Wound Care

Part of Germ Theory

Applying germ theory principles to wound management — cleaning, debridement, dressing, and monitoring for infection.

Why This Matters

Wounds are portals of entry for pathogens. Intact skin is an essentially impenetrable barrier against most organisms; a wound bypasses this barrier entirely. In the pre-antibiotic era, wound infections killed most surgical patients, most victims of significant traumatic injury, and many people with even minor contaminated lacerations. The introduction of antiseptic wound care by Lister in the 1860s transformed this mortality — not by treating established infection, but by preventing it.

In a post-collapse medical context, wound infections are among the most common causes of death from otherwise survivable injuries. A person who survives a fall, a tool injury, or an animal bite may die days later from wound sepsis caused by inadequate initial care. The good news: proper wound management using available materials can prevent the vast majority of wound infections. The principles are straightforward; the execution requires attention to detail and understanding of why each step matters.

The Biology of Wound Infection

When a wound occurs, organisms from the skin surface, environment, or contaminating object enter the tissue. Whether infection develops depends on:

Bacterial load: A large inoculum (many organisms entering the wound) overwhelms local defenses. A small inoculum (few organisms) is typically cleared by the immune response.

Wound characteristics: Deep, narrow wounds (punctures) trap organisms in an anaerobic environment ideal for Clostridium tetani and Clostridium perfringens. Wide, open wounds are less anaerobic and allow better immune response.

Dead tissue and foreign bodies: Dead tissue (necrotic) is a culture medium for bacteria and inhibits the immune response. Foreign material (soil, cloth fragments, wood splinters) shelters organisms from phagocytosis. Removing these through debridement and irrigation is the most important step in infection prevention.

Host immunity: Malnourished patients, diabetics (poor wound perfusion and impaired immune response), and those debilitated by other illness have impaired wound defenses.

Wound contamination category:

Category	Description	Infection risk	Initial approach
Clean	Surgical wound, no contamination	Low (<2%)	Primary closure
Clean-contaminated	Minor contamination	Low-moderate	Primary closure with irrigation
Contaminated	Traumatic wound, gross contamination	Moderate (10-15%)	Irrigation, debridement, delayed closure
Dirty/infected	Old wound with pus, fecal contamination	High	Open management, drain, no primary closure

Step 1: Hemorrhage Control

Before any wound management, control active bleeding.

• Direct pressure: Firm, sustained pressure with a clean cloth for 10-15 minutes without releasing. Do not remove the cloth — if soaked, add more cloth on top. Most wounds stop with sustained pressure.
• Elevation: Elevate the injured part above heart level to reduce blood pressure at the wound.
• Tourniquets: For life-threatening extremity bleeding not controlled by pressure: apply a tourniquet proximal to the wound as tight as possible, note the time. Tourniquet time beyond 2 hours risks limb loss from ischemia, but in life-threatening hemorrhage this is secondary to survival.
• Wound packing: For deep wounds (groin, axilla, neck) where tourniquets cannot be applied, pack the wound cavity tightly with cloth and apply continuous firm pressure.

Step 2: Irrigation

Irrigation is the single most effective step in preventing wound infection. Large volumes of clean water under pressure physically remove bacteria, soil, foreign material, and devitalized tissue.

Irrigation fluid: Boiled (then cooled) water is ideal. Adding salt to 0.9% concentration (physiological saline — 9 g/L, approximately 1 rounded teaspoon per liter) reduces tissue irritation and osmotic damage to cells, but plain boiled water is adequate.

Irrigation technique:

• Use a large syringe (35 mL or larger), squeeze bottle, or a tube with a small nozzle to create pressure. Pouring from a container without pressure is much less effective.
• Irrigate into the wound from above; allow fluid to flow out of the wound taking debris with it. Do not irrigate in a way that traps fluid in a pocket.
• Volume: use large amounts — a minimum of 500 mL for a moderate wound; 1-2 liters for heavily contaminated wounds. It is difficult to irrigate too much.
• Penetrate the wound: insert the tip into the wound cavity for deep wounds; irrigate under the wound edges for laceration flaps.

Antiseptic addition: For heavily contaminated wounds, a dilute antiseptic added to the irrigation fluid is reasonable:

• Dilute iodine solution (0.1%) — gentle and effective
• Dilute hydrogen peroxide (3%) — provides mechanical debridement through bubbling; brief exposure only (30 seconds then irrigate out) as it is toxic to healing tissue with prolonged contact
• Avoid: concentrated alcohol (damages tissue), full-strength bleach (highly caustic), or any concentrated antiseptic

Step 3: Debridement

Removal of devitalized tissue, foreign material, and heavily contaminated tissue.

Mechanical debridement:

• Use sterile scissors or forceps to cut away clearly dead or necrotic tissue (gray, purple-black, or clearly non-viable tissue)
• Remove all visible foreign material: soil, gravel, glass fragments, cloth fibers, wood splinters
• A dry-then-wet approach: allow irrigating fluid to soften adherent debris, then remove mechanically

Signs of devitalized tissue:

• Does not bleed when cut (healthy tissue bleeds)
• Gray, brown, or black color (healthy tissue is pink-red)
• Has no sensation (healthy tissue has sensation)
• Does not contract when touched (healthy muscle contracts)

Limits of field debridement: Remove obviously dead tissue; do not attempt extensive resection of borderline tissue. Borderline tissue that is allowed to stay may survive, or will declare itself dead within 24-48 hours and can be removed then. Over-enthusiastic debridement can damage viable structures.

Step 4: Wound Closure Decision

Primary closure: Closing the wound immediately with sutures or wound closure strips. Appropriate for:

• Clean wounds (<6 hours old, minimal contamination)
• Well-irrigated wounds on well-vascularized areas (face, scalp — these resist infection well)
• Wounds where open management would create other problems

Delayed primary closure: Leave the wound open, covered with moist dressings; close at 4-5 days after confirming no infection. Appropriate for:

• Contaminated wounds
• Bite wounds (high infection risk)
• Wounds over 6-8 hours old before treatment
• Wounds with uncertainty about extent of contamination

Secondary intention: Allow the wound to close by granulation tissue formation — new tissue grows from the wound base upward. Slower but very reliable for heavily contaminated wounds. Appropriate for:

• Frankly infected wounds
• Wounds with established necrosis
• Wounds where primary or delayed closure was not possible

Step 5: Dressing

A wound dressing:

1. Protects from environmental contamination
2. Absorbs wound exudate
3. Maintains appropriate moisture (too dry = poor healing; too wet = maceration and infection)
4. Reduces pain

Dressing materials:

• Boiled and dried cloth (linen, cotton): the standard dressing material. Multiple layers provide absorbency.
• Honey dressings: apply a thin layer of raw honey directly to the wound, then cover with boiled cloth. Honey is antimicrobial, maintains wound moisture, and is absorbed as the wound heals. Excellent for open, infected, or slow-healing wounds.
• Plantain leaf (Plantago major): traditional wound herb; gently antimicrobial and anti-inflammatory. Apply clean leaf directly or as a poultice.

Dressing change:

• Change when saturated with exudate or at least daily
• Each change is a new sterile procedure: wash hands, use clean instruments
• Gently remove adherent dressings by soaking with boiled water — do not tear
• Observe the wound at each change: is it improving or worsening? Is the surrounding tissue calm or inflamed?

Step 6: Monitoring for Infection

Normal wound healing timeline:

• Day 1-3: Inflammation — redness, swelling, warmth, pain at wound edges. This is normal and represents immune response. Not to be confused with infection.
• Day 3-7: Proliferation — pink granulation tissue appears in the wound base. Exudate decreases.
• Day 7+: Remodeling — wound edges contract; surface epithelialization visible.

Signs of wound infection:

• Increasing redness extending beyond the immediate wound edge (>1 cm beyond the wound, advancing)
• Increasing warmth and swelling
• Purulent discharge (pus): cloudy, thick, often colored (yellow, green)
• Foul odor
• Increasing pain after day 3 (pain should be decreasing with healing, not increasing)
• Systemic signs: fever, elevated heart rate, general malaise

Specific warning signs:

• Red streaks radiating from the wound (lymphangitis): bacteria spreading along lymphatic vessels toward the lymph nodes. Serious — requires urgent treatment (drainage, debridement, systemic antibiotics or antibiotic plants if available).
• Gas palpable in tissue (feels like bubble wrap under the skin), discoloration, extreme pain: possible gas gangrene (Clostridium perfringens). Surgical emergency — open widely, remove all affected tissue, allow open drainage.
• Wound not painful but with progressive necrosis in a contaminated wound in a patient with no tetanus vaccination history: consider tetanus — a systemic disease caused by toxin, not by wound infection per se. Wound must still be managed, but systemic supportive care for tetanus muscle spasms is the primary issue.

Tetanus Prevention

Tetanus is caused by Clostridium tetani spores in soil entering a wound and germinating in the anaerobic tissue. The resulting toxin causes progressive, often fatal muscle spasm.

High-risk wounds: Puncture wounds (especially with soil contamination), crush injuries, soil-contaminated lacerations, animal bites, wounds with necrotic tissue.

Prevention measures:

• Thorough wound irrigation (reduces spore burden)
• Wound debridement (removes necrotic tissue — the anaerobic niche)
• Wound aeration (keeping the wound from becoming sealed and anaerobic)
• Tetanus vaccination (if available): one of the highest-priority vaccines to stockpile

If tetanus develops: Muscle rigidity beginning at the jaw (trismus, “lockjaw”) progressing to generalized spasms. Treatment is supportive: control spasms (sedation — diazepam, phenobarbital), maintain airway, provide nutrition. No cure exists — the toxin must be cleared naturally. Wound management continues.