Figures 1 & 2
INTACT (SEALED) VESICLES:
After examining and cleansing to foot, the top of the intact vesicle is disinfected with an alcohol swab. The selection of the drainage site is important, as drainage needs to occur during sleep as well as during marching. Usually a puncture on the posterior aspect of the vesicle will allow for appropriate drainage.
The medical specialist uses a standard finger lancet to puncture the vesicle wall close to the base. The lancet prevents too deep of a puncture, just through the vesical roof. A very small puncture is made, and the vesicular fluid is expressed using the stick of the "Texas Q-tip" (large cotton tipped applicator). This process is extremely painful for the patient. The firm rolling of the plastic handle of the applicator irritates the extremely sensitive vesicular base, even though the roof is still intact. This rolling must be done repeatedly to ensure all of the vesicular fluid is removed.
If purulent fluid is expressed from the vesicle, the vesicular roof must be removed to allow debridement of the wound and further evaluation of the depth of the infection. If, after deroofing the vesical, there is no deep-seated infection and the surrounding tissue is not erythematous, tender and no lymphangitis is seen, the vesical may be treated using the procedure below.
DEROOFED OR TORN VESICLES:
If a vesical roof has tom, or is partially missing, the area is cleansed as above. The loose epidermis must be removed, as it no longer serves a purpose as a physiologic bandage. Use sterile scissors (iris, curved mayos or one point sharps) to fully trim the loose skin, beveling the edge of the erosion to prevent further friction injury. After debridement of the vesicle roof, cleanse the blister base with normal saline irrigation. This area is very sensitive, but gentle irrigation is vital to prevent infection. If active bleeding, extreme beefy redness or purulence exists at the blister base, then the soldier should be treated for cellulitis as outlined above.
DuoDerm is a soft polymer that becomes more flexible with body heat. It is used by the Dutch Red Cross to provide an airtight dressing over the sensitive blister base, and to fill the empty space left by the vesicle's debrided epidermis. Cut a section of 1/8" thick DuoDerm the same size as the eroded cavity, and warm it (or have the patient warm it) in a gloved hand for 5 minutes. When the film is soft, peel the backing and apply to the blister base. This provides a sterile dressing that soothes the wound. Ensure there is no "double thickness of DuoDerm and skin which may case additional friction pressure after dressing and taping.
DEEP DERMAL ABRASIONS
Deep dermal friction abrasions occur when the soldier's level of "Drive-On" exceeds the anatomical structural resilience of the skin and dermis. Deep dermal friction abrasions begin as simple "hot spots" of increased friction, progress to simple friction blisters, and on to deep dermal erosions. These can usually be recognized active bleeding, deeply abraded tissue, and extreme tenderness. Soldiers may recognize there is a problem when they notice bloody socks or blood in their boots.
It is very difficult to restore deep dermal erosions to marching status. It is more appropriate to remove the soldier from weight bearing on the affected foot for several days, dress with a bulky dressing and topical antibiotic, twice daily Domboro's soaks, foot elevation and observe wound for signs of cellulitis.
DUTCH RED CROSS BLISTER TREATMENT TAPING TECHNIQUE (See Figures 3&4)
Figures 3 & 4
For forefoot vesicles, Place the patient in a supine position with the feet extending slightly over the table edge. Tape the entire forefoot, beginning at the base of the toes and continuing to the mid arch. For heel vesicles, place the patient in the prone with the feet extending over the edge. Start at the top of the Achilles' fossa and continue to the mid arch.
Leukoplast 1/4" dressing tape is used because of its thinness and flexibility to molding to the foot. Other thin tapes may be used, but ensure it is cloth and non-stretch.
Begin by measuring the Leukoplast by
pulling from the roll and placing on the area to be taped by the non-adhesive side, then cut to the appropriate length (enough to go from the start of the plan- tar-textured skin on the upper medial foot, to where that type of skin ends on the opposite side of the foot.) It is important to use tape that is long enough; so cut the tape longer rather than shorter (it can be trimmed if it is too long) on the medial and dorsal side of the foot.
You will need different lengths of tape as you tape the different areas of the foot, so measure each area of the foot treated to ensure the proper length of precut tape.
When applying tape, stick the middle of the tape to the foot first, then carefully smooth it to the skin to ensure no wrinkles are applied. Start your next strip by overlapping the previous strip by 1/3 the width of the tape. Continue taping until the entire area is covered, and then ensure no wrinkles or excessive layers of tape are present (these may cause new friction points or hot spots). Tape carefully around blistered toes, cutting wedges from the tape as needed to prevent friction points.
End state must be a smooth, tight, even taping of the affected section of the foot. When this is achieved, dust the taped area with talc to prevent the tape edges from sticking to the socks. Ensure the borders of the taped area are well adhered to the skin and add additional tincture to those areas as needed to ensure the tape is secure.
Advise the soldier to dust the tape with talc every time a sock is changed, and to be aware of any fluid build up in the old blister pockets. These may be drained without removing the tape, a small area of tape may be peeled back from the drainage site, the skin disinfected, a sterile lancet or 18 gauge needle used to drain the vesicle, and reapply the old tape over the site (or, if the tape is non-adherent, apply a section of new tape, ensuring no wrinkles).
The soldier should be instructed to return to medical care in case of extreme pain, purulent or bloody exudate from the blister, or signs of infection occur.
References:
I. Foot Marches. US Army, Field Manual 21-18, US Government Printing Office, I June 1990.
2. Smith, JB., Medical After Action Report, Nijmegen 1995 International 4 Days Marches 19-22 July 1995, US Army 212th Mobile Army Surgical Hospital, 30 July 1995.
3. Versteeg, M.A., International 4 Days Marches Official Web site,
www.4daagase.nl. Koninklijke Nederlandse
Bond voor Lichamelijke Opvoeding (KNBLO) 1997-2002. 4. Cobb, S., US marchers get by without help from military, Stars and Stripes European Edition, 20 Jul 2000.
5. Dutch Landmacht, Camp Heumensoord Daily Newsletter (CCVM), Colophon #5, Netherlands, 21 Ju12000.
EDITORS NOTE: This paper was originally presented as the basis for a Poster Contest entry at the Society of Army Physician Assistant's Annual Refresher Course, Fayetteville, NC on 23 April 2002.
he presented this
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