Management of bad wounds and open fractures (Proceedings)
Practical management of severe wounds and open fractures begins with initial assessment and management. The first priority is the control of severe hemorrhage that may be associated with the injury.
Techniques to stop severe external bleeding
Described in order of preference1. Direct pressure: Apply direct pressure by hand over a dressing over the entire bleeding area. In the absence of compress, a bare hand or finger is used. A pad of cloth or gauze (compress) held between the hand and the wound helps control the bleeding by absorbing the blood and allowing it to clot. The compress can be bound in place using bandage material which frees the hands of the first aider for other emergency action. Do not disturb blood clots after they have formed within the compress. If blood soaks through the entire pad, do not remove the pad, but add additional layers of cloth, and continue to direct hand pressure more evenly.
2. Elevation: Unless there is evidence of a fracture, a severely bleeding open wound of the paw or leg can be elevated above the level of the heart. This elevation uses the force of gravity which helps reduce blood pressure in the injured area, thus slowing down hemorrhage. Elevation is more effective in larger animals with log limbs where greater distances from wound to heart are possible. Direct pressure with compress must also be continued to maximize the use of elevation.
3. Pressure on the supplying artery: If external bleeding continues following the use of direct pressure and elevation, application of digital pressure over the main artery supplying the wound can be very successful. Apply pressure to the femoral artery in the groin for severe bleeding of the rear leg; the brachial artery in the inside of the upper front leg for wounds of the front leg. Always supply direct pressure in addition to the pressure point when it is used.
4. Pressure above and below the bleeding wound: This can also be used in conjunction with direct pressure. Pressure above the wound will help control arterial bleeding (bright red, pulsating blood), pressure below the wound will help control venous bleeding (dark, oozing blood).
5. Tourniquet: Use of a tourniquet is dangerous and should only be reserved for a severe lifethreatening hemorrhage in a limb you do not expect to save. A wide (2" or greater) piece of cloth should be used to wrap round the limb twice, and a knot is tied. A short stick or similar object is then tied into the knot as well. Twist the stick to tighten the tourniquet until bleeding stops. Secure the stick in place with another piece of cloth and make a written note of the time that it was applied. After application it should not be loosened until in the OR. A pneumatic blood pressure cuff CAN be used without threat of limb loss for up to 2 hours in some cases this is because of the very wide with and it being full of air.
Next step - protect, prevent from becoming dehydrated
After the bleeding is controlled the next step is to protect the wound from getting any further contamination and prevent it from becoming dehydrated. This is most commonly done by applying a water or saline soaked dressing onto the wound and a protective bandage applied. Do not remove or disturb the cloth pad or dressing initially placed on the wound as this will cause further dehydration, pain, blood loss and heat. The wound should be "immobilized" using a compressive dressing. Irrigation and cleaning of the wound should follow. Sedation is often required. In severe wounds the addition of a local or regional anesthetic is recommended prior to the irrigation and debridement. An intravenous broad spectrum antibiotic should be give prior to the commencement of the debridement
Open Fracture Management. Splint them where they lie Use spica splints mad of newspaper if you have any doubt that there could be a fracture associated with the wound. These DO NOT cause a point of stress on the fracture. Most fractures do better and the soft tissues certainly survive better and have less microvascular injury. Sedation is generally required. Truetta even used these splints on open fractures with fair results.
Most fractures can wait for surgery until the patient is stable. However this is not the case with open wounds if at all possible and those involving the skull or spinal cord. Definitive surgery is best done as within hours of the injury.