Wound care is not the most glamorous of subjects but might come in handy down the road. We are not going to discuss the care we can provide in the here and now, which can be quite advanced as well as incredibly costly, but what we can do in a pinch if needed with stuff we have hanging around. This first part is the basic science of wound healing in a nutshell. It might glaze your eyes over but bear with it since it is always good to know what is actually happening in order to fix it.
It goes without saying that in order to talk about wound healing you first need a wound. Whether it is large or small the general process is the same and there are four phases: hemostasis, inflammatory, proliferative and remodeling.
If your body cannot stop the bleeding the outcome will not be good. Hemostasis (blood clotting) occurs in a couple of phases, which we will simplify. As an injury to a vessel occurs the vessel will constrict to stop the flow. The injury to the cells of the vessel wall will cause your platelets to activate which in itself has its own process. The platelets get sticky and try to stick to one another and to the injured cells, which causes a plug to form to try to stem the bleeding. This is primary hemostasis. Drugs such as aspirin, ibuprofen, and clopidigril (Plavix) inhibit primary hemostasis in a variety of ways. There effect on hemostasis is why people with heart disease, coronary and vascular stent placement, strokes, et cetera take these drugs. The science behind aspirin in relation to prevention of heart disease is undergoing some changes with newer long-term data, which does not show the benefit that was once thought.
This is probably a good time to mention that real science has real studies that take time to run. Data from long-term studies sometimes corroborates the early work, sometimes not. These studies can reveal new issues, unintended complications and maybe other benefits not previously known. The “science” and “data” over the past few years has at times been pretty shoddy. I think that is a polite way of describing the damage done. Enough of the soapbox. Let’s get back to hemostasis.
While the platelets are getting all sticky they change their shape and release their stored granules which contain fibrin which acts as a sort of scaffolding for more platelets and blood cells to attach to. It is like a dam for a blood vessel. This works really well in small vessels but larger vessels need more than a bunch of platelets sticking together. That is where secondary hemostasis comes in. The stuff that the platelet releases starts a process which strengthens the plug. This process is pretty complex and interrelated with dual pathways converging on a common pathway, which will provide a stable clot. A substance called thrombin helps stabilize the plug/clot and in conjunction with fibrin fixes the clot making it more solid. Each step in these pathways is a chemical reaction which can be interrupted or promoted to control the process. The study of these pathways has led to multiple medications to control the rate of blood coagulation to prevent clotting (Warfarin, Xeralto, Eliquis) and also promote clotting. Take a look at Quick Clot site and you can get a brief introduction to one of the clotting cascade pathways. Celox works in a different fashion which is not related to the clotting cascade.
After the bleeding has stopped we will soon enter the next phase, which is the inflammatory phase. As everyone can attest to, about a day after we get a cut the wound starts to get red, swollen, hot and painful. The reason for this is that during the prior phase (hemostasis) something a little more profound was going on. While the vessel is busy creating a dam, the injured cells and the hemostatic process sends chemical signals calling for the clean-up crew to come to the site. These signals tell the body to deposit neutrophils, monocytes, and macrophages, which perform the cleanup of dead tissue, kill bacteria and remove foreign material. These inflammatory cells also secrete cytokines and growth factors which cause the symptoms that you typically experience. Once again, medications that you take for inflammatory conditions can prevent the release or blunt the body’s response to decrease the symptoms that you feel.
Just like with the transition from hemostasis to inflammation, the signals from the prior phase promote the advancement to the next stage. The third phase of healing is the proliferative phase and the macrophage is the key cell during this period. In addition to the role of the macrophage in cleaning the wound and killing bacteria, it also signals the migration of fibroblasts to the injury site. The fibroblast will start laying down collagen and what is called the extracellular matrix to repair the injured site. Collagen is the support structure and the matrix is all the goop that is between that support structure and the cells. Also during this time a process called angiogenisis occurs, once again due to the cytokine release described previously. Angiogenisis is simply the creation of new blood vessels. Poor blood flow, poor healing.
The last phase is called remodeling which typically occurs over a few months. The scar which was formed during the proliferative phase and was initially large, raised and red will slowly flatten out and turn white and becomes less noticeable. There is a whole lot going on during this phase but the wound has already healed and we are not going to be worried about this phase for our present purposes. This link provides the basic nuts and bolts of the process if you want to do some heavy reading. It will give you an idea how amazingly complex our bodies are.
Why the brief overview on the basic science of wound healing? It is good to know what is going on so that if things are not going right we can figure out where we are in the process and why we are having problems. It is kind of hard to fix the engine if you do not know how it works. We can now move on to the heart of the discussion. How can we treat wounds when there is no medical care around? When I state around I mean like no doctor period, no one coming, ever.
Disclaimer time. If you have a nasty wound, infection, lump, bump or abscess you should go to the doctor and have them check it out. Even though we are going to discuss ways to treat wounds to help them heal do not misconstrue that this is a substitute for care you can receive in the here and now.
We are going to discuss ways to treat wounds with some simple procedures and dressings that can make a world of difference.
Let’s start with something quite common, the ubiquitous sebaceous cyst. A significant number of people will develop one of these in their lifetime. Known as a boil, pimple, or rising, these pesky ailments can become quite serious. We all have sebaceous glands and at times they will clog and start to grow. People have been squeezing them forever and they are represented by the white, cheesy, smelly stuff that comes out called sebum. Most people who have one of these describe that it has been small for years and for some reason the cyst will start to grow dramatically. That reason is typically an infection, which can be slow to progress or quite rapid. Sometimes they will come to a head and rupture, typically with the help of warm compresses (good idea-warm the area, increase blood flow, better healing). The bigger problem is if it does not come to a head and drain spontaneously, the infected cyst will break down its wall and the infection can spread beneath the skin through the subcutaneous tissue and even into the muscle. This can also occur if someone squeezes a cyst and it does not externally rupture. Now we have an abscess with subcutaneous spread and in this is something that needs to be addressed.
The key is opening the wound early to facilitate drainage. Clean the area first. Soap and water or just water is fine. Isopropyl alcohol is easy to purchase in the here and now and can be stored quite easily and can be used to clean the skin after you have washed the grime off. If you do not have a sterile scalpel blade or knife use the alcohol to create one. If you have lidocaine in your medical kits you might want to inject some. If not the next part is going to hurt to say the least.
Find the soft area under the skin and cut an ellipse of skin away exposing the abscess cavity. Not just a slice to drain the abscess but create a hole so the cavity is unroofed. If there is no soft spot you will need to cut down until you reach the abscess. You need to create a large enough defect in the skin to allow easy access to the cavity to wash it out and let it drain. Sebaceous cysts do have a wall which will need to be removed or chemically destroyed. If the wall is left intact the recurrence rates are quite high. You can typically see the wall of the cavity which looks different than the surrounding fat. If possible it would be beneficial to remove the wall by cutting it out. You may have some bleeding, which typically can be controlled with pressure and packing of the wound until hemostasis has been achieved. From here on out we hope that the body can do what it does so well. We have facilitated drainage and now need to keep the wound open, clean and free of dead tissue.
The easiest way is with Q-tips and peroxide. Dip the q-tip in the peroxide and generously scrub the wound twice a day. It would be best to place a piece of gauze into the wound to absorb any drainage and typically this piece of gauze will dry out in the wound and when you pull it out any necrotic tissue will come with it. Repeated applications of peroxide does do a decent job of clearing the bacteria. At first the wound will look quite bloody and have some necrotic tissue. After about 4-5 days the wound will typically become what I call soupy. The wound will start to drain a lot and will have a grayish red, filmy color. If the gauze gets too wet, change it out more frequently. Typically the q-tip and peroxide can continue during this time. This will last 3-5 days and then the wound will become beefy red in appearance and gauze changes can be decreased and the q-tip washings can stop. The packing of the wound needs to continue due to the fact that skin has the tendency to contract and close faster than the hole will fill in. We want the hole to fill in prior to the skin closing so that we do not create another abscess. We have taken our wound from hemostasis (initial opening of wound), inflammatory (serial debridement with q tip and gauze which also controls infection) to proliferative (beefy red appearance). Notice that we have not given any oral antibiotics because we may not have them. I can address that in a separate article. If these abscesses are caught early, you likely will not need them.
This same process of incision and debridement can be applied to any abscess or any open wound. Some subcutaneous abscesses are not sebaceous in origin. People frequently get insect bites which are infected from the get-go and some get infected when people scratch them. Your fingernails carry some nasty bugs. Let’s talk a little about spider bites. Brown recluse is a nasty bug and secretes a toxin in the skin which causes necrosis. The typical wound will be a raised red painful bump with a white part in the center. If approached early and the white part is excised at this point, the necrosis typically will be less extensive. The longer you wait the larger the area of necrosis and the resulting larger wound. After excision, the treatment is as above.
The wound from an insect bite that occurs after scratching is slightly different. The primary reason for the inflammation is the introduction of bacteria into the skin instead of a toxin of destroying the tissue. In the present day, a short course of antibiotics would likely take care of it. If no antibiotics are available warm soaks (blood flow), topicals such soap and water, alcohol wipes, bacitracin/neomycin may help. If there is any progression which typically appears as enlargement of the swollen area (edema), increased redness (erythema), and worsening pain it is time to open the wound to allow drainage. Again, taking an ellipse of skin is better than a simple cut since it will allow better drainage, allow access for your q tip and peroxide and allow a bit of packing to allow drainage to continue and prevent the skin from closing too soon.
(To be concluded tomorrow, in Part 2.)