Wound Assessment in the Field
Wounds are among the most visible injuries EMS providers encounter, ranging from minor abrasions to life-threatening hemorrhage. Proper wound assessment begins with identifying the type of wound, estimating blood loss, evaluating for associated injuries, and determining the appropriate level of care. The primary goal of prehospital wound management is controlling bleeding and preventing contamination, not definitive wound closure.
Common wound types include abrasions (superficial scraping injuries), lacerations (irregular cuts from tearing forces), incisions (clean cuts from sharp objects), puncture wounds (deep, narrow wounds with small surface openings), avulsions (tissue torn from the body, either partially or completely), and amputations (complete separation of a body part). Each type carries different risks: puncture wounds have high infection risk due to depth, lacerations may involve underlying structures, and avulsions often have significant bleeding.
Bleeding Control
The systematic approach to hemorrhage control follows a stepwise escalation:
- Direct pressure: Apply firm, constant pressure to the wound with a sterile dressing. This is effective for the majority of bleeding. Do not lift the dressing to check if bleeding has stopped, as this disrupts clot formation. If the dressing becomes saturated, add additional dressings on top.
- Wound packing: For deep wounds where direct pressure is ineffective, pack the wound with gauze (hemostatic gauze if available) and apply pressure. This is particularly effective for junctional wounds (groin, axilla, neck).
- Tourniquet application: For life-threatening extremity hemorrhage that cannot be controlled with direct pressure, apply a commercial tourniquet 2 to 3 inches above the wound. Note and communicate the time of application. Modern evidence supports early tourniquet use for severe extremity bleeding; do not delay application while attempting other methods if hemorrhage is clearly life-threatening.
Bandaging Principles
Proper bandaging serves multiple purposes: maintaining pressure on the wound, protecting from further contamination, immobilizing the injured area, and absorbing drainage. Apply bandages snugly but not so tightly that they compromise distal circulation. Check pulses, sensation, and movement (CSM) distal to the bandage before and after application.
Common bandaging techniques include the spiral wrap (for cylindrical body parts like arms and legs), the figure-eight wrap (for joints like ankles and wrists), and the pressure dressing (for wounds requiring sustained compression). Secure bandages with tape, clips, or by tying the tails of the bandage, and avoid circumferential taping that could act as a tourniquet if swelling develops.
Special Wound Considerations
Certain wounds require specific management. Impaled objects should be stabilized in place and not removed (removal may worsen bleeding). Amputated parts should be wrapped in moist sterile gauze, placed in a plastic bag, and kept cool but not placed directly on ice. Open chest wounds should be covered with an occlusive dressing, sealed on three sides to create a flutter valve (or use a commercial chest seal). Abdominal evisceration should be covered with a moist sterile dressing and an occlusive covering; do not attempt to push organs back into the abdominal cavity.