Content Extraction Summary

Expert-level practical reference covering wound assessment, cleaning, closure methods, suturing technique, burn management, infection control, dressing selection, and special wound scenarios. Includes specific irrigation pressures, suture sizing by anatomical location, closure decision flowchart, and a complete field wound care kit list. Sourced from ACS trauma guidelines, WMAI wilderness medicine protocols, and Auerbach's Wilderness Medicine. Educational reference only — not a substitute for professional medical training or treatment.

1. Introduction

Most wound infections don't come from insufficient antibiotics. They come from insufficient cleaning. A 2013 Cochrane review found that proper wound irrigation reduced infection rates more effectively than prophylactic antibiotic use in simple lacerations (Fernandez et al., 2013). The single most important intervention in wound management is mechanical removal of contaminants through pressurized irrigation — not what you put on the wound after, but what you wash out of it before.

This matters because the dominant instinct — apply antibiotic ointment, slap on a bandage — skips the step that actually prevents infection. Bacteria don't cause wound infections by landing on a wound surface. They cause infection when they colonize devitalized tissue and foreign material that remain embedded in the wound bed. Remove those, and the body's immune system handles the rest in the vast majority of cases.

The golden period — the window during which a contaminated wound can be cleaned and closed with acceptable infection risk — is traditionally cited as 6 to 8 hours. More recent evidence suggests this is location-dependent. Facial wounds, due to rich blood supply, can often be closed up to 24 hours post-injury with infection rates under 5% (Quinn et al., 2002). Extremity wounds in contaminated environments have a much shorter effective window.

Everything in this document is educational. Wound care is a skill that improves with practice under qualified instruction. Nothing here replaces hands-on training from a wilderness medicine course, a tactical combat casualty care (TCCC) program, or supervised clinical experience.

2. Wound Assessment

Before touching a wound, classify it. The type of wound determines your cleaning approach, closure method, and infection risk.

Wound Types

**Laceration.** A cut caused by a sharp object. Edges are clean or mildly irregular. Lowest infection risk of traumatic wounds. Most amenable to primary closure.

**Avulsion.** A flap of tissue partially or fully torn away. The flap may have compromised blood supply. If the flap blanches and does not refill with color when released, perfusion is poor and the flap may not survive closure.

**Puncture.** A deep, narrow wound — nail, tooth, thorn. Deceptively dangerous. The depth-to-width ratio makes cleaning difficult. Highest infection risk per surface area of any wound type. Do not close puncture wounds.

**Abrasion.** Superficial skin loss from friction. Often heavily contaminated with road grit or soil. Requires aggressive cleaning to prevent traumatic tattooing — permanent discoloration from embedded debris.

**Crush injury.** Tissue damage from compressive force. The primary concern is devitalized tissue — cells that are dead but still in place. Dead tissue is the ideal bacterial growth medium. Crush injuries carry high infection risk and poor healing potential.

Depth Assessment

Evaluate wound depth systematically:

  • **Superficial (epidermis only).** Bleeding is minimal, capillary ooze. No closure needed beyond wound strips.
  • **Partial thickness (into dermis).** Bleeding is brisk but controllable. Wound base is pink. Closure warranted for wounds over 2 cm or in high-tension areas.
  • **Full thickness (through dermis into subcutaneous fat or deeper).** Yellow fat visible, or deeper structures exposed. Requires layered closure or professional care.

Tendon, Nerve, and Vessel Check

Perform this before any local anesthesia — anesthesia masks the findings you need.

**Tendon function.** Test active range of motion against resistance distal to the wound. A partially severed tendon may still allow some movement but will fail under load. For hand wounds, test each finger individually: flexion at the DIP joint (flexor digitorum profundus), flexion at the PIP joint (flexor digitorum superficialis), extension (extensor mechanism). Tendon injuries require surgical repair.

**Nerve function.** Test two-point discrimination distal to the wound. Normal fingertip discrimination is 2-5 mm. Compare to the uninjured side. Test light touch in specific nerve distributions. Inability to distinguish sharp from dull indicates nerve damage.

**Vascular status.** Check capillary refill distal to the wound (normal: under 2 seconds). Check radial/ulnar pulse for forearm wounds, dorsalis pedis/posterior tibial for lower leg wounds. Pale, cool tissue with delayed refill indicates vascular compromise — this is a surgical emergency.

Contamination Level

  • **Clean.** Sharp object, indoor environment, less than 6 hours old. Glass cuts, kitchen knife lacerations.
  • **Contaminated.** Outdoor injury, visible debris, 6-12 hours old. Garden tool wounds, barbed wire lacerations.
  • **Heavily contaminated.** Soil-embedded debris, animal bites, farmyard injuries, crush mechanisms. These wounds should generally not be closed primarily.

3. Cleaning

Irrigation

Irrigation pressure matters more than irrigation volume or irrigation solution. The target is 5-8 psi (pounds per square inch). Below 5 psi, bacteria and debris are not effectively dislodged. Above 15 psi, you drive contaminants deeper into tissue and cause additional tissue damage (Stevenson et al., 1976).

**The gold standard setup:** a 35 mL syringe with an 18-gauge catheter tip (the plastic sheath, not the needle). This combination delivers approximately 8 psi — optimal irrigation pressure validated in multiple studies (Hollander & Singer, 1999).

**Volume guidelines:**

| Wound Type | Minimum Irrigation Volume | |---|---| | Clean laceration, <5 cm | 250 mL | | Contaminated laceration | 500-1000 mL | | Heavily contaminated wound | 1000-2000 mL | | Bite wound | 1000+ mL | | Puncture wound | Maximum possible (difficult due to geometry) |

**Irrigation solution.** Clean drinkable water works. A 2015 Cochrane review found no significant difference in infection rates between normal saline and clean tap water for wound irrigation (Fernandez et al., 2015). In the field, clean drinking water is an acceptable substitute for sterile saline. Do not use hydrogen peroxide, povidone-iodine at full strength, or alcohol directly in the wound — all are cytotoxic to the fibroblasts and white blood cells doing the actual healing work. Dilute povidone-iodine (1% solution — one part 10% Betadine to nine parts saline) is acceptable for heavily contaminated wounds when infection risk outweighs tissue toxicity concerns.

**Technique.** Hold the syringe tip 2-3 cm from the wound surface. Irrigate perpendicular to the wound bed. Work from the cleanest area toward the most contaminated area. Continue until the effluent runs clear and no visible debris remains.

Debridement

Debridement — removing dead, damaged, or contaminated tissue — is the second critical cleaning step. In field settings, limit debridement to:

  • Removing obviously nonviable tissue (gray, black, or mushy tissue that does not bleed when cut)
  • Trimming ragged wound edges to create a cleaner margin for closure (trim no more than 1-2 mm)
  • Removing embedded foreign bodies visible in the wound

Do not aggressively debride in the field unless you have training. Removing too much tissue creates a defect that is harder to close and heals more slowly.

Foreign Body Removal

Explore the wound under good lighting. Methodically probe with forceps. Glass fragments are common in laceration wounds and are notoriously difficult to feel. If you suspect retained foreign bodies but cannot find them, the wound should be evaluated with imaging.

Wood splinters and organic material are the highest-risk retained foreign bodies — they serve as a persistent nidus for infection and must be removed completely.

When NOT to Close

Do not close a wound under these conditions:

  • **Wound older than the golden period.** More than 6-8 hours for extremity wounds in contaminated environments. More than 12-24 hours for clean facial wounds.
  • **Heavily contaminated wounds.** Soil, feces, or organic debris that cannot be completely irrigated out.
  • **Bite wounds.** Animal and human bites have polymicrobial contamination. Exception: facial bite wounds may be closed after aggressive irrigation due to superior blood supply.
  • **Crush injuries with significant devitalized tissue.** Dead tissue enclosed by sutures becomes an abscess.
  • **Puncture wounds.** The geometry prevents adequate cleaning.
  • **Signs of active infection.** Purulent drainage, surrounding cellulitis, significant edema.

When primary closure is contraindicated, pack the wound loosely with saline-moistened gauze, apply a sterile dressing, and reassess in 3-5 days. If the wound bed is clean and granulating, delayed primary closure can be performed at that time. This approach — intentional delayed closure — has infection rates comparable to primary closure of clean wounds.

4. Closure Methods

Closure Decision Flowchart

``` WOUND ASSESSMENT ├── Is it actively bleeding and won't stop with direct pressure? │ └── YES → Control hemorrhage first (direct pressure, tourniquet if extremity) ├── Is there tendon, nerve, joint, or vessel involvement? │ └── YES → Do not close. Stabilize and evacuate to surgical care. ├── Is the wound contaminated beyond what irrigation can clean? │ └── YES → Do not close. Pack open, plan for delayed primary closure. ├── Is the wound a puncture or bite (non-facial)? │ └── YES → Do not close. Irrigate aggressively, dress open. ├── Is the wound older than the golden period? │ └── YES → Do not close unless facial (<24h) or scalp (<12h). │ └── WOUND IS APPROPRIATE FOR CLOSURE ├── Superficial, low tension, <5 cm → Wound closure strips or tissue adhesive ├── Scalp wound → Staples (fastest and most effective for scalp) ├── Linear laceration, moderate tension → Simple interrupted sutures ├── High-tension area or fragile skin → Horizontal mattress sutures ├── Irregular wound edges → Figure-8 or combination technique └── Small, clean laceration in child → Tissue adhesive (Dermabond) ```

Wound Closure Strips (Steri-Strips)

Best for: superficial lacerations under 5 cm in low-tension areas.

**Technique.** Apply benzoin tincture to dry skin on both sides of the wound (not in the wound). Allow it to become tacky — about 30 seconds. Approximate wound edges by hand. Apply strips perpendicular to the wound axis, starting at the center and working outward. Space strips 2-3 mm apart. Apply reinforcement strips parallel to the wound along each end to prevent peeling.

**Advantages.** No anesthesia required. Lowest risk of tissue damage. No removal needed — strips fall off as the skin heals. No suture marks (relevant for cosmetic areas).

**Limitations.** Cannot be used on hairy skin, wet surfaces, high-tension areas, or joints. Will not hold wounds under tension. Not appropriate for wounds deeper than the dermis.

Skin Staples

Best for: scalp lacerations, trunk wounds, and extremity wounds where cosmesis is not the primary concern.

**Technique.** Evert the wound edges using tissue forceps or by pressing down on each side of the wound. Align the stapler perpendicular to the wound. Place staples 1 cm apart. Staples should evert the edges slightly — flat apposition with staples often means insufficient tension.

**Advantages.** Fastest closure method. Lower infection rate than sutures in some studies (Kanegaye et al., 2006). Straightforward technique.

**Limitations.** Require a dedicated staple remover. Not appropriate for face, hands, or feet. More painful during placement than sutures under anesthesia.

Suturing

The gold standard for wound closure when precision, layered closure, or tension management is needed. See Section 5 for detailed technique.

Tissue Adhesive (Dermabond / 2-Octyl Cyanoacrylate)

Best for: small (under 4 cm), clean, superficial lacerations in low-tension areas. Particularly useful in children — no needles, no removal visit.

**Technique.** Approximate wound edges completely with fingers or wound strips. Apply adhesive in thin layers along the surface of the closed wound — never put adhesive inside the wound. Apply 3-4 thin layers, allowing 30 seconds between layers. Hold edges for 60 seconds after final layer.

**Advantages.** No anesthesia. No removal. Acts as its own dressing. Water-resistant. Cosmetic outcomes equivalent to sutures for appropriate wounds (Singer et al., 2002).

**Limitations.** Cannot be used on mucous membranes, across joints, on hands or feet, in hair-bearing areas, or on wounds under tension. Does not provide hemostasis. Breaks down with petroleum-based products (antibiotic ointment dissolves it — use only non-petroleum products).

5. Suturing Technique

Needle Selection

**Reverse cutting needle.** Has a cutting edge on the outer curvature. Standard for skin closure. The cutting edge faces away from the wound, reducing the risk of the suture pulling through tissue. Use for all skin suturing.

**Tapered needle (round body).** No cutting edge — pushes tissue apart rather than cutting. Use for deep tissue layers (fascia, subcutaneous), not for skin. Less tissue trauma but cannot penetrate skin effectively.

**Needle size.** Correlates with suture gauge. For skin closure, the needle should be large enough to pass through the full thickness of the skin in a single arc without excessive force.

Suture Material Selection

**Non-absorbable monofilament (Nylon / Ethilon, Prolene).** Standard for skin closure. Monofilament means bacteria cannot wick along the suture strand. Must be removed. Causes less tissue reaction than braided material.

**Absorbable braided (Vicryl / Polyglactin 910).** Use for deep layer closure (subcutaneous, fascial). Maintains tensile strength for 3-4 weeks, absorbed by 56-70 days. Braided structure means easier knot security but higher infection risk than monofilament — never use on skin surface in contaminated wounds.

**Absorbable monofilament (Monocryl / Poliglecaprone, PDS / Polydioxanone).** Deep layer closure where braided material is contraindicated. PDS holds strength longer (6 weeks vs 3 weeks for Monocryl). Use for fascial closure.

Suture Size by Location

| Anatomical Location | Suture Size | Removal Timing | |---|---|---| | Face | 6-0 non-absorbable | 3-5 days | | Scalp | 3-0 or staples | 7-10 days | | Trunk | 3-0 to 4-0 | 7-10 days | | Extremities | 4-0 to 5-0 | 10-14 days | | Hands/fingers | 5-0 | 10-14 days | | Feet/soles | 3-0 to 4-0 | 10-14 days | | Over joints | 4-0 | 14 days | | Deep layer (anywhere) | 3-0 to 4-0 absorbable | N/A (absorbed) |

Instrument Tie (Standard Knot Technique)

1. **Load the needle.** Clamp the needle holder at the junction of the middle and rear third of the needle. The needle point should face left (for right-handed operators). The needle should be perpendicular to the holder jaws.

2. **Entry.** Enter the skin 3-5 mm from the wound edge. The needle should enter perpendicular to the skin surface — not at an angle. Drive through with a rotational wrist movement following the needle's curve. Exit into the wound.

3. **Reload and exit.** Grasp the needle tip with the holder inside the wound. Re-clamp. Enter the opposite wound edge from the deep aspect, exiting the skin surface 3-5 mm from the edge. The bite should be symmetric — equal depth and distance from the edge on both sides.

4. **First throw.** Wrap the suture tail around the needle holder twice (surgeon's throw — provides friction to hold while you complete the knot). Grasp the short end with the needle holder and pull through.

5. **Second throw.** Wrap once in the opposite direction (a single square throw). Pull snug.

6. **Third throw.** Wrap once in the same direction as the second throw. Pull snug. Cut tails to 5-8 mm. Three throws minimum for nylon. Four throws for Prolene (it has more memory and wants to untie).

Bite Width and Spacing

The standard rule: bites should be **3-5 mm from the wound edge** and **3-5 mm apart**. Equal bite width on each side produces proper edge apposition.

**Edge eversion.** The finished wound should have slightly everted (raised) edges. This is critical. Flat or inverted edges result in a depressed scar. Achieve eversion by entering the skin perpendicular to the surface and ensuring the depth of the bite is slightly wider than the surface width (flask-shaped bite path).

Suture Patterns

**Simple interrupted.** The workhorse. Each stitch is independent — if one fails or becomes infected, you remove that single stitch without affecting the rest. Use for most wound closures.

**Horizontal mattress.** Enter and exit as for a simple interrupted stitch, then re-enter and exit 5-8 mm lateral to the first, creating a horizontal loop across the wound. Provides excellent tension distribution and strong eversion. Best for high-tension closures, elderly skin, and areas where wound edges want to invert.

**Figure-8.** Essentially two simple interrupted stitches crossing over each other, sharing a single knot. Provides strong closure with fewer knots. Useful for irregular wound edges and for reducing dead space.

6. Burns

Degree Classification

**First degree (superficial).** Epidermis only. Red, dry, painful. Sunburn is the classic example. Heals in 3-7 days without scarring. No dressing needed beyond moisturizer and sun protection.

**Second degree — superficial partial thickness.** Into the upper dermis. Red, blistered, weeping, very painful. Blanches with pressure. Heals in 10-21 days with minimal scarring if not infected. These are the burns that benefit most from proper wound care.

**Second degree — deep partial thickness.** Into the deep dermis. White or mottled, less painful than superficial (nerve damage). May not blanch. Often requires skin grafting. Difficult to distinguish from third degree in the first 24-48 hours.

**Third degree (full thickness).** Through the entire dermis. White, brown, or black. Leathery texture. Painless (nerve destruction). Does not blanch. Requires skin grafting — cannot heal by secondary intention except at the margins.

**Fourth degree.** Into muscle, tendon, or bone. Charred appearance. Surgical emergency.

Rule of Nines (Body Surface Area Estimation)

For adults:

| Body Region | % BSA | |---|---| | Head and neck | 9% | | Each upper extremity | 9% (each) | | Anterior trunk | 18% | | Posterior trunk | 18% | | Each lower extremity | 18% (each) | | Perineum | 1% |

For scattered or irregular burns, the patient's palm (including fingers) represents approximately 1% BSA. This is the most practical field estimation method.

Burns requiring professional care:

  • Greater than 10% BSA in adults (5% in children or elderly)
  • Any third-degree burn
  • Burns crossing joints, face, hands, feet, or genitalia
  • Circumferential burns (risk of compartment syndrome)
  • Electrical or chemical burns
  • Inhalation injury (singed nasal hairs, soot in mouth, hoarse voice)

Immediate Burn Care

**Cooling.** Apply lukewarm running water (12-18°C / 54-64°F) for a full 20 minutes. This is evidence-based — a 2008 study demonstrated that 20 minutes of cooling within 3 hours of injury significantly reduced burn depth and improved outcomes (Cuttle et al., 2008). Do not use ice or ice water — this causes vasoconstriction, which worsens tissue damage. Do not apply butter, oil, toothpaste, or any folk remedy.

**Blisters.** Leave intact blisters alone if they are small and unbroken. They are a sterile biological dressing. Large blisters (greater than the size of the patient's fingertip) that are likely to rupture with activity can be drained with a sterile needle at the base — leave the blister roof in place as a protective layer.

Burn Dressings

**Silver sulfadiazine (Silvadene).** The traditional burn cream. Apply 1/16 inch thick layer to the burn surface, cover with non-adherent gauze. Change daily. Note: do not use on the face (can cause discoloration) or on patients with sulfa allergy. Recent evidence suggests silver sulfadiazine may actually slow healing compared to newer dressings, but it remains widely available and familiar.

**Non-adherent gauze (Adaptic, Telfa).** Base layer over burn cream or on clean superficial burns. Prevents gauze from adhering to the wound bed.

**Hydrogel dressings (Burnaid, Water-Jel).** Pre-hydrated sheets that cool the burn and maintain moisture. Excellent for first aid and transport. Available as individual packets for wound care kits.

**Alginate dressings.** For weeping, exudative burns. The alginate fibers absorb exudate and form a gel that maintains a moist healing environment. Change when saturated.

7. Infection Management

Signs of Infection

Listed in order of typical appearance:

1. **Increasing pain** after 48 hours (pain should be decreasing by this point, not increasing) 2. **Expanding erythema (redness)** beyond the immediate wound edges — mark the border with a pen and recheck in 6-12 hours 3. **Warmth** — infected tissue is warmer than surrounding skin 4. **Edema (swelling)** disproportionate to the injury 5. **Purulent drainage** — cloudy, yellow-green, or foul-smelling discharge 6. **Red streaking (lymphangitis)** — visible red lines tracking from the wound toward proximal lymph nodes. This indicates lymphatic spread and requires urgent antibiotic treatment. 7. **Systemic signs** — fever, chills, malaise, elevated heart rate. Indicates bacteremia. This is a medical emergency.

Wound Culture Basics

If infection is suspected, obtain a wound culture before starting antibiotics when possible. Proper technique: clean the wound surface with saline first (you want to culture the infecting organism, not surface colonizers). Use a sterile swab rolled across the wound bed with enough pressure to express fluid from the tissue. Send for aerobic and anaerobic culture with sensitivity testing.

Antibiotic Selection Principles

This section outlines general principles for educational purposes. Antibiotic prescribing requires clinical judgment and awareness of local resistance patterns.

**Skin flora infections** (Staphylococcus aureus, Streptococcus spp.) — these are the most common wound pathogens. First-generation cephalosporins (cephalexin) cover these organisms in most communities.

**Contaminated wounds with mixed organisms** — amoxicillin/clavulanate (Augmentin) provides broad coverage including anaerobes. Standard choice for bite wounds.

**MRSA risk factors** (prior MRSA infection, incarceration, athletic team contact, healthcare worker) — trimethoprim-sulfamethoxazole (Bactrim) or doxycycline cover community-associated MRSA.

**Water exposure wounds** (freshwater and saltwater) — add coverage for Aeromonas and Vibrio species. Fluoroquinolones (ciprofloxacin) or doxycycline are typical choices.

Antibiotics do not replace adequate wound cleaning. A clean wound rarely becomes infected regardless of antibiotic use. A poorly cleaned wound frequently becomes infected despite antibiotic use.

8. Dressing and Bandaging

Moist Wound Healing Principle

A moist wound environment heals 30-50% faster than a dry one. This was established by Winter (1962) and has been confirmed repeatedly since. The mechanism: epithelial cells migrate across the wound surface to close the defect. They migrate faster across a moist surface than a dry one. A scab is not a sign of good healing — it is a barrier that epithelial cells must dissolve before they can continue migrating.

The practical application: wounds should be kept moist with an appropriate dressing, not left open to air or allowed to dry and scab.

Wound Bed Preparation

Before applying any dressing: 1. Irrigate the wound (see Section 3) 2. Achieve hemostasis (direct pressure, not chemical hemostatic agents unless specifically trained) 3. Apply thin layer of antibiotic ointment or petroleum jelly (maintains moisture, reduces dressing adherence) 4. Select dressing based on wound characteristics

Dressing Types

**Gauze (woven and non-woven).** The most available dressing. Requires a secondary layer (tape, wrap, or bandage) to stay in place. Must be changed at least daily. Use moistened with saline for wound packing. Dry gauze on a wound surface adheres to granulation tissue and causes trauma on removal.

**Non-adherent dressings (Telfa, Adaptic).** A layer of gauze with a non-stick surface. Apply shiny side to wound. Use as the primary layer on sutured wounds, abrasions, and burns. Change daily or when soiled.

**Hydrocolloid (DuoDERM).** Self-adhesive, occlusive dressings that form a gel over the wound. Good for superficial wounds, abrasions, and partial-thickness burns. Can stay in place 3-5 days. The gel has a characteristic odor when removed — this is normal, not infection.

**Alginate (Kaltostat, Sorbsan).** Made from seaweed-derived calcium alginate fibers. Highly absorbent — absorbs 15-20 times its weight in fluid. Use for heavily exudative wounds. Forms a soft gel as it absorbs. Change when saturated. Not appropriate for dry wounds.

**Foam dressings (Mepilex).** Absorptive, cushioning, non-adherent. Good for wounds with moderate exudate over bony prominences. Can stay in place 3-7 days.

Bandaging Techniques

**Spiral wrap.** The standard wrap for extremity dressings. Start distal and wrap proximally (toward the heart) with 50% overlap. This promotes venous return and prevents distal edema.

**Figure-8 wrap.** For joints (ankle, knee, elbow, wrist). Provides coverage across the joint while allowing some range of motion. Anchor above and below the joint, cross over the joint with each pass.

**Pressure dressing.** For wounds that continue to ooze. Apply absorbent dressing, then elastic wrap at moderate tension. Check distal circulation every 30 minutes for the first 2 hours — numbness, tingling, coolness, or cyanosis indicates excessive pressure.

Change Schedule

| Wound Type | Dressing Change Frequency | |---|---| | Sutured laceration | Daily for first 48h, then every 2-3 days | | Open wound (packing) | Daily | | Abrasion | Daily until epithelialized | | Burn (with silver sulfadiazine) | Daily | | Hydrocolloid-covered wound | Every 3-5 days or when leaking | | Alginate-covered wound | When saturated (1-3 days) |

Remove sutures or staples on schedule (see Section 5 table). Leaving them too long causes suture marks — permanent scarring along the puncture tracts.

9. Special Wounds

Animal Bites

**Dog bites** account for 80-90% of mammalian bite wounds. Infection rate is approximately 5-15% — lower than cat bites due to the crushing mechanism, which devitalizes tissue but doesn't deeply inoculate bacteria.

**Cat bites** have infection rates of 30-50% (Talan et al., 1999). The sharp, narrow teeth create deep puncture wounds that inoculate Pasteurella multocida into deep tissue. Virtually all cat bites should be treated with prophylactic antibiotics (amoxicillin/clavulanate).

**Human bites** carry the highest infection risk of any mammalian bite. The "fight bite" — laceration over the metacarpophalangeal joint from striking someone's teeth — is notoriously underestimated. These wounds often penetrate the joint capsule and require surgical washout.

**General rules for bites:**

  • Irrigate aggressively — at least 1000 mL
  • Never primary close bite wounds on the hand
  • Facial bite wounds may be closed after thorough irrigation (superior blood supply reduces infection risk)
  • All bite wounds: update tetanus if more than 5 years since last booster

**Rabies protocol.** Consider rabies exposure for any bite from a wild mammal (bat, raccoon, skunk, fox, coyote) or an unvaccinated domestic animal. Bats are the leading cause of rabies deaths in the United States — any bat contact, even without a visible bite, warrants evaluation. Rabies is nearly 100% fatal once symptomatic. Post-exposure prophylaxis (rabies immune globulin + vaccine series) is 100% effective when administered before symptom onset. This is one of the few true medical emergencies that can present as a trivial-seeming wound.

Fishhook Removal

**Advance-and-cut technique.** The most reliable field method. Grasp the shank with pliers. Push the hook forward (following the curve) until the point and barb exit through the skin. Cut the barb off with wire cutters. Back the barbless hook out the way it entered.

**String-yank technique.** Wrap a loop of fishing line or string around the bend of the hook. Press down on the shank with one finger to disengage the barb. With a firm, quick yank parallel to the shank (not upward), pull the hook out. This works best for superficial hooks in fleshy areas.

Clean the wound, irrigate, do not close. Update tetanus status.

Splinter Removal

Superficial splinters visible under the skin surface: nick the skin over the leading end of the splinter with an 18-gauge needle or #11 scalpel blade. Grasp the exposed end with fine-tipped tweezers and pull along the axis of entry.

Deep splinters not visible: if the wound is not infected and the splinter is not causing functional impairment, it can be observed. Many small splinters are extruded by the body's inflammatory response within days. Surgical exploration for a splinter that is not visible, not palpable, and not causing symptoms is rarely productive without imaging guidance.

**Wood splinters are the exception.** Wood is porous and harbors bacteria. Wood splinters that cannot be fully removed require medical evaluation and likely antibiotic coverage.

Blister Management

**Friction blisters.** Intact blisters less than 2 cm can be left alone — the blister fluid contains growth factors that promote healing. Protect with a donut-shaped pad (moleskin with a hole cut over the blister) to offload pressure.

Large blisters or those in weight-bearing locations: drain with a sterile needle at the base (puncture at the lowest point to allow gravity drainage). Leave the blister roof intact. Apply antibiotic ointment and a non-adherent dressing. The blister roof is the best available dressing — do not remove it.

**Blood blisters.** Indicate deeper tissue damage. Do not drain unless they are tense and painful — the blood will be reabsorbed. If you must drain, use strict sterile technique as the deeper injury is more susceptible to infection.

10. Wound Care Kit

A comprehensive field wound care kit for 2-4 people, designed for extended backcountry or remote scenarios.

Irrigation and Cleaning

| Item | Quantity | Purpose | |---|---|---| | 35 mL syringes | 4 | Irrigation (pressure source) | | 18-gauge catheter tips (plastic sheath) | 6 | Irrigation nozzle | | Normal saline (0.9% NaCl), 500 mL bags | 2 | Irrigation fluid | | Povidone-iodine 10% solution, 4 oz | 1 | Dilute for contaminated wounds | | Benzoin tincture swabs | 10 | Skin prep for adhesives | | Fine-tipped forceps (splinter forceps) | 1 | Foreign body removal | | Hemostats (curved Kelly clamps) | 2 | Clamping, grasping |

Closure Supplies

| Item | Quantity | Purpose | |---|---|---| | Wound closure strips (Steri-Strips), 1/4" x 3" | 20 strips | Superficial laceration closure | | Skin stapler (disposable, 15-staple) | 1 | Scalp and trunk wounds | | Staple remover (disposable) | 1 | Staple removal | | Suture kit — 4-0 Ethilon on reverse cutting needle | 4 packets | Extremity skin closure | | Suture kit — 5-0 Ethilon on reverse cutting needle | 2 packets | Hand/face closure | | Suture kit — 3-0 Vicryl on taper needle | 2 packets | Deep layer closure | | Needle holder (5") | 1 | Suturing instrument | | Tissue forceps (Adson with teeth) | 1 | Wound edge handling | | Iris scissors (curved) | 1 | Suture cutting | | Tissue adhesive (Dermabond), single-use | 3 | Small wound closure |

Dressings and Bandaging

| Item | Quantity | Purpose | |---|---|---| | Non-adherent dressing (Telfa), 3"x4" | 20 | Primary wound coverage | | Gauze pads, 4"x4" | 30 | Wound packing, dressing layers | | Gauze roll, 3" | 4 rolls | Wrap dressings | | Elastic bandage (ACE wrap), 3" | 2 rolls | Pressure dressings, joint wraps | | Hydrogel burn dressings, 4"x4" | 4 | Burn first aid | | Hydrocolloid dressings (DuoDERM), 4"x4" | 4 | Extended wear, abrasions | | Alginate dressings, 2"x2" | 4 | Highly exudative wounds | | Medical tape, 1" | 2 rolls | Securing dressings | | Moleskin sheets, 3"x4" | 4 | Blister management | | Adhesive bandages, assorted | 20 | Minor wounds |

Medications and Topicals

| Item | Quantity | Purpose | |---|---|---| | Triple antibiotic ointment, single-use packets | 20 | Wound moisture, minor infection prevention | | Silver sulfadiazine cream, 25g tube | 1 | Burn dressing | | Lidocaine 1% (with epinephrine), 10 mL vial | 2 | Local anesthesia (not for digits/nose/ears/penis) | | Lidocaine 1% (without epinephrine), 10 mL vial | 1 | Local anesthesia for digits | | 25-gauge needles | 6 | Anesthetic injection (initial) | | 18-gauge needles | 4 | Drawing up anesthetic | | 3 mL syringes | 6 | Anesthetic delivery | | Ibuprofen 200mg tablets | 30 | Pain management, anti-inflammatory | | Diphenhydramine 25mg capsules | 12 | Allergic reaction, mild sedation |

Tools and Miscellaneous

| Item | Quantity | Purpose | |---|---|---| | Nitrile gloves (non-latex) | 10 pairs | Barrier protection | | SAM splint (36") | 1 | Fracture/sprain stabilization | | Tourniquet (CAT or SOFT-T) | 1 | Extremity hemorrhage control | | Trauma shears | 1 | Cutting clothing, dressings | | Headlamp | 1 | Wound examination lighting | | Skin marking pen | 1 | Marking erythema borders | | Waterproof kit bag | 1 | Storage | | Wound care reference card (laminated) | 1 | Quick reference |

11. Sources

1. Auerbach, P.S. (Ed.). *Wilderness Medicine* (7th ed.). Elsevier, 2017. 2. American College of Surgeons. *Advanced Trauma Life Support* (10th ed.). ACS, 2018. 3. Wilderness Medical Associates International. *Wilderness First Responder Curriculum*. WMAI, 2022. 4. Fernandez, R., & Griffiths, R. "Water for wound cleansing." *Cochrane Database of Systematic Reviews*, 2012. 5. Quinn, J.V., et al. "Traumatic lacerations: What are the risks for infection and has the golden period of laceration care disappeared?" *Emergency Medicine Journal*, 19(4), 2002. 6. Singer, A.J., et al. "Comparison of wound closure strips and tissue adhesive for laceration repair." *Academic Emergency Medicine*, 9(1), 2002. 7. Hollander, J.E., & Singer, A.J. "Laceration management." *Annals of Emergency Medicine*, 34(3), 1999. 8. Stevenson, T.R., et al. "Cleansing the traumatic wound by high pressure syringe irrigation." *JACEP*, 5(1), 1976. 9. Kanegaye, J.T., et al. "Comparison of skin stapling devices and standard sutures for pediatric scalp lacerations." *Pediatrics*, 108(6), 2006. 10. Talan, D.A., et al. "Bacteriologic analysis of infected dog and cat bites." *New England Journal of Medicine*, 340(2), 1999. 11. Cuttle, L., et al. "The optimal duration and delay of first aid treatment for deep partial thickness burn injuries." *Burns*, 36(5), 2010. 12. Winter, G.D. "Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig." *Nature*, 193, 1962.

*This document is an educational reference for practical skills development. It is not medical advice and does not substitute for professional medical training, clinical judgment, or emergency medical services. Wound care skills should be practiced under qualified supervision before being applied in field settings. When professional medical care is accessible, use it.*

`[practical-skills]` `[advanced]`