# Do you replace an avulsed...



## aunaturelgal (Jul 14, 2009)

flap of skin if it has visible dirt in it?  If not, what do you do?

Thanks!


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## Ridryder911 (Jul 14, 2009)

Do as the curriculum teaches you to do. The pedicule (avulsed flap) should be bandaged with the lacceration. Patient skin will be scrubbed and cleansed in ED after analgesic and re-attachment can usually occur. 

One is not licensed or certified to debride skin in the prehospital arena. 

R/r 911


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## fma08 (Jul 14, 2009)

Ridryder911 said:


> Do as the curriculum teaches you to do. The pedicule (avulsed flap) should be bandaged with the lacceration. Patient skin will be scrubbed and cleansed in ED after analgesic and re-attachment can usually occur.
> 
> One is not licensed or certified to debride skin in the prehospital arena.
> 
> R/r 911



Would you consider rinsing with sterile saline before bandaging?


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## Sail195 (Jul 14, 2009)

fma08 said:


> Would you consider rinsing with sterile saline before bandaging?



Ya I was wondering the same, I guess it would depend if there was major bleeding or not?


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## DrankTheKoolaid (Jul 14, 2009)

*re*

Yes rinse it with irrigating solution and wrap with dry dressings


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## NomadicMedic (Jul 14, 2009)

Corky said:


> Yes rinse it with irrigating solution and wrap with dry dressings




Sorry, no. 

According to my textbook, "Do not try to remove dirt from an open wound, no matter how dirty... Rubbing, brushing or washing an open wound will only cause additional bleeding and unnecessary pain. The wound will be appropriately cleaned at the hospital."

Source: _Intermediate Emergency Care and Transportation of the Sick and Injured_ Page 685


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## aunaturelgal (Jul 14, 2009)

So then you leave the flap as is and cover with dressing?  Or replace the flap and cover with dressing?


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## ResTech (Jul 14, 2009)

I would use "passive" cleansing of the wound to rid any gross contamination of dirt or debris... irrigate with sterile water or saline. Dry and then bandage in place to prevent additional contamination and bleeding. I think its bad wound management to bandage a wound with gross contaminates that could be easily flushed away with irrigation. Of course if bleeding is heavy, your priority is bleeding control so you may not have a chance to irrigate. Just depends. Dont remove a dressing just to irrigate..

I would flap it back into its normal position as long as its not at risk of detaching all together or causing the patient increased pain which more than likely it wont. .


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## Ridryder911 (Jul 14, 2009)

Personally unless there was a lot of debris, I would not rinse off as it might even contaminate more. Truthfully a light sterile dressing and bandaging. It will take much more cleansing than we can perform and most likely antibotic tx. 

R/r 911


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## DrankTheKoolaid (Jul 14, 2009)

*re*

Sorry not sure what your book say's.  I spent 10 years as an ER Tech doing wound management, so to be honest i don't remember what the books say.  But personally if it's my wound i would appreciate you cleaning the gross debris before bandaging.  And by cleaning i just mean running irrigating fluid across it to flush any large junk off


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## Summit (Jul 14, 2009)

Corky said:


> But personally if it's my wound i would appreciate you cleaning the gross debris before bandaging.  And by cleaning i just mean running irrigating fluid across it to flush any large junk off



This please


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## mycrofft (Jul 14, 2009)

*Do what your protocols say...*

...but here are my observations, having followed some patients from first aid through tx and dressing changes later..

1. The doc makes the decision if a flap is vital or not. Sometimes a questionable flap is kept and acts as a bandage for new granulation underneath. No snipping and keeping it aligned/in place maximizes remaining circulation.
2. Don't start on-scene tx with ointments or greases because that will require more scrubbing.
3. I have opened up a 4X4, doused it with SNS, and placed it intimately into the wound with a SNS dressing over that to keep it moist and osmotically neutral. When we went to clean it out, much of the crud was on the gauze, the wound suffered no setback, and clotting/scabbing was at a minimum.
4. Little dirty avulsions have done well with a little betadine dripped on them. The following healing etc was not slowed by it, versus other tx's.

I half-jokingly say doctors should never be asked to talk about dressing changes and healing simply because they do not do them on a daily basis.


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## PapaBear434 (Jul 14, 2009)

Couple weeks back a coworker of mine had a guy that avulsed his head.  From right above his left eye and back to the rear corner of his skull, like half his head apparently.

When it's that big, I think just plopping it back over might be the best course of action, so long as there isn't a clump of sod in it or something.  But for little avulsion, like along the finger or something like that...  Just rinse it through with some irrigation fluid, try to dry it, and place a nice dry dressing on it.


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