# should you replace an avulsion flap of skin if its covered with gravel?



## wutthedutch (Feb 10, 2012)

and alot of dirt? in the field would you normally try to brush it off first?before applying a bandage


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## Maine iac (Feb 10, 2012)

What do you mean replace...? Since it is still attached are you going to pack around it to isolate it from the rest of the body?

I think you should be able to answer this question.... If you avulsed a large chunk of your own flesh and it was filthy would you clean it off and then bandage it, or just make sure all that garbage was ground into the wound?


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## wutthedutch (Feb 10, 2012)

like if a big chunk is hanging to the side covered with dirt from a motorcycle accident would you brush it off first before setting it back in place and bandaging? or would it be more important to get them to the hospital as fast as possible and just pack the wound dirty (rocks and dirt)


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## Veneficus (Feb 10, 2012)

Doesn't matter, when you get to where you are going it will have to be cleaned anyway.

Potentially surgically scrubbed or debrided.


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## firetender (Feb 10, 2012)

Veneficus said:


> Doesn't matter, when you get to where you are going it will have to be cleaned anyway.
> 
> Potentially surgically scrubbed or debrided.


 
So now would you see any contraindications to brushing off or removing (saline flush) debris from the wound pre-transport?

And the OP asked if placing the flap of skin back on to its original position (over other traumatized tissue) WITH the debris in it would be something to do.

Would it still not matter?

Or are there certain steps that could be taken to help assure no further harm would be done to the patient?


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## Veneficus (Feb 10, 2012)

firetender said:


> So now would you see any contraindications to brushing off or removing (saline flush) debris from the wound pre-transport?



Unless there is a clot keeping hemostasis, I don't see any problem with cleaning a wound.

There are 2 schools of thought on surgical scrubbing, but I am in the pro category. (you just will not be able to reproduce that in the field under most circumstances)



firetender said:


> And the OP asked if placing the flap of skin back on to its original position (over other traumatized tissue) WITH the debris in it would be something to do.
> 
> Would it still not matter??



Won't matter, it still has to be explored and cleaned at the hospital. If the deep fascial planes are broken, it is going to the OR. 

Placing the flap in it's original position may help keep blood flow to it, thus keeping it viable for repair. The technique of finding out if it is viable I will not talk about because it is not something EMS people can do without getting in trouble usually. 



firetender said:


> Or are there certain steps that could be taken to help assure no further harm would be done to the patient?



Make sure you don't dislodge a primary clot.

There is considerably more TXA2 (endogenous vasoconstrictor) in a primary clot than in reclotting. So if you dislodge a primary clot, you can expect to have a more difficult time controlling that bleed and could lose a decent amount of blood trying depending on the severity of the wound.

Creating a skin flap is a common surgical repair, so it should not be a wound that is overly intimidating to field providers.

This can even be done outpatient under local anesthesia.

http://www.youtube.com/watch?v=J4gqR7J9QXg


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## EpiEMS (Feb 10, 2012)

So, under typical urban EMS conditions, the right move is to just cover it, with saline flush being optional? That is, what's the CYA move?


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## Remeber343 (Feb 10, 2012)

If you have time and there are no apart life threats, and you have time to play before you get to the hospital, you might as well try to make it look pretty and clean it up a little.


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## Handsome Robb (Feb 10, 2012)

Really? Lets use some common sense here....


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## bigbaldguy (Feb 11, 2012)

Assuming you're not dealing with a critical patient who has more pressing injuries I would probably use sterile water to flush the wound and flap. You would probably want to do this to better assess the wound anyway. I wouldn't be overly aggressive though, as mentioned you don't want to cause rebleeding. Yes in theory they will clean the wound again at the ER but there is no reason to wrap it up dirt and all.


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## Veneficus (Feb 11, 2012)

NVRob said:


> Really? Lets use some common sense here....



What's wrong? It was a fair question.


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## mycrofft (Feb 11, 2012)

*Done this and the ER wasn't mad.*

1. If threatening amount of bleeding, work fast.
2. Moisten sterile gauze, displace flap, place (not pack) gauze in place intimately as you can (touching all surfaces) without cramming, then attend to bandaging. If bleeding is minimal, try to debride a little, all that stuff will glue into place with serum and blood if you don't.

Make sure lots of any gauze you put in sticks out to fascilitate re-opening and removing it when ready to debride. It will stick some but not as bad as dry gauze, when you remove it much of the debris will adhere and come out too. I've also placed single layer (only single) of Adaptyic (sterile plastic mesh with petrolatum on it) in a simple avulskion or on an abrasion, lets serum by, keeps serum from gluing crud to tissue somewhat.
Ask about tetanus status.

written in Ron's office on my netbook


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## zmedic (Feb 11, 2012)

I'd say the biggest issue is that in the ER the patient is likely to get a fair amount of local (and potentially general) pain control before cleaning. They aren't likely to tolerate a lot of gravel removal/ washing in the field without something for the pain. Those abrasions hurt a lot. I'd probably pour a little saline over the wound if you 

1) Have completed your assessment
2) Have treated all other injuries
3) It will not delay transport. 

It sounds obvious but big avulsions are the sort of thing that rookies can get hung up on and miss the fact that the patient is tachycardic or needs rapid transport. 

Speaking of wound care, can I get on my soap box for a second? Okay EMS. If the patient isn't actively bleeding, just stick a 4x4 over whatever wound they have. especially if it is on the anterior surface like the knee or shin and it will stay in place on it's own, or the patient can hold the guaze on their arm wound. I see all these people come in with these elaborate gauze wraps around the laceration or whatever, and the first thing I'm going to do is to cut it off and take a look. Sure there are times when it makes sense to wrap. But if you are transporting a patient 5 minutes to the ER for a hand laceration that isn't bleeding, save the time and money and not wrap them up like a mummy.


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## zmedic (Feb 11, 2012)

mycrofft said:


> 1. If threatening amount of bleeding, work fast.
> 2. Moisten sterile gauze, displace flap, place (not pack) gauze in place intimately as you can (touching all surfaces) without cramming, then attend to bandaging. If bleeding is minimal, try to debride a little, all that stuff will glue into place with serum and blood if you don't.
> 
> Make sure lots of any gauze you put in sticks out to fascilitate re-opening and removing it when ready to debride. It will stick some but not as bad as dry gauze, when you remove it much of the debris will adhere and come out too. I've also placed single layer (only single) of Adaptyic (sterile plastic mesh with petrolatum on it) in a simple avulskion or on an abrasion, lets serum by, keeps serum from gluing crud to tissue somewhat.
> ...



What is your thinking for putting gauze between the two layers of the avulsion? The best place for avulsed tissue is generally back where it belongs. Putting gauze between two contaminated flaps of skin isn't going to reduce your infection.


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## Veneficus (Feb 11, 2012)

zmedic said:


> Speaking of wound care, can I get on my soap box for a second? Okay EMS. If the patient isn't actively bleeding, just stick a 4x4 over whatever wound they have. especially if it is on the anterior surface like the knee or shin and it will stay in place on it's own, or the patient can hold the guaze on their arm wound. I see all these people come in with these elaborate gauze wraps around the laceration or whatever, and the first thing I'm going to do is to cut it off and take a look. Sure there are times when it makes sense to wrap. But if you are transporting a patient 5 minutes to the ER for a hand laceration that isn't bleeding, save the time and money and not wrap them up like a mummy.



Amen


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## Hunter (Feb 11, 2012)

Basically what everyone else is saying, if there aren't any more immediate life threats than clean ti before you place it back, i wouldn't place it back dirty, your primary goal in wound care of these type of injuries is to reduce the chance of infection, its the biggest problem other than bleeding,i wouldn't brush it with anything because you might accidentally injure the tissue more, but rinsing it with NS, or Sterile Water would probably get the job done.

Someone said something about rapping it without replacing it,  as in wrapping it away from the body, I think it would damage the avulsed tissue to the point where it would no longer be viable to be reattached.


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## Veneficus (Feb 12, 2012)

Hunter said:


> Basically what everyone else is saying, if there aren't any more immediate life threats than clean ti before you place it back, i wouldn't place it back dirty, your primary goal in wound care of these type of injuries is to reduce the chance of infection, its the biggest problem other than bleeding,i wouldn't brush it with anything because you might accidentally injure the tissue more, but rinsing it with NS, or Sterile Water would probably get the job done.
> 
> Someone said something about rapping it without replacing it,  as in wrapping it away from the body, I think it would damage the avulsed tissue to the point where it would no longer be viable to be reattached.



If the tissue is seperated from the body and does not have its own blood supply, replacing it is much less likely.


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## mycrofft (Feb 12, 2012)

*Pick it back up, dust it back off, try all over again...*


1. The wound is infected, if it has been avulsed in the field and dusted with dirt, beyond anything you are going to do to it interferfing with that infection. Maybe irrigate it with bacitracin solution, Dakin's solution, but unless that dirt is sterile, it's done already.
2. Foreign object reaction will set in (road rash with tattooing) and healing will be greatly delayed and infection worsened if that dirt is allowed to sit, and the longer it's there and the serum is exuding and setting up the harder the debridement and the worse the followup.
3. Saline gauze, even tap water gauze, will delay this gluing process until seen by medical authority. Bacitracin oint would also but it then has to be cleaned out.
4. Returning the flap to it's aproximate position probably allows the microcirculation keeping it alive to avoid being pinched or kinked.

WARNING: not paper towels, not Kleenex, not toilet paper, not cotton balls or wadding. Gauze, maybe muslin.

PS: some tribes used human blood to glue on drum heads for generations' of service.


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## Handsome Robb (Feb 13, 2012)

Veneficus said:


> What's wrong? It was a fair question.



Maybe it's the way I look at it but if the patient's critical then I'm not worried about a bit of dirt. 

If I have time and the patient will tolerate it I'm going to flush it, at minimum. Replacing it with all that gunk still on the avulsed flap isn't going to feel good, trust me, I've dealt with it before through all the sports and stupid things I have done in my life.


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## EMTBell (Feb 23, 2012)

*Saline Flush*

I agree, I would flush with normal saline and use some gauze to scrub out any remaining debris. Of course try to avoid any clots that have formed unless upsetting them won't cause major bleeding. Bandage with some more gauze. Either way it'll be debrided in the ER so just make it as clean as you can without wasting time. I definitely wouldnt just put the avulsed flap back into place without a saline flush at the very least.


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## Veneficus (Feb 23, 2012)

EMTBell said:


> I definitely wouldnt just put the avulsed flap back into place without a saline flush at the very least.



Why not?

Who cares?


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## EMTBell (Feb 23, 2012)

*the patient cares?*

I certainly don't want any infection or abscess that the ER doc has to deal with on my ***!


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## Veneficus (Feb 23, 2012)

EMTBell said:


> I certainly don't want any infection or abscess that the ER doc has to deal with on my ***!



Do you think it isn't going to be washed when it gets to the hospital?

How long does it take for any bacteria to overcome the immune response?

Did you know that most infections are caused by the patients own flora?

Whether or not the patient gets an infection probably has more to do with what is done when it is reattached than what is done in the field.


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## EMTBell (Feb 23, 2012)

Maybe it is a difference in our training, I'm a wilderness responder so I have to think more long term, but I feel it would be irresponsible to not thoroughly clean the avulsion with aseptic fluid prior to bandaging. Whether or not I was going to close with steri strips would determine how thoroughly I clean.

I know abscesses can form in minutes, so even with an urban situation of thirty minutes injury to ER you may have the beginnings of infection to show. Furthermore if you decide not to replace the avulsed flap because it hasn't been cleaned, you may prevent some capillary circulation by the position you transport in.


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## Veneficus (Feb 23, 2012)

EMTBell said:


> Maybe it is a difference in our training,



Probably, I think rather long term too  though


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## mycrofft (Feb 23, 2012)

*Please, ask someone who has had to perform delayed debridement*

Even in a delayed response situation, the only justification for closing a presumably septic and/or foreign-object contaminated wound would be save the life. Like deadly bleeding that didn't respond to packing, or deep chest wall penetration.

In the field, and especially in a wilderness situation, (read lips) *you will not* be able to adequately clean an avulsion to prevent either infection, or foreign object reaction to the dirt etc. Hard to do even in a clean fully equipped facility. You could conceivably find a way to scrub it, but the result is (degree dependent upon the size and site of the injury) excruciating agony, potentially more injury to the avulsed tissue, and the near certainty the site will still be contaminated. Positive thinking does't come into this.

Having seen the follow-up care for such cases, I know aiming for facilitation of later debridement and allowing the avulsion to fall back into a nearly correct position to help allow peripheral circulation are uppermost, not some armchair argument about how to clean it enough to replace or (!!!) steristrip it back into place. It will rot off, unless you are extremely lucky, and/or heal with tattooing,  and could potentially lead to anaerobic sepsis.

Promptly rinse with potable or sterile solution and take out the pine cones and pea gravel. Intimately dress with sterile saline or potable water wetted gauze. Get to care. Treat other problems. Ask about tetanus status.


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## Always BSI (Feb 29, 2012)

Had a similar question when I took my EMT written exam at AMR. I wont dare say what I picked I don't want to get flamed, lmao.


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## beefaroni (Feb 29, 2012)

Flush with sterile.. Bandage with sterile ... Go to hospital...


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