closure strips.
For most wounds that you decide to close, you should use skin closure strips(Steri-strips, Butterfly).
Follow guidelines below or on package.
If you do not have packages of these strips, you may decide to cut your own from adhesive tape, as in the following drawing:
1. If needed, cut away dead tissue, the same as when suturing (p.347).
2. Prepare the skin around wound, so strips will stick better:
Clean skin with an ALCOHOL wipe.
Dry it with a sterile 4x4.
If you have tincture of benzoin, put it on skin around wound.
Be careful not to get alcohol or benzoin in to open wound.
Get wound closure strips ready:
Grasp package tabs and peelback.
Remove strips as you need them, being careful not totouch the part that will go over the wound.
4. Apply strips: Place one half of strip on one side of wound as in next drawing.
Press firmly into place.*Visual augmentation
Gently pull on other end of strip with your fingers.
With your fingers, push skin edges together exactly.
Press other half ofstrip into place.
* More Visual augmentation
Keep skin dry with sterile 4x4 so that strips will stick.
Close entire wound with strips, 1/8 in apart.
After you have finished, if wound is not closed inder a strip, take it off and reapply it.
You may add extra strips for more strength.
5. Place a dry,sterile dressing over wound, if needed.
6. For other plan, includingTETANUS TOXOID and DIPTHERIA (Td) shot, patient education and recheck information, see plan for wound care on p.342.
7. Removing strips:
Leave strips in place 7-14 days.
When removing strips, pull each end towards middle.
Suturing (stiching or sewing skin wounds)
Begin here after you have used the wound care guidelines that start on p 339.
This means you have already done the following:
Carefully examined, cleaned, and reexamined the wound.
Decided that this is a cut that should be closed with sutures.
You should be taught and checked out on suturing by a qualified person.
This section is to be used as a reminder.
If you can NOT reach a doctor, you should suture only if the doctor has signed for you to do this when you canNOT reach him.
Suturing Equipment/supplies needed:
syringe: 5,10, or 20 cc,depending on how much LIDOCAINE you will use.
20G needle 25G or smaller needle
ALCOHOL or POVIDONE-IODINE (Betadine) wipes
1% LIDOCAINE (Xylocaine)
Drape: small, disposable plastic drape, such as Steri-DrapeSterile
4x4's (gauze sponges)
suture material, nylon, 4-0 (on face use 5-0or 6-0, if available)
Instruments for suturing, including:
Tissue forceps (with teeth)
1. Getting started
1.1 Instruments should be as sterile as possible.
Use one of the following:
Clean instruments that have been boiled for 20 minutes.
Clean instruments that have been wrapped in foil, baked for two hours at 350F, and kept wrapped until needed.
Disposable suture set.
1.2 Reassure patient and explain what you are going to do.
Keep talking to a child while you work.
Have a parent stay, if helpful.
1.3 Place a good light over the wound.
1.4 Place a chair near patient, so you can sit down as you work.
1.5 Wash hands.
1.6 If there is hair around the wound that you think will get in the way, trim or cut it.
DO NOT trim or shave an eyebrow, or you may sew it together at the wrong spot.
2. Lay out Sterile Materials as you do this, teach a helper how to give you extra supplies when you have on sterile gloves.
2.1 On a flat surface, carefully peel open outer wrapper that holds sterile gloves.
Be careful not to touch inside of wrapper.
Peel wrapper all the way open, so it will lay flat.
Remove package inside, which holds the gloves, and set aside.
2.2 Onto the wrapper, carefully peel open and drop:
2.3 Nearby, place your container of instrumnets for suturing.
You may want to move some or all of the intruments onto the sterile area after you put on your gloves.
3. Numb (anesthetize) the wound
3.1 Ask patient if he is allergic to LIDOCAINE (Xyolocaine)
3.2 Draw up more LIDOCAINE than you think you will need.
3.3 Inject LIDOCAINE to numb thewound.
Use a 25G or 26G needle to inject: Inject LIDOCAINE (Xylocaine 1% solution).
Tell patient,"The medicine will burn for 15 seconds or so".
Do NOT inject any more than the following amounts in a 1.5 hour period:
Weight Approximate Age Dose
Less than 11 lbs, less than 2 months 1cc
11-21 lbs.2-11 months 2 cc.
22-31 lbs. 1-2 years 4cc
32-44 lbs. 3-5 years 6cc
45-59lbs. 6-8 years 8cc
60-89 lbs. 9-11 years 12cc
90-109 lbs. 12-13 years 16cc
110 lbs. or more 14 years or more 20cc
Start at one end of the wound, and work towards the other.
If injected correctly, LIDOCAINE will always be in front of your needle, and patient will only feel very first needle stickplus burning of the medicine. begin injecting as soon as needle is into skin.
You may see a little bump (wheal, like a mosquito bite) appear in theskin at the needle tip.
Keep injecting into the skin (NOT deeper) as youpush the needle in further. Watch the tissues as they swell with LIDOCAINE.Inject as needed, about every .25 to .5 inch along the wound. *visualaugmentation: Inject in these directions 3.4 check for numbness. Use tissueforceps (with teeth) to gently squeeze skin. Ask patient, "Does this hurt?"If numb, patient may feel pressure but it should not hurt. If needed,inject more LIDOCAINE. 4. Recheck wound with Gloves and Drape on 4.1 Put onsterile gloves. 4.2 Place drape around wound so you have a sterile area foryour work. 4.3 recheck the wound: Use your hemostat to help spread thetissues. Look closely for: dirt (foreign bodies). If found, you will needto clean and irrigate the wound again. damage to muscles, tendons, bloodvessels, nerves, or other structures. If found, report to your referraldoctor. 5. Trim wound edges, if needed. doing this helps to preventinfection and make less of a scar. 5.1 Wound edges probably should betrimmed away (cut, debrided) if the following is true: Tissue is ragged.tissue is dead Tissue is dark in color tissue is crushed pieces of tissueare too small to live. ONLY if skin feels loose enough so that edges willpull together easily after you trim. If skin is tight and wound needs to bedebrided, consider leaving wound open to heal (p.342), or it may getinfected. *visual stimulation: Plan to trim ragged wound edges. 5.2 Holdskin gently with tissue forceps (with teeth). 5.3 trim wound edges so theybecome sharper and neater to pull together when suturing. It is OK to usesharp, sterile surgical scissors. to stop bleeding, apply pressure with a4x4. 6. Suture the wound If wound is very deep, your referral doctor maysuggest that you put in some deeper stiches, with absorbable suturematerial (such as 3-0 Chromic Gut) if you know how. Use the followingguidelines for placing skin sutures only: 6.1 Use your instruments to helpyou. grasp needle with needle holder as in next drawing. Use tissue forceps(with teeth) as needed to hold skin. As you begin, make sure wound edgescome together to at the right spot. for most wounds, start suturing at oneend of the wound and work towards the other. Fi wound is very long, it nayhelp to sew wond in sections: Place first suture in center of wound. Placenext suture in center of one half of the wound, and so on. 6.3 Place theneedle: About 1/8in away from wound edge. look at 1/8in on a ruler, so youknow for sure. Placing the needle any closer to wound edge may cut offblood supply to that area. Angle the needle away fron the wound edge, as inthe next drawing. 6.4 insert the needle. As you use the needle, rememberthat is is curved. it should go through the wound in a curved direction.Suture will go deeper than its width at wound edge. If you try to makeneedle go in a straight direction, it will bend. Push and twist needleholder. *Visual augmentation suture should go to the bottom fo the wound.this prevents leaving a gap under the skin where infection may start. inorder to get suture deep enough, you may need to bring out needle in centerof wound, regrasp it, re-insert it in center of wound, and then finish thesuture. 6.5 Bring out needle the same distance away from wound edge(about1/8in) as where you entered on the other side. Since needle iscurved, it should come out of the skin angled toward the wound edge, as inthe next drawing. *More visual augmentation: Correct placement of suture.6.6 tie suture well. As you tie, skin edges should come together on thesame level and turn slightly out. if edges turn in, consider replacing thesuture or the scar will be larger. Do NOT tie very tightly. pull suture sothat skin edges are just touching. swelling will make sutures tighter. Itworks well to tie three square knots. 6.7 Cut the suture and pull the knotto one side. Leave ends of suture ling enough so you can easily grasp themwhen removing sutures: 0.5in is safe for more sutures. 1in may be good forscalp wounds *visual augmentation: Pull the knot to one side. 6.8 Spacesutures as needed: On most areas, sutures are put as close together asneeded to hold wound edges together well. usually about0.25 in apart. Onface, sutures are put closer together to make a smaller scar usually about1/8in apart. 7. Other Plan 7.1 Fro other plan including dressing, TETANUSTOXOID and DIPTHERIA (Td) shot, patient education and recheck information,see plan for general wound care, p342. Removing sutures 1. decide when toremove sutures 1.1 face: 4 dyas. put on wound closure strips for 3 moredays. Other body parts: usually one week. Back, arms, and legs: 10 days.Areas of body where skin will stretch as patient moves may need to be in upto 14 days (example:knee). 2. Get Ready Removing sutures equipment/suppliesneeded: Sharp scissors and forceps (or suture removal set) Sterile 4x4'sBandage scissors Basin 2.1 Gather equipment. 2.2 wash hands. 2.3 Cut awaypatient's bandage away if needed. 2.4 wash hands again. 2.5 open sutureremoval set. 2.6 gently clean sutures with wet soapy gauze. 2.7 Rinsesutures with water and dry with sterile gauze. 3. remove Sutures 3.1General guidelines for removing all sutures: Pick up one end of suture withforceps. Use sterile scissors to cut under knot close to skin. Do not cutsuture in middle. This drags dirt through skin when suture is removed. Withthe forceps take hold of end of suture or knot and gently pull out suture.Do this until all sutures are removed. *Visual Augmentation: The mostcommon type of sutures. 3.2 For a specific type of suture, remove as shownin one of the following drawings: *Visual Stimulation (stiches) * " (morestiches) *"(more stiches) *": Apply gentle pressure over wound as you pull.*": Apply gentle pressure over wound as you pull. 4. After suture removal4.1 After all sutures are out, clean and dry the area again. 4.2 applywound closure strips for a few more days, if needed. 4.3 Dispose of dirtydressings. 4.4 Wash instruments well with soap and water. 4.5 Wash yourhands. 4.6 Tell patient to return to clinic if he has problem,s, such assigns of infection (getting red, tender or swollen; pus seen) 4.7 checkyour suture supplies and reorder items. Removing a ring Remove patient'sring any time there is an injury to finger, hand, or arm. If a ringcompletely cuts off circulation in patient's finger, there may only be afew hours before serious problems happen. If you can not remove a ring withsoap and cold water, follow these steps: 1. you will need 2-3 yards of finestring or dental floss and some adhesive tape. 2. move ring to its loosestspot; often this is nearest to the knuckle. 3. Thread one end of stringunder ring and pull several inches through ring toward hand. If you havetrouble getting string under ring, slip in a match. toothpick, or forcepsand then slip string under. Tape string to hand. 4. wrap string tightlytoward fingertip: Start right next to the ring. Wrap string tightly aroundfinger. wrap in one smooth layer. wrap string close enough together toprevent swollen tissue from bulging through. wrap past the area of greatestswelling. *Visual augmentation:Wrap string tightly toward fingertip. 5.Place tape over end of string without taping over any of wrapped string (asshown in next drawing). 6. Untape the end of string near the knuckle, andand pull string toward the fingertip. *visual augmentation: Pull stringtoward fingertip. Keep pulling and unwinding string asn ring slips overwrapped string. do this until ring slips off finger. If ring gets stuckalong the way, try putting Vaseline on the string ahead of the ring. If youstill can not remove the ring, use a ring cutter if available. Removing aSplinter If serious injury from splinter because it is very large, is in alocation where serious damage may happen, or has damaged a nerve, tendon,or artery: Contact your referral doctor. Bandage it the same way you woulda foreign body (p341). Arrange for transport to a a hospital. If splinteris not very deep, follow these guidelines for removing: 1. wash skin aroundsplinter. 2. If needed, use sterile needle to find top of splinter. 3.Pullsplinter back out along same line it went in. If splinter is wood, use thepoint of a 23 or 25 gauge neede to catch and pull splinter back out. Ifneeded, use tweezers or forceps tp pull splinter. * Visual augmentation:Removing a Splinter. 4 After splinter is out, wash and care for wound as onp. 342 ("General Wound Care") If splinter is deep but it has not injuredany important tissues, report to your referral doctor. He may suggest thatyou do the following: 1 Wash the skin well. 2. Inject a small amount ofLIDOCAINE (Xylocaine) around the area (p346). 3. Put on sterile gloves. 4Cut down to splinter with sterile scapel blade. remove splinter withsterile tweezers or forceps. Wash and care for wound as on p 342 ("GeneralWound Care"). If splinter is infected, treat as for any infected wound (p321). Removing a Fishhook If fishook seems to be in a location whereserious damage may happen, or if it has damaged nerves, tendons, orarteries: Report to your referral doctor. Bandage it the same way you woulda foreign body (p341). Arrange for trasnport to hospital. If you feel youcan remove fishook without causing more damage: Read a about the followingmethods. Choose the method which seems best for this patient. After hook isremoved, wash and care for wound as on p342 ("General Wound Care"). Do notclose wound with wound closure strips or sutures. Method 1 1. push barb upthrough skin. *Visual stimulation 2 clip off barb. 3 Slide hook back out. *Visual Stimulation of similr sorts Method 2 1. Take a piece of fishlineabout 2 feet long. 2. Loop fish line around hook. 3. Wrap ends of linearound your pointer finger. *Visual Augmentation 4. Press down on eye ofhook. this will loosen barb. Hold fish line as in the next drawing: thenyank. * Visual stimulation: YANK!! Method 3 1. Find a darning needle ortapestry needle that is slightly larger around than shank of fishook. thepoint must be blunt, as a sharp point will make a new hole instead offollowing the hole made by fishook. 2. Gently insert needle on one side ofhook and push it in until needle and hook are same depth. 3. Pull needleend back so it is about even with barb. 4. Push sideways with needle, awayfrom barb (moving skin away). *Visual Augmentation: Blunt darning ortapestry needle. 5. Now, slide hook back out. Method 4 If hook is verydeep, report to your referral doctor. He may suggest to you: 1. Wash theskin well. 2 Inject a small amount of LIDOCAINE (Xylocaine) around hook. 3.Put on sterile gloves. Cut down to fishook with sterile scapel blade.Remove fishook with sterile tweezers or forceps.u CARE FOR WOUNDS/ CUTSQáVx R S
Þemoglobin, if patient has lot a you CANNOT reach a doctor, give Patient Do NOT If dressing becomes wet, it Do NOT put medicine, lotion, or 3. Warning! The wound Getting more Foul es (lumps; may be neck, armpit, Swelling For the d, raise injured part above the When sitting, rest W standing, rest hand of injured leg or foot, raise injured part When a bruised area, it will help to apply cold packs (ice placed in ARepeat as Ao days, sooner if serious wound If ot remove After two healing well, you may decide to F-skin closure strips, pen: do not remove dressing for Ainfection, your referral doctor , sure strips (p.344) or suturing th a sea mammal (such as a seal is hurting more after 4-5 days, und is