Lacerations, Abrasions, and Dressings
Definition: Laceration
General Treatment
The goals of wilderness wound management are to control bleeding, minimize infection, promote healing, and decrease the need for evacuation. Five specific steps should be followed: examination, anesthesia, cleaning and debridement, wound closure or packing, and bandaging (Box 20-1).
Box 20-1 First-Aid Supplies for Wound and Abrasion Care
10- to 15-mL irrigation syringe with an 18-gauge catheter tip
30 mL (1 fl oz) povidone–iodine solution USP 10% (Betadine)
Wound closure strips 
× 4 inches
Polysporin, mupirocin, bacitracin, or other antiseptic ointment
Nonadherent sterile dressing (Aquaphor, Xeroform, Adaptic, Telfa)
Examination
1. For an extremity injury, evaluate and keep a record of distal neurovascular function before administering local anesthesia.
a. For wrist and hand lacerations, palpate the radial and ulnar pulses.
b. Compare capillary refill, color, and temperature of each digit to the corresponding digit on the uninjured extremity.
c. Assess sensation of the radial and ulnar aspects of each finger to sharp pain and two-point discrimination.
2. Explore the wound in a well-lighted environment to assess for tendon, muscle, or nerve injury; also look for foreign material. Test the motor function of each joint against resistance by isolating the joint and asking the patient to flex and extend the digit against resistance. A tendon that is 75% lacerated can still function, but its function may be decreased when it is offered resistance and is more painful during movement compared with the uninjured finger on the opposite hand.
Anesthesia
1. Mix equal parts of 4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine (LET). Soak a 2 × 2 inch sterile gauze pad with this mixture. Place the pad directly into and around the wound for 7 to 10 minutes. The maximum dose of the solution is 2 to 5 mL for adults.
2. Use LET with caution on highly permeable tissue such as mucous membranes. Note that LET should be stored in a light-resistant container and is stable for 6 months when refrigerated and 4 weeks stored at room temperature. It should be discarded if the solution becomes discolored or cloudy.
Local Anesthesia
1. Infiltrate the wound with 1% lidocaine (Xylocaine) or 0.25% bupivacaine (Marcaine) using a 25-gauge (or smaller) needle and syringe.
2. The adult dose of lidocaine should not exceed 4 mg/kg (28 mL of a 1% solution in a 70-kg [154-lb] adult).
3. Buffering lidocaine reduces the pain of local anesthetic infiltration. To buffer, add 1 mL of sodium bicarbonate (1 mEq/mL solution) to 10 mL 1% lidocaine. Once buffered, the shelf life of the product is greatly reduced; discard the solution after 24 hours.
4. Alternative anesthetic strategies include the following:
a. Diphenhydramine (Benadryl) has anesthetic properties similar to, but less potent than, those of lidocaine. Dilute a 50-mg (1-mL) vial in a syringe with 4 mL normal saline (NS) solution to produce a 1% solution. Perform local infiltration as usual.
b. Use NS solution alone as the injected agent. This may provide enough anesthesia to suture a small wound.
c. Place ice directly over the wound to provide a short period of decreased pain sensation.
Cleaning and Debridement
1. Perform wound cleansing to remove as much bacteria, dirt, and damaged tissue as possible. The best method is to irrigate with a high-pressure liquid stream. See the following procedure.
2. Make sure the irrigating solution is clean and nontoxic to the tissues. Sterile NS solution, disinfected potable water, and 1% povidone–iodine solution (not “scrub”) are all suitable for irrigation. The quantity of irrigation fluid should be at least 400 mL.
3. In addition to a vigorous soap-and-water scrub, use benzalkonium chloride to cleanse wounds inflicted by animals suspected of being rabid (see Chapters 42 and 43).
Irrigation Method
1. Draw the irrigation solution into a 10- to 15-mL syringe, and attach an 18-gauge catheter tip.
2. Hold the syringe so the catheter tip is 2.5 to 5 cm (1 to 2 inches) above the wound and perpendicular to the skin surface. Push down forcefully on the plunger while prying open the edges of the wound with your fingers, and squirt the solution into the wound (Fig. 20-1, A). Be careful to avoid being splashed by the irrigant after it hits the skin. If you are not carrying a splash shield, such as ZeroWet, put on a pair of sunglasses or goggles to protect your eyes from the spray or place the catheter through the bottom of an upside down plastic or Styrofoam cup.
FIGURE 20-1 Wound irrigation. A, Syringe. B, Plastic bag.
3. Repeat this procedure until you have irrigated the wound with at least 400 mL of solution.
4. Remove any residual debris or devitalized tissue with a tweezers, scissors, knife, or any other sharp object. Any dirt left in a wound increases the likelihood of infection.
5. If the wound edges are macerated, crushed, or necrotic, perform sharp debridement.
