Discussion the use of Prehospital Antibiotics.

[tniuqs]

So next Question: What would be the best "anti bacterial agent" to use in this scenario?

The choices I had would have been:

1- Betadine.

2- Green soap from the dark ages of time.

3- H Peroxide...now don't get medieval on me I would NOT have used that.

4- Normal Saline, with a 20 cc syringe, and a sharp to pressure flush the one degloving wound.

ps The bite through the hamstring was bleeding (venous) after 2.5 hours so a Mark 3 battle dressing was implemented.

What is used in your "hood" for wound cleaning care ?

[Ridryder 911]

So next Question: What would be the best "anti bacterial agent" to use in this scenario?

The choices I had would have been:

1- Betadine.

2- Green soap from the dark ages of time.

3- H Peroxide...now don't get medieval on me I would NOT have used that.

4- Normal Saline, with a 20 cc syringe, and a sharp to pressure flush the one degloving wound.

ps The bite through the hamstring was bleeding (venous) after 2.5 hours so a Mark 3 battle dressing was implemented.

What is used in your "hood" for wound cleaning care ?

1. No ?

2. Phisohex or Phisoderm ? No

3. H202-Definitely not !

4. Maybe .. probably no, unless you have copious amount.

Sorry, wound care is a difficult topic. Even though I was once certified in such, there is so many new changes and endless microbacterial cleansing agents out there that is much superior these days. So many feel initial debridement and cleansing is essential, but should be done thoroughly.

Betadine has been the old school, but many feel it can provide a medium for bacteria development as well so many are now have allergies to it. It is still used and maybe better than nothing. Phiso-soap, have not seen often in ER's, maybe OR (Spock can answer that better) H202- chemical debridement of the skin and tissues.. looks neat when it bubbles, but that is all. Saline..good, but a good thorough irrigation with a pressure device such as a syringe, ear bulb syringe, or some may have pulsating pressure washers designed for irrigation. Again, some feel if not performed properly, one can actually force more bacteria into spaces, and scatter debris if not cleansed well.

This is a WOCN (wound care nurses specialty) .. I would suggest to discuss this with regional skin care nurses and surgeons that will be receiving those type of patients what they might prefer or want (if anything). I would believe the surgeon discussing it with your local GP would be more effective and probably yield higher results.

Good luck !

R/r 911

[tniuqs]

Ridryder 911

I would believe the surgeon discussing it with your local GP would be more effective and probably yield higher results.

Good luck !

I do appreciate the advice a diplomatic "Punting" out of the end zone is a the best idea so far, I don't want to reinvent the wheel or become a speed bump either.

cheers

[chbare]

Spock, thank you for the correction. I had 10% in my head, and this was obviously incorrect.

Tniuqs, what kind of critter bites are most commonly encountered? For example, cat bites are more prone to infection with the microbe Pasteurella multocida. (Early wound infection that is) Cats will inflict more puncture wounds while dogs inflict crush and laceration type wounds. So, you can appreciate the difference from animal to animal. As I recall cat bites are more prone to infection, and I bet this is related to the puncture mechanism.

Wound care is a pretty heated topic. Agents such as hydrogen peroxide and iodine based solutions have antimicrobial activity; however, I have seen many docs quit using these agents because they are toxic to healthy tissue and may cause delayed healing. I think most people could agree that aggressive irrigation of a contaminated wound with sterile saline would be helpful. Forced irrigation with copious amounts of saline wound help remove gross contamination. I have seen people use mild soap and hibicleanse solutions as well.

For superficial abrasions and road rash like wounds, I have used a mild solution of soapy water and a hand brush to cleanse gross contamination. (I use the same type of brush that surgeons utilize for hand washing) Following the scrub, I will aggressively irrigate with saline and then assess the wound for devitalized tissue and additional foreign body contamination.

Deep puncture wounds and abdominal wounds that could involve communication with internal structures really need surgical evaluation. Puncture wounds like the one you described could receive aggressive irrigation and the application of a sterile dressing. Of course this is all secondary to hemostasis. In addition, the equipment required and time required would also be a factor. I would also argue that attempting to provide involved wound care in a helicopter enroute to definitive care may have limited benefits versus the hassle of additional resources and access problems while on the helo.

Try to find a wound care specialist or certified wound care nurse for additional information. This is really a specialized area of medicine.

Take care,

chbare.

EDIT: I just saw Ridryder911's post and agree that having the surgeon involved may lead to better results.

[tniuqs]

Hmmm, did I forget to mention a Grizzly Bear? there not true hibernaters..... and news to me.

We are seeing more cougar attacks too as man infinges on the remote areas.

Personally I look for the cougars in the bars...you know, the ones that have a cell phone number.

te he.

[kevkei]

Wow, great discussion! It amazes me that stuff like this can be debated professionally and eloquently. Would your perspective be to trying to limit it to one or two agents to maximize as much of a broad spectrum as possible?

Have you looked at what the evidence suggests from a research perspective? It sounds like a big part of this is the significant delay to primary care, which for the most part is not common so I doubt there is much from an evidence based perspective.

Now to be a troll,

tniuqs, we carry Polysporin, if you would like I can grab you some from Pyxis.

[chbare]

Still a difficult discussion. I have posted a link to a report from the Committee Tactical Combat Casualty Care. While this does not equate to civilian medicine, some of the situations may have similarities to the situation at hand. The discussion regarding ABO therapy starts on page 14. In addition, this information is a few years old and the world of medications is ever changing.

What are the surgeon's thoughts on this subject?

http://phtls.org/datafiles/military5th2003sept04.pdf

Take care,

chbare.

[tniuqs]

Dear Troll:

Please deliver one gallon of Poly and does Pyxis have Ancef and Rocephin too?

I won't tell anyone where I got it...really, really.

There is beers and wings in it for you!

chbare...... thanks for the link.

[Spock]

I'm not up on wound care so I can't help much. We do use betadine to clean the site prior to surgery. The scrub is now something called triseptin (SP?). It is waterless and does not require a brush. The old scrub brush with phisohex prove to increase the contamination risk because of the abrasive effect on the skin. Triseptin is a liquid which is applied and rubbed in until dry. I think it is mostly alcohol because it burns like hell.

We irrigate wounds with saline which sometimes has ancef added to it. A pulse lavage is used which applies the saline under pressure and 2-3 liters is usually used.

Live long and prosper.

Spock

[Dustdevil]

I agree that IV antibiotic prophylaxis would be indicated in the scenarios you are referring to. But I also agree that a third generation cephalosporin would probably not be the ideal choice. Back in the early 80's, before nursing school and microbiology, I was with a rural service that had IV Ancef in the protocols for open fractures, GSW's, abdominal wounds, and other dirty wounds. After doing a little basic study of antibiotics, I decided that Rocephin was a better antibiotic and brought that up to my medical director, who explained to me that I was an idiot. It was a lesson I never forgot, lol.

On the other hand, out here Rocephin is our first-line antibiotic in the field for everything, simply to keep our formulary simple, while still covering everything from wound sepsis to pneumonia. Yes, it is shotgunning and overkill. But we do stupid things in war. At the MASH centres, they still use Ancef though.

Anyhow, I digress. Antibiotics in field treatment are not a new concept by any means. If your GP were a surgeon, I agree that he would probably have a different viewpoint. Perhaps you can find a surgeon to be your mediator in these matters? Try and find the one who treated your friend and have a little professional discussion about the case, as well as the benefits of abx prophylaxis, then casually mention that your MD had some misgivings about it.