Wound of the Month: Avulsion

Objective: Using moulage to create a realistic avulsion wound.

Time: 5-7 minutes

Skill Level: Advanced

Supplies: (Shop www.moulageconcepts.com for all your moulage needs)

• Silifex Gel set
• Moulage-gel Blood
• Setting powder, translucent
• Latex, clear
• Wax, flesh
• Tulle, 3" x 1" oblong
• Caramel color

Equipment:

• Palette knives
• Laminated board
• Blush brush
• Paint brush, small
• Toothpick
• Blow dryer
• Scissors, small

Technique (see Figure 1)

Using separate palette knives, remove large amounts (approximately each the size of a quarter) of Silifex gels A & B in equal portions and place on palette board to activate. (see Figure 2)

Using the back of palette knife, combine ingredients until fully mixed. Note: To ensure long-term integrity of both products, use separate palette knives or utensils to remove product from each container prior to combining on palette board, as the combination of products creates a chemical reaction that readies it for use. (see Figure 3)

Using a palette knife or your fingers, begin spreading Silifex over desired avulsion site, creating a large, thin layer, approximately 4 x 2 inches in diameter. (see Figure 4)  

Working quickly, place tulle over Silifex, centered, adding additional Silifex as needed over the tulle to completely coat. Using a blow dryer on low-cool, gently dry the Silifex until set, approximately 1 minute, or allow to air dry 2-3 minutes and dry to the touch. (see Figure 5)

Using scissors to create an opening, gently cut 2/3 around the perimeter of the tulle, leaving one side of the Silifex attached. (see Figure 6)

Carefully hold avulsion flap open and using your fingers or wax tool, apply a small amount of wax, approximately 1",  to the corner of (exposed) skin underneath, where it meets along the Silifex edge.  Using your finger, gently blot wax to increase stickiness and create mottling and texture. (see Figure 7)

Using a small paint brush, apply a light coat of latex over the exposed skin and mottled wax, carefully holding avulsion flap open until latex has fully set. (see Figure 8)

Using red moulage gel, apply a thin coat of gel over the entire surface; natural skin, wax and underside of avulsion flap (to highlight different avulsion depths, maintain a 1/4 inch perimeter of natural skin around the underside of the flap) spreading the gel out as necessary using your fingers or paint brush. (see Figure 9)

Using a paint brush, create texture and mottling by gently blotting the moulage gel on both the opening and flap until the gel begins to strand and create raised texture variations; continue holding avulsion flap open until moulage gel has fully set. Using a blush brush that has been lightly dipped in setting powder, apply powder to the inside of the avulsion and flap, wiping away the excess, to keep the pieces from sticking together, and set gel. (see Figure 10)

Using a paint brush that has been dipped in thinned caramel color (1 drop of caramel to 3 drops of water) create wound depth by applying colorant to opening of avulsion and skin flap. (see Figure 11)

To set Silifex and ready for make-up, carefully coat top of avulsion with translucent powder or skin tone make-up. Using a make-up blush brush that has been dipped in translucent powder (gently tap edge of brush to container to release the excess powder) brush the Silifex until surface is matte or no longer shiny. (see Figure 12)

Create additional abrasions close the avulsion area as desired.

Quick Fix

Do you want your avulsion flap to remain open?  Use a small amount of Silifex, glue bottom outside corner, on the top of the avulsion flap, out and away from the opening. 

Training Scenario

Dispatch: Medic 24, Respond Code 3 to 98 Bruce Street; Kingco Restaurant unknown injuries. Nearest cross street, Ross Road. Marin County Fire responding. 1215 hrs. Dispatch clear.

On Scene: Using a make-up sponge, apply white makeup to the face of victim, blending well. Apply avulsion covering the area between thumb and index finger and reaching to middle of hand.  Place victim sitting on the ground, near food prep station; place a large amount of blood on cutting board, work station and large knife. Advise patient to moan, rock and not want to be touched. Carefully wrap a "blood-soaked" towel around hand.   

Use in Conjunction With: Blood; sweat

Cleanup and Storage

Advise victim to carefully remove the avulsion from their skin; using their fingers instruct them to lift the wound around the edges of the Silifex. Using a gentle upward motion, continue to peel away the wound until all Silifex has released from the skin. Using a soft clean cloth or make-up remover towelette, remove the make-up and any remaining product residue from the skin. Blood-soaked towel can be air dried and stored in moulage box for future use.

Bobbie Merica is the author of Medical Moulage: How to Make Your Simulations Come Alive, Moulage! Bridging the Gap in Simulation and Moulage Magic! Theatrical Tricks to Bring Simulation to Life. All works are based on her popular Moulage Mastery! Bridging the GapTM in Simulation workshops. She received her certification in Moulage-The Art of Injury Simulation; Biological/Chemical/Terrorism and WMD terrorism training through TEEX. Upon discovering the absence of moulage specific to a clinical/hospital setting, she designed and implemented the first of a series of 3D clinical wounds, moulage kits and courses that she teaches all over the country. She began her career as a simulation technologist with California State University, Chico, where her collaborative work in the development of the Rural Northern California Simulation Center earned runner-up honors in Advance magazine 2009 Best Nursing Team contest. She is a contributing author for EMS World and HealthySimulations.com, and medical moulage & trauma expert for the Bureau of Public Health Emergency Preparedness, AZ. For more information, visit www.moulageconcepts.com.