Page 73 - JSOM Spring 2024

Water Decontamination Products
for Wound Irrigation in Austere Environments

Benchtop Evaluation and Recommendations

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Ian B. Holcomb, BS , Stefanie M. Shiels, PhD *; Nathan Marsh, MD ; Daniel J. Stinner, MD ;
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Gerald McGwin Jr., PhD ; John B. Holcomb, MD ; Joseph C. Wenke, PhD 7
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ABSTRACT
Background: Irrigation is used to minimize infection of open reducing the risk of infection and preserving tissue function
wounds. Sterile saline is preferred, but potable water is becom- following combat injury. 1–5
ing more widely accepted. However, the large volumes of water
that are recommended are usually not available in austere en- When treating a heavily contaminated combat wound in the pre-
vironments. This study determined the long-term antimicrobial hospital setting, especially if evacuation is delayed, it is crucial
effectiveness of military purification powder compared with to generate large amounts of potable water for irrigation from
currently available civilian methods. The study also compared any available source. Conventionally, open wounds are irrigated
the physical characteristics and outcomes under the logistical with sterile saline, which is usually not available due to size and
constraints. Methods: Six commercially available water de- weight constraints in the far-forward or austere environment.
contamination procedures were used to decontaminate five According to preclinical studies and a recent Cochrane review,
different sources of water (pond water, river water, inoculated potable water with similar infection-related outcomes as sterile
saline, tap water, and sterile saline). Each product was evalu- saline can be used as a substitute. 1–4,7 Commercially available off-
ated based on six different parameters: bacterial culture, pH, the-shelf products can be used to convert contaminated ground-
turbidity, cost, flow rate, and size. Results: All methods of treat- water into drinkable water. In some cases, these products may
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ment decreased the bacterial count below the limit of detection. be quicker and more effective and rugged than CHLOR-FLOC,
However, they had variable effects on pH and turbidity of the the traditional standard powder used for military water purifi-
five water sources. Prices ranged from $7.95 to $350, yield- cation. Herein, we performed a comprehensive search to identify
ing 10–10,000L of water, and weighing between 18 and 500g. products with appropriate size, weight, price, and rate of decon-
Conclusion: In austere settings, where all equipment is carried tamination for potentially viable generation of large volumes of
manually, no single decontamination device is available to opti- water to irrigate wounds in austere environments. This study
mize all the measured parameters. Since all products effectively was conducted to determine how the current military method
reduced microbial levels, their size, cost, and production capa- for decontaminating a water source compares with currently
bility should be evaluated for the intended application. available civilian methods and whether any of the commercial
devices would be suitable for the far-forward environment.
Keywords: infection; wound care; prehospital care
Methods
Four portable, commercially available, water purification sys-
Introduction
tems were evaluated along with boiling water and the stan-
Readily available potable water is required for soldiers on the dard method of personal purification specified by the Army.
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battlefield. Purified and potable drinking water is routinely These systems were organized based on seven key variables to
transported via air or ground to forward tactical staging ar- determine their optimal use in an austere environment (Table
eas. However, far-forward and prolonged casualty care scenar- 1). The tested systems can be categorized into two main mech-
ios may require civilians or soldiers in austere settings to rely anisms of purification: chemical methods and filtration/ultra-
on rucked-in or available groundwater. Soldiers are issued violet light. Chemical purification techniques use chemicals to
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small survival kits, which contain essential survival tools and kill the bacteria within the water. Several methods of chemical
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equipment needed for the austere battlefield, including water purification are available. Aquamira Water Treatment drops
purification tablets. These CHLOR-FLOC tablets have not (Aquamira Technologies, Logan, UT) use chlorine dioxide to
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changed since the 1940s and are used to decontaminate water kill bacteria. Potable Aqua Water Purification Germicidal
for drinking and washing out wounds. Wound irrigation with Tablets (Pharmacal, Jackson, WI) release both free iodine and
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a large volume of decontaminated water is a critical step in hypoiodous acid into the water to inactivate microorganisms.
*Correspondence to stefanie.m.shiels.civ@health.mil
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1 Ian Holcomb graduated from Texas A&M University, College Station, TX. Dr. Stefanie Shiels is a research scientist in Combat Wound Care at
the U.S. Army Institute of Surgical Research, Fort Sam, Houston, TX. COL Nathan Marsh is an orthopedic surgeon at Womack Army Medical
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Center, Fort Liberty, NC. COL Daniel Stinner is an orthopedic trauma surgeon at the Department of Surgery, Blanchfield Army Community
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Hospital, Fort Campbell, KY, and associate professor, Department of Orthopedic Surgery, Vanderbilt University Medical Center, Nashville, TN.
5 Dr. Gerald McGwin is a professor in the Department of Epidemiology, School of Public Health, University of Alabama at Birmingham, AL.
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6 Dr. John Holcomb is a professor in the Division of Trauma & Acute Care Surgery at University of Alabama, Birmingham, AL. Dr. Joseph Wenke
is a professor in the Department of of Orthopedic Surgery & Rehabilitation at the University of Texas Medical Branch, Galveston TX, and direc-
tor of research at Shriners Children's Texas, Galveston, TX.
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