Category Archives: skin

Does paper tape prevent blisters?

Feet get blisters, and the longer distances you move, the more likely they are to get them. While nuisances by themselves, blisters can lead to more concerning conditions such as cellulitis. Then they become a real problem, especially if you’re in an austere environment. Thus preventing these blisters can make a significant difference in your race, hike, or military operation.

Since commercial products are relatively expensive and poorly studied, these authors wanted to see if a cheaper alternative would be effective. Their choice for this cheaper alternative was paper tape. The fiscal impact is comical considering they tested this on people running 7 day, 250 km ultramarathons in such exotic locations as China, Egypt, Nepal, and Chile. Registration alone is $3600, and then there are the rest of the gear, travel, and food costs. That being said, if the tape worked in such extreme conditions, it would likely have worked for the more mundane activities the majority participate in.

Sadly, it didn’t work. Using patients as their own controls, they taped one foot and left the other native.  Even though they covered a significant portion of the foot with tape, there were more blisters on the taped foot than on the control foot. If you just examined the taped foot, there were more blisters under the tape than the surrounding exposed skin. After all of this, a large majority (84%) of their runners said they would use tape again in the future. Laughably, this same group didn’t usually use blister prevention prior to the study.

Even more interesting is that when they broke down the subgroups, they discovered that if you taped the foot ipsilateral to the dominant hand, tape suddenly became protective (statistically). Also, having a smaller pack weight to body weight ratio was similarly protective. unfortunately, use of toe socks increases blister formation. Of course, of their final study group of 90 patients, 100% had blisters. It may be that the 31 patients they lost to followup simply did not have blisters, which would completely change the results of this study. Also, while runners were asked not to tape the control foot, the study authors were not able to control for other lubricants and powders that could have affected outcomes.

In the end, not much you can take from this. The theoretical friction barrier that tape would provide does not seem to prevent blisters. However, the runners sure did like it due to ease of application and relatively low-cost. There’s nothing in this study that makes me tell runners change their routines. Throw this on in the “needs further study” bin.

A Prospective Randomized Blister Prevention Trial Assessing Paper Tape in Endurance Distances (Pre-TAPED)
http://www.wemjournal.org/article/S1080-6032(14)00197-5/abstract

Wilderness wound pitfalls

Wounds happen out there. Even with maximum preventive measures, they’re inevitable, so we should definitely know how to manage them appropriately.

This handy little report talks about a Grand Canyon boatman who injured himself at the beginning of a trip down the Colorado. It goes downhill from there, but it is a useful case to point out the things they didn’t do right, and did do wrong. The narrative is also mostly written by the river guide himself, and the style is quite humorous.

Serendipitously, or so he thought, there were two doctors on the trip, one of which whipped out his suture kit and fixed the rather large bleeding wound on his shin. I don’t have a problem with closing the wound, as it was large and likely to cause problems if left open. 

What did they do wrong? First, they didn’t irrigate the wound. It goes without saying that the raft, the pack, and the Colorado River were not sterile, and thus the wound wasn’t clean either. They also shaved his leg with a razor, because apparently JCAHO was going to make a trip to the park that day. Must have left the batteries out of the electric clippers. 

They correctly covered the wound with Tegaderm and Coban for protection on the first day, with subsequent dressing changes. 4 days later, the wound developed cellulitis, so he was started on Bactrim (TMP/SMX). It wouldn’t be my first choice for cellulitis, but it isn’t the worst drug to use as it covers Aeromonas. Levaquin (levofloxacin) would be great, or just adding Keflex (cephalexin) to the bactrim for better gram positive coverage coverage.

Two days later the cellulitis is progressing even with antibiotics, and now there is a pitting edema below the wound. Too late to evacuate that day, they elect to open the wound that evening. Anesthesia provided by gin and tonic. They irrigate using Betadine  and pack it with Betadine-soaked gauze. The tissue-toxic solution could certainly reduce wound healing, and I can’t recommend using it.  Using a squirt gun for higher pressure irrigation is a neat trick though. 

Azithromycin is added to the antibiotic regimen, likely because it’s all they had. The next morning he is flown out. The good news is that after a washout in the OR and two days of wound vac therapy, they get the skin closed and it heals nicely.

Recap of important points for austere wound therapy

  • Irrigate with clean water, but nothing toxic. You want to clean and promote healing, not kill tissue.
  • Consider prophylactic antibiotics for dirty wounds that can’t be cleaned, especially penetrating injuries in water.
  • Use occlusive dressings. They promote healing and decrease infection rates.
  • Wounds less than 1 inch do not need closure, as cosmesis and infection rates are similar open or closed. Close if in an area prone to reopening certainly. Sutures, adhesive strips, and skin glue are all similar in efficacy if used appropriately.

They Had Me in Stitches: A Grand Canyon River Guide’s Case Report and a Review of Wilderness Wound Management Literature.
http://www.ncbi.nlm.nih.gov/pubmed/24418453