This chapter will discuss the role of the EMS physician in the treatment of acute wounds and hemorrhage. As a first responder, a physician should be able to accurately characterize wounds, differentiate between stable and life-threatening hemorrhage, and effectively treat these wounds in a timely manner. We will start with a discussion of wound evaluation and treatment fundamentals. Then, we will cover the role of advanced hemorrhage control procedures, the use of hemostatic agents, and administration of blood products. An understanding of these fundamentals is essential to the EMS physician operating in the prehospital settings. These are especially important to providers operating in austere environments such as tactical medicine, urban search and rescue, and those tending to the entrapped victim.
Describe the initial prehospital evaluation and management of acute traumatic wounds.
Describe the initial prehospital evaluation and management of open nonacute wounds.
Describe the initial prehospital evaluation and management of active hemorrhage.
Discuss prehospital use of tourniquets.
Discuss prehospital use of hemostatic agents.
Discuss prehospital use of blood, blood products, and factors for acute traumatic blood loss anemia.
Most wounds evaluated during EMS operations are acute traumatic wounds. These include a large spectrum of injuries ranging from abrasions to amputations. Evaluation of each of these wounds should include the same components. When first evaluating a wound, identify if there is a source of acute life-threatening hemorrhage. If present, address the source of hemorrhage first. The techniques for managing hemorrhage will be discussed later in this chapter. Wounds without life-threatening hemorrhage can be evaluated for the extent of tissue damage present and structures involved.
When evaluating extremity wounds, placing a temporary tourniquet similar to those used when placing a peripheral IV may be useful when evaluating a wound with non-life-threatening hemorrhage. Similarly, a blood pressure cuff may be used to temporarily control bleeding during wound evaluation. The temporary tourniquet is used only long enough to evaluate the extent of the wound and should not exceed a total of 15 to 20 minutes in duration.1
When evaluating the wound, note the depth, involved structures, and signs of contamination. If the wound involves major vascular structures, your priority should focus on hemorrhage control. If no major vascular structures are identified, continue to evaluate the wound for gross contamination.
The same components are required when evaluating wounds of the abdomen and thorax. Wounds involving the groin, axilla, and clavicles are at high risk for life-threatening hemorrhage. The close proximity of major vascular structures found within these areas make then more susceptible to injury. Wound packing and pressure dressings should be applied immediately to wounds with life-threatening hemorrhage in these locations. Additional techniques for hemorrhage control will be discussed later in this chapter. If the wound involves deep structures of the abdomen or thorax, immediately treat the underlying injury (pneumothorax, bowel evisceration, etc) All other wounds should be evaluated for depth, involved structures, and contamination.
When operating in austere conditions, transportation to a definitive care facility may be delayed for several hours or days. Under these conditions, wounds may require closure in the field. If the patient is unable to be transported for an extended period of time, grossly decontaminate the wound by irrigating. This is accomplished by irrigating with tap water or normal saline.2 Irrigation can effectively be completed using an 18- to 20-gauge angiocatheter, or blunt needle, and a 35- to 65-mL syringe. For larger wounds, various high-volume techniques can be employed to remove gross contamination. However, irrigation with a syringe and angiocatheter as described above is the most effective way to decontaminate a wound prior to closure.3 If the patient will be quickly transported to definitive care, hemorrhage control alone is appropriate.
It is important to remember that the wound may not be completely decontaminated in the field. Closure of the wound should be consistent with techniques used for other contaminated wounds. Since suture is a foreign material, it can lead to an increased likelihood of infection. Sutures should be placed at further intervals, allowing for the least number of sutures possible, while allowing the approximation of the wound edges to control hemorrhage and promote healing. Both suture and staples placed in the prehospital environment are effective for wound closure.
The evaluation of nonacute open wounds in the field requires further understanding of wound healing and signs of infection. Patients may present with postoperative wounds from recent surgery or subacute wounds from injuries incurred several days earlier. Subacute traumatic wounds will often be encountered during deployment to disaster areas or when working with rescue teams in austere conditions. Elderly patients and those with diabetes, venous stasis, lymphedema, previous radiation therapy, paraplegia, or other disability may also have chronic nonhealing wounds that may suffer infection or other complications.
It is appropriate to consider the individual phases of wound healing. Initially, involved tissues undergo vasoconstriction and localization of platelets. Both of these actions initiate the process of hemostasis. The wound will then express a variety of inflammatory changes. These will result in localized vasodilatation, and phagocytosis of retained bacteria and contaminants. Both hemostasis and the inflammatory phase occur within the first hour following injury. The proliferative phase results from the localized release of chemical markers, which stimulate cells to multiply and repair damaged tissue. Additionally, fibroblasts work to develop a collagen framework, forming a basis for the proliferative phase. Granulation tissue is the product of the collagen deposition, which begins approximately 12 hours after the injury. Eventually the wound margins will contract and remodeling will complete the healing process4 (Figure 57-1). Wound can be closed at several points during the healing process. Primary closure describes wounds repaired within the first 6 hours. Closure by secondary intention describes wounds allowed to heal simply by following the natural phases of wound healing. These wounds will heal without sutures or staples. Closure by secondary intention is preferred for highly contaminated wounds. Delayed primary closure describes wounds closed with sutures or staples after an initial period of healing. These wound have been allowed to initiate the proliferative phase of healing prior to wound closure. These wounds are irrigated and left open for 2 to 4 days prior to closure with suture or staples.1 Delayed primary closure is effective for treating contaminated wounds and allows for improved healing and aesthetic results.
Understanding the phases of wound healing and types of wound closure are essential to evaluating the open nonacute wound. Often, minor wounds evaluated after the first 6 hours of healing do not require further intervention. These wounds will require cleaning and decontamination, but have already established hemostasis. If these wounds do not involve deeper structures, further treatment is unnecessary.
Nonacute wounds involving deeper structures require exploration prior to definitive treatment. If the wound complicates safe extraction or limits mobility, consider delayed primary closure for these patients. It is important to remember that contaminated wound should not be closed. If closure of a contaminated wound or one involving deep structures is necessary for safe extraction, the wound will need to be reopened and explored once definitive care can be established.
When evaluating postoperative wound complications, focus on the anatomy of the structures involved. Some wounds are intentionally allowed to close by secondary intention due to extensive contamination or edema during a procedure. Wound dehiscences with bowel or omental evisceration are unique complications to abdominal incisions. These wounds should be evaluated for signs of infection and hemorrhage. Eviscerated organs should not be forced back into the abdominal cavity. This can lead to increased chance of infection or injury to the bowel. Dehiscence may result from excessive increase in intra-abdominal pressure. As a result, the viscera may have improved blood flow secondary to expansion allowed by the wound dehiscence. Eviscerated organs should be covered with saline soaked sterile gauze, and secured with a bulky dressing. These wounds will require emergency surgical intervention once definitive care is reached.
Infection is a frequent complication of subacute wounds. First, evaluate the wound for signs of erythema and warmth. If the area of erythema extends beyond the immediate margins of the wound, this should be noted and marked. Placing a marker line around the involved area will act as a baseline for the tracking a developing wound infection or cellulitis. Additionally, these wounds should be evaluated for the presence of purulent discharge. Fibrin and slough overlying healthy granulation tissue is often confused for purulent drainage and may appear as a white to yellow colored material located over the wound. However, fibrin and slough are typically adherent and will not express or wipe clear from the wound. Granulation tissue appears as a bumpy red soft tissue pattern in the wound base. When palpating the infected area, feel for areas of fluctuance under and around the wound. Palpation over an abscess or fluid collection will often cause the expulsion of material from open wounds. An abscess may still form within the subcutaneous tissue without direct extension to the open portion of the wound. Additional sutures may need to be removed when evaluating partially opened surgical wounds with possible abscess. It is prudent to never remove deep or subcutaneous sutures in the typical prehospital setting. This may lead to a variety of complications. However, superficial sutures may be removed to allow drainage of fluid collection when definitive treatment will be delayed for an extended period of time. Partially open wounds under strain from fluid collections, such as an abscess, hematoma, or seroma, may suffer catastrophic complications if not drained in a timely manner. Additionally, intentional drainage and irrigation of an abscess can definitively treat an early incisional wound infection.
