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Monday, May 25, 2009

TEOTWAWKI Medicine and Minor Surgery--Part II: Skin Infections, by Dr. K.

The skin has three layers.
1. The epidermis is the outermost layer. It protects our bodies from the environment and has pigment cells.
2. The dermis is the middle layer, and it contains hair follicles, sweat glands, oil glands, and capillaries.
3. The hypodermis (or subcutaneous layer) is the inner layer, and it contains layers of fat that provides cushion and insulation for our body… some more than others.
Any of these layers can become infected, in whole or in part. In a TEOTWAWKI scenario, that minor scratch could lead to a painful death. Knowledge is vitally important. Understanding how to prevent and treat a skin infection is relatively straightforward, and it could be a matter of life and death when TSHTF.
Signs of a skin infection are pain, redness, swelling, warmth and/or drainage of pus.

Cellulitis: a diffuse infection of the dermis and subcutaneous tissues. Signs of cellulitis are red, warm, swollen, and tender skin.
Erysipelas: similar to cellulitis, but this infection is more superficial and has very clear borders.
Skin abscess: a collection of pus that is in the dermis and subcutaneous tissues. An abscess presents as a tender mass just under the skin. It is pink to red and may be warm to the touch.
Furunlce (or “boil”): an infection of the hair follicle that causes an abscess.
Carbuncle: a collection of several boils that grow together. This looks like a very large abscess.

These skin infections can develop in any individual and most are caused by bacteria. Having minor scrapes and cuts, insect bites, rashes, burns, swelling, or being around another person with a skin infection can increase your risk. Having diabetes, being immunosuppressed (HIV, on chemotherapy medicines, autoimmune disease, etc.), or having a history of methicillin-resistant Staphylococcus aureus (MRSA) infections also increases your risk.
If an infection is left untreated, it can keep spreading into the surrounding tissues and into the bloodstream. This may lead to local tissue damage, a body-wide infection, and even death in a worst case scenario.
All skin wounds, no matter how minor, should be cleaned and dressed immediately. Changing the dressing when it becomes wet or dirty will aid in prevention. In a TEOTWAWKI scenario, you cannot afford to brush aside that thorn scratch or knife nick. Take the time to clean it right away. Skin infections don’t care how tough you think you are.

Cellulitis and erysipelas are sometimes watched and not treated with antibiotics right away. However, if these infections become severe (which can happen quickly), IV antibiotics are the best choice. In a TEOTWAWKI scenario, IV antibiotics will be much harder to store and/or obtain. Because of this, I recommend using oral antibiotics with cellulitis and erysipelas immediately.
Antibiotics are typically not needed with a draining abscess or after an incision and drainage (I&D). Once the pus pocket is ruptured, your immune system usually takes care of things rather well. However, I would start antibiotics if a growing redness and warmth develops after the wound has been drained.
Also, I would start antibiotics right away if the patient has multiple skin infections, the patient is immunosuppressed, the patient has previous MRSA infections, or if the patient has signs of body-wide infection (feeling ill, fever, nausea and/or vomiting, increased heart rate, low blood pressure, etc.).
Any of the following oral antibiotics (unless there is an allergy) should be used for 10 days minimum, but can be used longer as long as the infection is improving (search past Survivalblog posts for medication procurement):
Cleocin (clindamycin) 300 mg every 6 hours (currently treats most MRSA)
Dicloxacillin 500 mg every 6 hours
Keflex (cephalexin) 500 mg every 6 hours
Cleocin (clindamycin) 30-40 mg/kg per day divided in 3-4 doses (treats most MRSA)
Dicloxacillin 25-50 mg/kg per day divided in 4 doses
Keflex (cephalexin) 25-50 mg/kg per day divided in 3-4 doses

Non-Surgical Treatment
Small boils and small abscesses may respond very well to non-surgical treatments:
* Keep the infected area elevated.
* Warm compresses (a clean wash cloth soaked in hot water and wrung out) and warm water soaks will help promote drainage.
* If it comes to a head, continue with warm compresses until it ruptures.
* Wash with antibacterial soap.
* Continue to use warm compresses until the pus stops flowing.
* Apply antibacterial ointment (such as Neosporin) over the wound.
* Keep a clean and dry dressing in place over the wound.
* Wash the wound and change the dressing 2-3 times a day.
* There should be improvement in about a week.
* If there is a growing area of redness and warmth, consider antibiotic treatment.

Surgical Treatments:

Incision and Drainage
Larger boils, larger abscesses, and carbuncles require incision and drainage (I&D) to heal.
Note: A surgical option, regardless of the problem, is always best treated by someone who has been trained to perform the procedure. You don’t want to be patient number one in a survival situation. Finally, while I am explaining how to do this procedure, I only recommend that you attempt this in a post-TEOTWAWKI scenario where there are no other healthcare options. Proceed at your own risk.
Light (a bright headlamp works well. Consider working outside in the bright sunlight.)
Non-sterile gloves
Sterile gloves
Alcohol or povidone-iodine solution (sold as Betadine)
Gauze pads
10-mL syringe
25- to 30-gauge needle
12- to 18-gauge needle if desired
Lidocaine 1% or 2%
No. 11 or 15 blade scalpel or sterile razor blade
Curved hemostats (small device that resembles scissors but has curved clamps instead of blades) a pair of needle nosed pliers (sterilized) can be used in a pinch
Packing material (such as iodoform gauze which are thin medicated gauze strips)

Dressing Materials:
Antibiotic ointment such as Neosporin
Gauze for wrapping the wound
Roll of 1-inch tape

Step-by-Step Instructions

1. Have the patient get into a comfortable position. Have them lie down if possible just in case they pass out - it can happen to anyone! [JWR Adds: Vasovegal and other fainting responses are highly unpredictable. Just the sight of spurting blood can induce a faint in even someone that big and macho. In two separate incidents, I've personally witnessed two "manly men" who claimed "no problem, it won't bother me" pass out, unconscious, within moments of seeing their own blood.]

2. Clean the wound. Put on non-sterile gloves and clean the entire wound and surrounding tissue with povidine-iodine or alcohol.
3. Numb the wound with medicine: The easiest method is a field block. Inject the lidocaine around the base of the wound on all sides. If the wound is not on a small body part, you can use lidocaine with epinephrine.
Note: Make sure the lidocaine does not have epinephrine in it if the wound is on a small body part. Epinephrine is a vasoconstrictor, meaning it clamps down blood vessels. This can prevent circulation. If you stop circulation with medicine, you have no idea how long it will last, and you could kill tissue. Your patient won’t feel the procedure, but they may lose a body part! Bottom line: Never use epinephrine on the fingers, toes, ears, penis, or nose.
Note: Please read how to load lidocaine and inject it in Part I: Ingrown Toenails. [JWR Adds: Of course check for contraindications and potential drug interactions before using any "-caine" drugs!]
Note: Please read how to dull the pain without medicine in Part I: Ingrown Toenails

4. Make an incision. Using the scalpel blade or sterile razor blade make a straight cut the entire length of the abscess (the deepest red central portion of the abscess). The cut should be deep enough to go to the subcutaneous tissues. Try to follow the natural skin folds for a more cosmetic healing (do an online image search for “cleavage skin lines” to see an illustration). For small infections, you may be able to drain the abscess by perforating it with the large bore (a 12-18 gauge) needle.
5. Probe the incision if large enough. If there are no pain meds, this will be painful. Insert the curved hemostats to slowly spread out the tissues under the cut. This will break up some of the connective tissues that may be holding pockets of pus. You also may find a foreign body (thorn, glass, etc.) that was actually causing the infection.
6. Express the wound. Provide gentle pressure to the sides of the wound to squeeze out any extra pus and blood. Do not be aggressive here.
7. Pack the wound. If the wound is big enough to leave a pocket, then filling the wound with a medicated packing material (iodoform gauze) will aid in healing. Using the hemostats, stuff the material into the wound until full. Leave about a half inch hanging out of the wound. This tail aids in drainage. Trim to size with a pair of scissors.
If the wound is not very large, you do not need to pack it.
8. Dress the wound. Apply antibiotic ointment over wound. Apply a bulky gauze wrap, but do not wrap it too tight. It will throb as sensation returns. Use acetaminophen or ibuprofen for pain.
9. Check the wound after 24 hours. If there continues to be more pus draining, remove the packing material, repack the wound, and change the dressing. Keep checking every 24 hours. When the drainage stops, perform warm water soaks 3-5 times daily, change the dressing, and apply topical antibiotic ointment. Healing should occur in 7 to 10 days.

Surgical Complications
Infection: The wound will have some initial throbbing, but should start to improve dramatically in a few days. If your patient is having an increase in pain, swelling, redness, warmth, or drainage, there is likely a continuing or secondary infection. If this occurs, start antibiotics as described above. Consider probing the abscess a second time to make sure no pockets of pus are hiding.

Things to consider
If the wound involves the hand or the abscess is very large, it will be very difficult to treat without IV antibiotics and potentially major surgery. This would be a case where attempting to find a physician may outweigh the risks of leaving your retreat. In rare cases a skin infection can spread to the facial tissue (this is called necrotizing fasciitis or “flesh eating disease”). Signs of this infection are intense pain out of proportion to the wound, fast swelling, spreading redness, fever, and vomiting. This would be a case where lack of immediate surgery by highly trained physicians will mean death.

It will be difficult to acquire hands on training for this procedure unless you work in the medical field. However, this is a fairly straightforward procedure. If you see it once, most people should be able to repeat it. One way to see how it is done is to go to the doctor with a friend or family member who has an abscess or boil. Another option is to do an online video search for “I&D”. There are currently a few videos up that give a nice demonstration.


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