A wound is a break in the continuity of a tissue of the body, either internal or external. Wounds are classified as open or closed. An open wound is a break in the skin or in a mucous membrane. A closed wound involves underlying tissues without a break in the skin or a mucous membrane.
Wounds usually result from external physical forces. The most common causes of wounds are motor vehicle accidents, falls, and the mishandling of sharp objects, tools, machinery, and weapons.
Any injury, unless it is very minor, may be harmful not only to the tissues directly involved but also to the functions of the entire body. Wounds that threaten life include those that produce cessation of breathing, severe bleeding, shock, or damage to the brain, heart, or other vital organ.
The local effects of an open or closed wound may include loss of blood, interference with blood supply, destruction of tissue, nerve injury, functional disturbances, and contamination with foreign material. These effects often involve nearby uninjured tissues. Even superficial wounds sometimes take a week or more to heal. The healing process includes absorption of blood and serum that have seeped into the area, repair of injured cells, replacement of dead cells with scar tissue, and recovery of the body from functional disturbances, if there were any.
The two most serious first aid problems caused by open wounds are a large, rapid loss of blood, which may result in shock, and contamination and infection of exposed body tissue.
TYPES AND CAUSES OF OPEN WOUNDS
Open wounds range from those that bleed severely but are relatively free from the danger of infection to those that bleed little but have greater potential for becoming infected. Often the victim has more than one type of wound.
An abrasion (Fig. 1) results from scraping (abrading) the skin and thereby damaging it. Bleeding in an abrasion is usually limited to oozing of blood from ruptured small veins and capillaries. However, there is a danger of contamination and infection, because dirt and bacteria may have been ground into the broken tissues.
Abrasions commonly result from falls or the handling of rough objects. Examples are skinned knees, rope burns (which are actually abrasions, not burns), and shallow multiple scratches.
Incised wounds, or cuts (Fig. 2), in body tissues are commonly caused by knives, metal edges, broken glass, or other sharp objects. The degree of bleeding depends on the depth and extent of a cut. Deep cuts may involve blood vessels and may cause extensive bleeding. They may also damage muscles, tendons, and nerves.
Lacerations (Fig. 3) are jagged, irregular, or blunt breaks or tears in the soft tissues. Bleeding may be rapid and extensive. The destruction of tissue is greater in lacerations than in cuts. The deep contamination of wounds that result from accidents involving moving parts of machinery increases the chances of later infection.
Puncture wounds (Fig. 4) are produced by bullets and pointed objects, such as pins, nails, and splinters. External bleeding is usually minor, but the puncturing object may penetrate deeply into the body and thus damage organs (as well as soft tissues) and cause severe internal bleeding. Because puncture wounds generally are not flushed out by external bleeding, they are more likely than some other wounds to become infected. Tetanus organisms and other harmful bacteria that grow rapidly in the absence of air and in the presence of warmth and moisture can be carried deep within body tissues by a penetrating object.
Avulsion wounds (Fig. 5) involve the forcible separation or tearing of tissue from the victim's body. Avulsions are commonly caused by animal bites and accidents involving motor vehicles, heavy machinery, guns, and explosives. They are usually followed immediately by heavy bleeding. A detached finger, toe, nosetip, ear, or, in rare cases, whole limb may be successfully reattached to a victim's body by a surgeon if the severed part is sent with the victim to the hospital.
FIRST AID FOR OPEN WOUNDS
If the wound is in an inconspicuous location, is not deep, and gapes slightly, the first-aider may find that he need only hold the wound edges together and dress and bandage the injury. At times, however, it may be difficult for the first-aider to decide whether a wound needs medical care. He may ask himself, for example, whether it will need suturing by a physician. Identified below are a number of open-wound conditions that require medical treatment after emergency care has been provided:
Loss of more than a quart of blood is a threat to a person's survival. Hemorrhage from the aorta (the largest blood vessel of the body) or from combined external and internal injuries (such as those in a gunshot wound) may be so rapid and extensive that the victim dies almost immediately. The loss of blood in some other kinds of wounds, such as the partial or complete severing of an arm or a leg, may not cause death as quickly, but large amounts of blood can be lost, and bleeding must be controlled.
The body of a victim who is bleeding severely can make some natural adjustments that help to slow down the blood loss. Even initial severe bleeding, such as the uncontrolled hemorrhage from a cut artery, may lessen or stop spontaneously. When a large blood vessel is completely severed, the normal elasticity of muscle layers in the vessel walls tends to make the cut ends retract. This retraction reduces the size of the opening through which blood can escape, and the flow of blood may slow down enough to permit clotting to begin. However, if a blood vessel is only partially cut, it will not retract to reduce the size of the opening, and bleeding will continue unless clotting occurs or the blood pressure decreases.
Blood pressure is another natural influence on bleeding. As the pressure drops, owing to the decreased volume of blood in the vessels, bleeding from the wound tends to slow down. A lowered pressure, however, is a grave sign, and death from severe shock is possible. In the case of some wounds that would be expected to bleed severely but are producing little or no evident loss of blood, the victim may already be in an advanced degree of shock. Such wounds must be watched carefully, because rapid bleeding may begin when measures to combat shock help to restore normal blood circulation.
First-aiders are urged to remember that a relatively small amount of bleeding, such as that from an open scalp wound, can make a victim look as if he were in a critical state, even when there is no danger of death due to bleeding. However, it is logical to assume that any loss of blood is harmful to the victim, inasmuch as it could interfere with the normal functioning of his circulatory system; and, because it is possible for a person to bleed to death in a very short period, blood loss of any extent should be stopped immediately.
Three distinct techniques are recommended to stop severe bleeding: direct pressure, elevation, and pressure on the supplying artery. A fourth, technique, the use of a tourniquet, may be considered only when all other methods have failed to control severe bleeding. The four techniques are described below in order of preference.
Severe bleeding of an open wound can usually be controlled by pressing with the palm of one hand on a compress of cloth over the entire area of the wound. A thick pad of sterile gauze is preferable, but any soft, clean cloth can be used in an emergency. Even unclean material can be used, but only if nothing better is immediately available.
In an emergency, in the absence of compresses, the bare hand or fingers may be used, but only until a compress can he applied. Do not disturb blood clots that form in the cloth. If blood soaks through the entire compress, do not remove it; add more thick layers of cloth and continue direct hand pressure even more firmly. The objective is to control the hemorrhage by compressing the bleeding vessels against something more solid, such as underlying bone or uninjured tissues.
The reason for applying hand pressure directly is to prevent loss of blood from the body without interfering with normal blood circulation. The first-aider is handicapped in carrying out other emergency care, and if such care is necessary, the compress should be secured in place by a pressure bandage. To apply the pressure bandage, place and keep the center of the bandage or strip of cloth directly over the pad on the wound; maintain a steady pull on the bandage to keep the pad firmly in place as you wrap the ends of it around the body part. Tie the bandage with a knot directly over the pad.
Unless there is evidence of a fracture, a severely bleeding open wound of the head, neck, arm, or leg should be elevated—that is, raised above the level of the victim's heart. Elevation uses the force of gravity to help reduce the blood pressure in the injured area and thus aids in slowing down the loss of blood through the wound opening. However, direct pressure on a thick pad over the wound must be continued.
Pressure on the Supplying Artery
If direct pressure and elevation do not stop severe bleeding from an open wound of the arm or leg, the pressure point technique may be required. This technique involves applying pressure at a specific point on the arm or leg to temporarily compress the main artery supplying blood to the affected limb. There is one recommended pressure point on each arm and leg.
The use of a pressure point not only stops blood circulation to the injured limb but also stops circulation within the limb. Therefore, pressure points should not be used unless the technique is absolutely necessary to help stop severe bleeding. If the use of a pressure point is necessary, do not substitute the technique for direct pressure and elevation but use it in addition to those techniques. You may need some help to apply all three control methods at the same time. As a rule, do not use a pressure point in conjunction with direct pressure and elevation any longer than is necessary to stop the bleeding, but be prepared to reapply pressure at the pressure point if bleeding recurs.
For a severely bleeding open arm wound, apply pressure over the brachial artery, forcing the artery against the arm bone. This pressure point is on the inside of the arm in the groove between the large muscle masses (biceps and triceps) about midway between the armpit and the elbow. To apply pressure on the brachial artery, grasp the middle of the victim's upper arm with your thumb on the outside of his arm and your other fingers on the inside. Press your other fingers toward your thumb to create an inward force from opposite sides of the arm. Use the fiat inside surface of your fingers, not your fingertips. This pressure inward holds and closes the artery by compressing it against the arm bone.
For severe bleeding from an open leg wound, apply pressure on the femoral artery, forcing it against the pelvic bone. This pressure point is on the front of the thigh just below the middle of the crease of the groin where the artery crosses over the pelvic bone on its way to the leg. To apply pressure on the femoral artery, quickly place the victim on his back and put the heel of your hand directly over the pressure point. Then lean forward over your straightened arm to apply pressure against the underlying bone. Apply pressure as needed to close the artery. Keep your arm straight to prevent arm tension and muscular strain. If bleeding is not controlled, it may be necessary to compress directly over the artery with the flat of the fingertips and to apply additional pressure over the fingertips with the heel of the other hand.
A tourniquet is a wide band of cloth or other material placed just above a wound to stop all flow of blood. Do not use a narrow band, rope, or wire. Application of a tourniquet can control severe bleeding from an open wound of the arm or leg but is rarely needed and should not be used except in a critical emergency where direct pressure on the appropriate pressure point fails to stop bleeding. The use of a tourniquet is dangerous. Properly applied, the tourniquet will stop all blood circulation to a limb beyond the point of application. But if it is left in place for an extended period, uninjured tissues may die from lack of blood and oxygen. Releasing the tourniquet tends to increase the danger of shock, and bleeding may resume. If a tourniquet is improperly applied (too loosely), it will not stop arterial blood flow to the affected limb, but will only slow or stop venous blood flow from the limb. The result is increased, instead of controlled, bleeding from the wound. The decision to apply a tourniquet is in reality a decision to risk sacrifice of a limb in order to save a Life. Once a tourniquet is applied, care by a physician is imperative.
To apply a tourniquet, place it just above the wound. Do not allow it to touch the wound edges. If the wound is in a joint area or just below, place the tourniquet immediately above the joint.
Once the tourniquet has been applied, it should not be loosened except on the advice of a physician.
Prevention of Contamination and Infection
Open wounds are subject to contamination and infection. The danger of infection can be prevented or lessened by taking the appropriate first aid measures, depending on the severity of bleeding. Once a compress has been applied to control bleeding, whether bleeding has been severe or not, do not remove or disturb the cloth pressure pad initially placed on the wound. Do not attempt to cleanse the wound. The victim must have medical care, and cleansing the wound may cause resumption of bleeding.
A wound that is not bleeding severely and that does not involve tissues deeper than the skin should be cleansed thoroughly to remove contamination before it is dressed and bandaged, especially if medical attention will be delayed. Do not remove foreign materials from muscle or other deep tissues; such removal should be carried out only by a physician. To cleanse a wound that does not involve tissues deeper than the skin, wash your own hands thoroughly with ordinary hand soap or mild hand detergent. Wash in and around the victim's wound to remove bacteria and other foreign matter. Rinse the wound thoroughly by flushing with clean water, preferably running tap water. Blot the wound dry with a sterile gauze pad or clean cloth. Apply a dry sterile or clean dressing and bandage it firmly in place.
Caution the victim to see his physician promptly if evidence of infection appears (see page 40).
Removing Foreign Objects
In small open wounds, wood splinters and glass fragments often remain in the surface tissues or in tissues just beneath the surface. As a rule, such objects only irritate the victim; they do not usually incapacitate a person or cause systemic body infection. However, they can cause infection if they are not removed. Use tweezers sterilized over a flame or in boiling water to pull out any foreign matter from the surface tissues. Objects embedded just beneath the skin can be lifted out with the tip of a needle that has been sterilized in rubbing alcohol or in the heat of a flame. Foreign objects, regardless of size, that are embedded deeper in the tissues should be left for removal by a physician.
The fishhook is probably one of the more common types of foreign objects that may penetrate the skin. Often, only the point of the hook enters, not penetrating deeply enough to allow the barb to become effective; in this case, the hook can be removed easily by backing it out. If the fishhook goes deeper and the barb becomes embedded (Fig. 17), the wisest course is to have a physician remove it. If medical aid is not available, remove the hook by pushing it through (Fig. 18) until the barb protrudes. Using a cutting tool, cut the hook either at the barb or at the shank and remove it. Cleanse the wound thoroughly and cover it with an adhesive compress. A physician should be consulted as soon as possible because of the possibility of infection, especially tetanus.
Some penetrating foreign objects, such as sticks and pieces of metal, may protrude loosely from the body or even be fixed, such as a stake in the ground or a wooden spike or metal rod of a fence on which the victim has become impaled. Under no circumstances should the victim be pulled loose from such an object. Obtain help at once, preferably from ambulance or rescue personnel, who are equipped to handle the problem. Support the victim and the object to prevent movements that could cause further damage. If the object is fixed or protrudes more than a few inches from the body, it should be held carefully to avoid further damage, cut off at a distance from the skin, and left in place. To prevent further injury during transport of the victim, immobilize the protruding end with massive dressings. The victim should then be taken to the hospital without delay.
Dressing the Wound
A dressing is a cover placed over a wound to protect it from additional injury and contamination and to assist in the control of bleeding. Bandaging a wound holds the dressing in place, assists in control of bleeding, offers support, and promotes restraint of movement. For detailed instruction on the application of dressings and bandages, see chapter 14.
The period of healing after an injury may be greatly prolonged by infection, which is the result of invasion and growth of bacteria within the tissues of the body. Bacteria are normally present in large numbers on the skin, in the nose, in the mouth, in the upper air passages, in the digestive tract, on hair, in hair follicles, in discharges from the body, in the air, and in soil. Serious infection may develop within hours or days after an injury, when bacteria get inside the tissues of the body through breaks in the skin or mucous membranes, even if the injury seems insignificant.
Careful cleansing of an open wound removes particles of dead tissue and foreign matter and reduces the number of bacteria, thereby helping to prevent infection. Bacteria tend to multiply rapidly in devitalized tissues; one reason is that white cells and other blood elements that ordinarily combat infection by destroying bacteria or by neutralizing bacterial products cannot reach dead tissues.
The threat of tetanus infection (lockjaw) must never be overlooked. A current immunization record will assist the physician in determining whether a tetanus injection or a tetanus toxoid booster injection should be given. Tetanus infection is so serious that a penetrating wound of any kind that involves tissues deeper than the skin should be seen by a physician as soon as possible.
Even if measures are taken to prevent contamination in a wound, infection may still develop. An infected wound can be recognized by the presence of any of the following symptoms:
Interim Emergency Care
Infected wounds require prompt medical care, but if a long delay is necessary before the victim can be treated by a physician, the following temporary steps should be taken:
Remember—the above directions are for interim care only; do not delay efforts to get medical care for the victim.
Injuries produced by animal or human bites may cause punctures, lacerations, or avulsions. Not only is care needed for open wounds but also consideration must be given to the dangers of infection, especially rabies.
All human bites that break the skin may become seriously infected, because the mouth is heavily contaminated with bacteria. Cleanse the wound thoroughly, cover it, and seek medical attention.
The bite of any animal, whether it is a wild animal or a pet, may result in an open wound. Dog and cat bites are common. Although a dog bite is likely to cause more extensive tissue damage than a cat bite, the cat bite may be more dangerous, because a wider variety of bacteria is usually present in the mouth of a cat. Many wild animals, especially bats, raccoons, and rats, transmit rabies. Tetanus is an added danger in animal bites. Any animal bite carries a great risk of infection.
Rabies, or hydrophobia, is an infectious disease due to a virus. It can be transmitted through the infected saliva of a rabid animal to another animal or to a human being. The infection can be spread when the rabid animal's bite causes an open wound, even a scratch, or when the rabid animal licks an existing open wound on a human or a nonrabid animal.
The indications that an animal is rabid are variable and may be misleading. On the one hand, a rabid animal may drool, be irritable, be unusually active, or be clearly dangerous; on the other hand, it may be quiet, partially paralyzed, stuporous, or even affectionate. Every effort must be made to restrain any suspected rabid animal so that it can be kept under observation to see whether it develops the final stages of the disease. Do not kill such an animal unless it is absolutely necessary. If killing is necessary, take precautions not to damage the animal's head, which must be examined by public health authorities. Get help and advice from the police, a veterinarian, a physician, or local public health authorities as to how long a live animal that is thought to be rabid should be observed. Regulations vary from one community to another, but the average period is 15 days. If the animal cannot be caught for observation, arrange for immediate rabies immunization for any person it has bitten.
An animal in the final stages of rabies will develop some of the signs of the disease within 48 hours and will usually die within a few days after those signs appear. If the animal proves to be rabid, vaccine therapy must be given to build up body immunity in the victim in time to prevent the disease.
There is no known cure for rabies once its final-stage symptoms develop. After a person is bitten and the rabies virus is transmitted to him, the virus must go through an incubation period that may vary in duration. Any person who is bitten by an animal thought to be rabid should take no chances and should get medical care immediately. In the meantime, before a physician takes charge, thoroughly wash the wound with soap and water, flush it liberally, and apply a dressing. Movement of the arms and legs should be avoided until the victim has had medical care.
Most closed wounds are caused by external forces, such as falls and motor vehicle accidents. Many closed wounds are relatively small and involve soft tissues; the black eye is an example. Others, however, involve fractures of the limbs, spine, or skull and damage to vital organs (see page 44, Fig. 19) within the skull, chest, or abdomen. Massive injury to soft tissues—such as muscles, blood vessels, and nerves—can be very serious and can result in lasting disabilities.
Signs and Symptoms
Pain and tenderness are the most common symptoms of a closed wound. Usual signs are swelling and discoloration of soft tissues and deformity of limbs caused by fractures or dislocations. Suspect a closed wound with internal bleeding and possible rupture of a body organ whenever powerful force exerted on the body has produced severe shock or unconsciousness. Even if signs of injury are obvious, internal injury is probable when any of the following general symptoms are present:
Carefully examine the victim for fractures and other injuries to the head, neck, chest, abdomen, limbs, back, and spine. If an internal injury is suspected, get medical care for the victim as soon as possible. If a closed fracture is suspected, immobilize the affected area before moving the victim. Carefully transport him in a lying position and give special attention to preventing shock. Also, watch the victim's breathing and take measures to prevent either blockage of the airway or stoppage of breathing. Do not give fluids by mouth to a victim suspected of having internal injury, regardless of how much he complains of thirst.
When a relatively small closed wound occurs (such as a black eye), put cold applications on the injured area. The applications will help to reduce additional swelling and may slow down internal bleeding.