Gordon, thanks for clarifying. Anyway, I think you've hit on the most important aspect of wound management! Flushing it with water. Never heard of cleaning a wound with Purell -- sounds icky and very irritating -- perfume and stuff. Ointments tend to create a bit of a seal between the wound and the outside world so you may end up sealing "germs" in.

Edited by backpackerchick on 10/05/2009 17:31:47 MDT.

"Mupuricon (trade name Bactroban) is probably a better choice than "triple ointment". Broader coverage and more potent."

Spot on. It's the same stuff they prescribe for applying in your nasal passages to kill off MRSA. It's a highly effective antibiotic. It's what I carry in my 1st aid kit.
Only downsides are the weight: ~ 1 oz. and the fact that it requires a prescription.

I had an assignment at a NZ hospital and had to do the MRSA swabs. Was negative. Many people were hoping they were carriers as they would get something like 6 weeks off with pay -- and they aren't even sick! I think testing for MRSA carriage has gone out of vogue. I think about 20% of us are carriers. Sorry off topic but it's an off-topic kind of day.

BTW, the last place you want to find out about neomycin sensitivity is the nose. Years ago, pre-bactroban, had an ENT prescribed neomycin for use in my nose. Really irritating -- sinuses, crying.

If you're traveling abroad, can often pick this stuff up -- "pharmacist's discretion" exists in a lot of countries. This also goes for tinidazole, levofloxicin, cipro, analgesics (tend to be stricter here!) and other drugs one tends to carry.

If you have any reason to visit an MD or other provider, always enquire about sample tubes of bactroban, steroid creams, etc. regardless of what brought you in! Also, mini sample inhalers if this is something you carry! These little tubes are precious! A regular size tube of bactroban would last me a decade probably if the tube didn't fall apart. A little goes along way. The problem with the sachet packets is that they have about a week's worth of ointment (for a small laceration) and there's not really a good way to close them.

Saw a comment about the benadryl wafers -- these are amazing -- use them SL (under tongue) for faster action. Get hives running sometimes -- from vibration I think -- can keep these in pocket. Packaging would probably go through washer and dryer.

Edited by backpackerchick on 10/06/2009 06:39:22 MDT.

> Nothing like getting a crazy little skin tear ten feet from your front door on
> the way to the car and ending up with an IV in your arm.

Everyone seems to have missed a vital clue here. This infection did NOT happen in the backcountry: it happened in suburbia. It is very likely that the source of the infection was urban dog-poo or something similar.

I would wager that most of the infections people talk about come from an urban environment (and very often from dogs), not from a wilderness area. I've treated quite significant wounds in the mountains with no trouble (and no antibiotics) at all.

Cheers

Americans have grown up with the idea of applying antibiotic ointment to their boo-boos. We have TV commercials telling us that this makes our boo boos heal faster. We have "band aids" containing such ointment. Several antibiotic ointments are available in US grocery stores. Did my MBBS at Sydney and don't remember such an obsession among the public there. Last time I checked, I don't think such antibiotic ointments were available without a doctor's prescription in Australia. Don't think there is much evidence to support the use of topical antibiotics in the absence of infection -- no solid evidence that they prevent infection. The real danger may be a perception that such ointments negate the need to adequately clean and care for the wound. If the wound is not clean, the ointment may seal in "germs". Personally, I use bactroban on my boo boos. Placebo effect can be powerful!

Don't really understand the point about infection being acquired in an urban area vs. the backcountry. Most often the culprit is normal skin flora anyway. Once an infxn has manifest, I would think you'd be more interested in treating it than in where you acquired it.

Edited by backpackerchick on 10/06/2009 06:43:26 MDT.

A few years back I was on a 3 day trip and was bitten on my shin at the top of my hiking boot (assumed mosquito). My boot top rubbed the bite and it became infected in a single day. By the time I got out from the trip my ankle was very swollen and the infection around the bite was as big as my open hand. The infection spread incredibly fast and if I had been on a week long trip I would have been in serious trouble.

I now carry prescription antibiotics (Moxifloxacin HCL) as well as triple antibiotic ointment. The antibiotics weigh only .3 of an oz., so not a heavy insurance policy.

Moxifloxacin and the other late generation fluoroquinolones are great antibiotics to have around. Keep a course in my pack. Taken once a day orally, they quickly reach high levels in the body. They have very broad coverage of bacteria affecting the respiratory tract (even the atypical pneumonias and anthrax), GI tract and GU system (chlamydia and gonorrhea as well as the most common causes of UTIs). They do however have an FDA black box WARNING in regard to tendon rupture. Most reported cases have involved the Achilles.

"I would wager that most of the infections people talk about come from an urban environment (and very often from dogs), not from a wilderness area. I've treated quite significant wounds in the mountains with no trouble (and no antibiotics) at all."

Well, good for you - and you missed another point, probably because I didn't state it clearly enough, that I have had years of little scrapes and cuts that did not get infected and did not get antibiotics, both in and out of the wilderness... this was a one time thing out of hundreds of other silly little abrasions. And one time in the wilderness is probably one time I cannot afford, if we're talking about walking 20-50 miles with an infection crawling up my leg/arm. In frontcountry, I'm more likely to take chances - the consequences are less severe.

Remote as the possibility is, dumb stuff happens.

Fairly standard medical advice and some good explanations for the layperson:

http://www.backpackinglight.com/cgi-bin/backpackinglight/forums/thread_display.html?forum_thread_id=11475

BTW, what is this stuff about dogs? Pets? Wild dogs? Never heard dogs implicated in this context. We do exchange skin flora --staph in particular -- with our pets and with each other -- not that big a deal.

It's when our defenses are breached -- in this case our skin is cut that the microbes can more easily overcome our immune defenses. Which is the whole point of irrigating the heck out of wound if possible and if you so desire applying an antibiotic ointment.

Edited by backpackerchick on 10/06/2009 09:20:13 MDT.

Hartley, that's a good post by Patrick you linked to. Roger is australian, land of nappy rash, so who knows what goes on over there...kidding Roger.

Patrick's writeup is helpful. Thanks Hartley.

A couple questions..

(1) Patrick uses the terms "close the wound" and "open wound" without defining them. What is the precise definition of these terms?

(2) What is a good weight to shoot for a 20 cc syringe that one could include in a first aid kit?

I figured I'd ask in this thread, since the thread with Patrick's writeup has only one response since '08.

Edited by northwesterner on 10/06/2009 11:00:20 MDT.

No offense folks, but I think carrying syringes is getting a bit overkill for a basic backpacking first aid kit. We're not going out and fighting VC in the jungle...

If it's a bad enough wound that it can't be cleaned well enough by pouring water on it and washing then I it might be time to get evacuated for real medical care anyway.

I have a hard time imagining cutting myself on anything on a backpacking trip that is filthy enough to cause some sort of rapid and serious infection.

I think irrigation is key. If you are near a waterfall great you can stick your wound under, great. Or if you can pour water in the wound and rub it with a clean finger, great. But cleaning the wound is key. And a small syringe is very helpful for that.

Hike your own hike, but I would rather have a properly cleaned cut and use a old t-shirt for a bandage then not irrigate the wound and use a sterile bandage.

Just my two cents.

I think the post is sound advice. Again, not an MD, but my first aid training and other experience seem to concur. The main points:

1) Get the bad stuff out. That means scrubbing and flushing. I remember some advice for dealing with road rash from biking where they suggest getting a clean brush and scrubbing the scrape with it. Yes, it will hurt but will hopefully get the germs/dirt/rocks out. Also, it's less an issue of how much bacteria are present on the granite rocks at altitude that you fall on (probably very few since it's UV exposed), it's the bacteria on YOUR SKIN that's at issue. It's what you brought with you.

2) Keep the remaining bad stuff from growing. If it's a surface scrape or cut, then antibiotic ointment might help prevent infection. Deep wounds are harder to deal with, irrigation with dilute iodine, as suggested in the article, may help if you have it. Alcohol and peroxide will damage tissue. Closing the wound means holding the skin together so there's no gaping hole and sealing it up from air. This can turn bad if some anaerobic (non-oxygen) bacteria start to grow inside and make pus. Then you have to open the skin and clean it out again.

3) Keep more bad stuff from getting in. Closing the wound does this, but can lead to infection. Certainly covering the wound with something clean would help.

So does everybody else who it happens to. A NOLS instructor in a podcast said an irrigation syringe was in her top five things in a first aid kit.

Craig said,
"I have a hard time imagining cutting myself on anything on a backpacking trip that is filthy enough to cause some sort of rapid and serious infection."

Edited by jshann on 10/06/2009 14:05:36 MDT.

If you are in the backcounrty and need to irrigate a wound but didn't bring your syringe (or like me you just don't carry one)here is a good substitute. Rinse out a zip-lock baggie and fill with clean water. Snip the corner or poke a pin-hole and squeeze!

I know about nappy rash too. LOL

Best to defer the question to Patrick though I will give a general answer. I believe closing a wound in this context implies "surgical closure" of some sort -- sutures, steristrips, butterfly adhesives, "glues" etc. Leaving the wound open would be NOT closing it -- basically cleaning it out best you can and just leaving it open (perhaps with some packing -- the cleaner the better -- and pressure to stop bleeding) until it can be properly addressed. Off hand, here are a couple considerations -- nature and extent of the wound, dirtiness of the wound, the care available at the scene (is the ER doc there with his full kit?), the time it will take to receive more formal medical care. Generally, dirty wounds are best not closed until they are well-irrigated and assessed. Bites and punctures would probably almost never be closed on the scene. They also require specific antibiotic treatment depending on the animal or in the case of a puncture -- what it was and did it go through a sneaker (nasty pseudomonas lives in the "rubber" sole). If you must close a dirty wound, you want to open it back up in controlled settings as soon as possible, REALLY irrigate it and take any further action that might be necessary at that point. Just a couple examples. It's much more complex than this. Bet Patrick would be keen to take this on! Would be interested in what he has to say! And of course, his kit!

Did a winter hike in Tasmania -- met up with an Ozzie ICU specialist who brought next to nothing in terms of a medical kit -- Tegaderm for blisters and some Panadol maybe. Note: he had 50+ lbs and lots of camera equipment so I doubt he was attempting to save weight. He had some nasty stuff going on in terms of blisters but refused any of my quality blister supplies out of pride, I suppose. Admired my collection but refused to take any. We only had 2 days left, and I had a week's worth -- I had needed none. I left them out that night -- hope he snuck some. After all, he spent about 3 hours building a fire from wet wood and fuel blocks so we could attempt to dry stuff while I curled up in my bag with a Nalgene bottle of hot water. He was with another bloke and I think he was keen to show off his fire making skills -- lined up all the materials like he was doing a medical procedure and then proceeded in a very orderly fashion. Works for me!

Edited by backpackerchick on 10/06/2009 14:22:20 MDT.

Here is a 12 cc irrigation syringe at the NOLS web site that weighs approximately 4.8 ounces:

http://www.nols.edu/store/product.php?productid=16249&cat=0&bestseller

I was hoping for something closer to one ounce.

Here is a 10cc one that weighs 1.7 ounces:

http://www.exploroz.com/Shop/FirstAid/Equip/Curved_Irrigation_Syringe_10ml.aspx

(I have no idea about the reliability of those web sites.)

http://www.amazon.com/20-Disposable-Syringe-without-Needle/dp/B0002YFRA2

You can irrigate with a platypus and hose, under a waterfall. Glad this came up. Never bothered to carry a syringe -- would also come in handy for flushing the eye, I would think -- low pressure please. Bigger one might be better -- more serious irrigation -- I'll check the weight differences. Joined here to become obsessive! LOL