Wound Care and Improvised Saline Solutions

This is some random information that I stashed during an internet search.


 Use of massive saline lavage - in short, you keep the wound
clean using lots of normal saline solution - this doesn't kill
bacteria, it just keeps the bacteria count down at a level where
the body can handle it; normal saline made from clean, ideally
distilled, water and salt (NaCl) would probably be a produceable


To add to your irrigation information, all the current sources,
including Dr. Eric Weiss (one of the 5 or 6 MD's involved in
wilderness medicine education) city tap water may prove more
effective in wound irrigation than even sterile saline.

In any event, as a rule, any water clean enough to drink is clean
enough to use for wound irrigation.


 For simple irrigations, I would go along with the idea that
purified tap water is probably at least as good as good as
sterile saline (among other things, the residual chemicals in the
tap water can kill bacteria that are not dislodged).

I would also agree that water pure enough for drinking is useful
for irrigation in survival situations (watch out for iodine
sensitivities if you are using iodine-purified water, of course).

My reason for suggesting normal saline was that I was thinking in
terms of repeated or continuous lavage of a large wound, in which
case I feel you want to use saline or better isotonic solutions
in order to avoid causing too many imbalances.

(I am including surgical wounds here as well as injury wounds;
consider surgeries under austere conditions where you may need to
do a delayed closure but also need to insure that the wound wound
does not dry - the normal practice of placing a drain may even be
inappropriate in the austere environment due to the possible
increase in the frequency and magnitude of infections).

Since I very cleverly kept this thinking to myself, my post was
unclear. Certainly, when using pressurized irrigation (probably
using a syringe under austere conditions) as part of the initial
cleaning/debridement of the wound, saline is optional.

                    Although not a pharmaceutical in the traditional
                    sense, potable water (disinfected with chlorine
                    or iodine tablets, or filtered) is the best way
                    to disinfect/clean a wound that extends below the
                    dermis. While sterile water intended for irrigation
                    is preferable, clean, disinfected water is preferable
                    to dirt, bugs, and leaves in a deep wound. Betadine
                    solution should not be used to irrigate a deep
                    wound in the field in the vast majority of cases.




CARE OF WOUNDS: This is mainly for non-surgeons who might be reading this monograph, but surgeons may also find some benefit from it, as it pertains to "non-clean" conditions in particular.

The important thing to remember in primitive settings is that wounds sustained in such a setting are usually very dirty. The environment is dirty. Sanitation and personal cleanliness may be poor. The article causing the wound is usually very dirty. Initial wound care at the site of the incident causing the wound may have introduced even more contamination into the wound-such as manure, leaves, urine, caustic chemicals, and various unknowns.

A good policy is to consider practically all wounds dirty and debride them carefully. "Debridement" really means "excision" of the wound, as much as is possible without harming important structures. This must be done under good lighting and must be meticulous, with copious irrigation with normal saline. Gentle scrubbing with a surgical brush may help dislodge sand and small bits of rock. Soap can be used (mild soap), but must be rinsed out thoroughly. When all contaminated or devitalized tissue possible has been excised, the decision must be made whether to close the wound, or to leave it open. If there is ANY doubt as to the cleanliness of the wound, or of the viability of the remaining tissues, the best course is to pack the wound open with saline-soaked gauze, and bring the patient back to the operating room in a few days for secondary debridement. This may have to be done several times before the wound can be considered clean enough to close.

One must also remember that there will be swelling of the tissues around the wound. Any closure will become tighter, due to this swelling, and circulation to the skin may be further compromised. This is particularly true in the lower leg. Closure may be possible after this swelling has run its course, with salvage of much more skin than if primary closure had been attempted.

Wounds that are left open and allowed to heal by secondary intention do surprisingly well. We saw this well illustrated in patients who came in with multiple machette cuts, some of which went very deep into muscles. After debriding these as much as possible, they were left open and allowed to heal by secondary intention, avoiding any risk that might accompany attempts to close them. In most cases these healed with no greater scarring than might have been expected if they had been closed primarily.

Wounds over joints deserve special mention and discussion. A wound that penetrates a joint is a special situation, because the wound may have introduced foreign matter or infected material into the joint. Untreated, this may result in septic arthritis and possible loss of the joint cartilage. If there is any doubt as to whether or not the joint has been penetrated, it is better to open it through a separate incision, and do a thorough inspection and lavage. If there has been penetration, after the lavage it is best to close the joint wound with a small Penrose drain that should remain for several days. Do not instill antibiotics directly into the joint, as they are very irritating to the synovial tissues.

In the case of a wound that exposes a joint, every effort should be made to close the synovium and not leave the joint open. Again, leave a small drain for a few days. You may have to transpose a bit of muscle or other soft tissue to provide closure of the joint. This same principle is true in regard to major vessels, nerves and tendons--if left open they will dry out and become necrotic. Try to cover them with something.

Many years ago, while in general practice, I used to use a poultice paste called "Osmopak". It was magnesium sulfate paste, with brilliant green dye. This was a powerful poultice. In Bangladesh we decided to use a saturated solution of magnesium sulfate for our wet dressings, to provide a "poultice-like" effect, as well as stimulating granulation tissue formation. The main drawback is that it stings a lot when applied, but it has been very effective in helping soupy wounds to clean up. In my hands it works much better than normal saline. We changed the wet dressings every eight hours (once per shift), and put them on "sloppy wet".

Gentian violet has been a good friend in wound care. It is bacteriostatic, is a good stimulant of granulation tissue growth, and also is an epithelial cell growth stimulant. It also provides some psychological benefit, in that the patient can definitely see that you have applied some medicine (much better than a colorless solution).

Granulation tissue formation can also be stimulated by application of granulated sugar in the wound. This is very effective in bed sores. It was my routine practice to apply a triple antibiotic ointment to the suture line whenever I closed an incision, even in clean cases. This may be "empirical", but I very seldom saw any suture abscesses. Hydrogen peroxide can be used at the time of dressing changes, or at pin sites, but should not be applied to open wounds as it is too harsh for the tissues.


In making your own saline, can you use ordinary table salt, or do you have to find pickling/canning salt or kosher salt? There was an article a few years back which said that table salt was fine, but many otolaryngologists are concerned about the extra chemicals in table salt. Since a box of pickling/canning salt will cost you under $2 and last for months to years, why take a chance?


The Recipe:

Choose a one-quart glass jar and clean it thoroughly.

Fill it with tap water or bottled water. You do not need to boil the water.

Add two to three heaping teaspoons of pickling/canning salt (available at Meijer's) or kosher salt. Do not use table salt, which contains many additives.

Add 1 teaspoon Arm & Hammer baking soda.