puncture wounds

Replies to This Discussion

Permalink Reply by Joe P. on July 4, 2009 at 12:44am

First question:

Does the patient want treatment? In general, if I'm doing something like pulling out a puncture like that, it's because I'm not planning on calling an ambulance.

Second, if it's out, it's out. Pressure dressing, monitor, transport. If the patient is in pain (and if the provider is of a level to be able to), administer pain medication.



On a side note, don't use H2O2 to clean wounds. The bubbling from H2O2 is from the cells breaking it down because H2O2 is cytotoxic.

▶ Reply to This

Permalink Reply by Nathan on July 4, 2009 at 1:02am

Depends on where it is, sucking chest wound? Your instance he needs to worry about bone type infections if it hit the bone. Joe pretty much summed it up for most protocols.............. Stabilize embedded objects and TX get a tetanus shot. Im not sure we are understanding what your asking?

▶ Reply to This

Permalink Reply by Duncan Hitchcock on July 4, 2009 at 7:16am

Take him to the hospital.

▶ Reply to This

Permalink Reply by Sandra VandeBruinhorst on July 4, 2009 at 11:57am

treatment for puncture wounds ( where its an embedded object through any of the limbs or digits) in general - this is just one scenario , i think back to one that happened about 4 or 5 years ago, we were all standing in a circle showing an uncle a crossbow when it fired (safety was on) and the arrow went into another brothers leg - that instance also the arrow got pulled out, and we took him to the hospital then and they stitched up the opening, so we took him home again and when cleaning him up discovered that there was an exit wound also so in we went again (this is at a urgent care facility) and this time they called the ambulance to take him to a larger facility to be taken care of. we were all upset because we had just transported him 3x ourselves and then they decided to call the ambulance, the town's volunteer EMS did not have the staff so they call the next town 20 min away for a trip that took maybe 25 min to the nearest emerg. Are these feeling justified, or is it just an out of town/ farm attitude that 'one can take care of their own problems and not have to take the ambulance)

▶ Reply to This

Permalink Reply by Joe P. on July 4, 2009 at 1:35pm

Coming also from a "damn it, if I can fix it myself, I'll fix it myself" attitude, unless you needed help with movement issues or needed monitoring/pain medication, I don't really see the need for an ambulance if the family was willing to transport.

One thing to note with puncture wounds with barbed ends (fish hooks, some types of arrows, etc), some situations make it better to push the object all the way through, cut off the barbed end, and then remove the object. Of course for ambulance work, if you can leave the object in, leave it in.

▶ Reply to This

Permalink Reply by Nathan on July 4, 2009 at 5:01pm

There is an insurance liability issue for that clinic to just tell you to take him yourself, you could have refused the ambu and tx yourself

▶ Reply to This

Permalink Reply by Chance Gearheart on July 5, 2009 at 8:45am

The issue here is a major one of what-if. Is your approach going to be best for the patient, or are you just wanting to show off your nifty wound care skills. Every boy should know how to remove a rusty nail or fishhook if they get one in them, but is it really appropriate most of the time to do so in the field? There is so much left to chance in most situations: Possible penetration of a vessel or nerve, pneumo/hemothorax or abdominal cavity penetration, tamponade, air emobolism. In addition, many impaled objects can do severe tissue damage if removed improperly, such as an arrow or a fishhook, and it is incredibly painful without the proper anesthetics. We don,t really have the environment to perform sterile wound care in the back of an ambulance, either, and Hydrogen Peroxide is a poor choice for penetrating wounds, as flushing with sterile saline and oral/IM/IV and topical antibiotics in most cases are the best. In addition, do we carry tetnus toxoid vaccination on the rig? Thats not to say I havent removed feet before from nails in boards, but it needs to be done with online medical control or strictly addressed in protocols and training: Wilderness or Critical Care Paramedic is a great training resource for wound care, as they focus more on delayed transport situations.

There's too much that can legally and medically go wrong with patients with even a small nail in the leg to not have them evaluated in our culture today: expecially with our medically defiant culture. They may not have had a tetanus shot in 15 years, or they may have gotten a nice implant of Group A Strep into that deep tissue and develop Nectrotizing Fascitius two weeks down the road. Treat and release is great for scrapes, minor burns, and even some lacerations, but a puncture raises a gray area that is best left to a more advanced provider to determine.

▶ Reply to This

Permalink Reply by Joe P. on July 5, 2009 at 9:01am

Chance, I don't think anyone here is advocating treat and release or many of the other issues you brought up. What I see in this thread is people discussing from a "I'm not at work and a family member or friend just did something to themselves" view. No one is going to call for orders when treating a family member at home while off duty.

▶ Reply to This

Permalink Reply by Mike Rubin on July 5, 2009 at 9:23am

I'm no expert, but I'm not sure the benefit outweighs the risk (allergic rxn) of putting a topical antibiotic on a deep wound, particularly if the pt is being transported for definitive care.

"We don,t really have the environment to perform sterile wound care in the back of an ambulance, either, and Hydrogen Peroxide is a poor choice for penetrating wounds, as flushing with sterile saline and oral/IM/IV and topical antibiotics in most cases are the best."

▶ Reply to This

▶ Reply to This