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Chapter 18

### Clinical Summary

The goals of minor wound care are to achieve optimal wound aesthetics and infection prevention. Preliminary wound management begins with assessment, adequate hemostasis, foreign body removal, and irrigation. For most uncomplicated wounds, irrigation is the most effective means of reducing bacterial count. However, debridement may be necessary in contaminated wounds because devitalized tissue may impair the wound's ability to resist infection.

### Emergency Department Treatment and Disposition

Rendering appropriate analgesia is important prior to initiating any wound cleansing or irrigation. While normal saline and sterile water are often used for irrigation, running tap water has been shown to be equally efficacious in simple well-vascularized wounds. In contaminated wounds, antiseptic solutions, such as povidone-iodine diluted in a 1:10 ratio using normal saline as the diluent, may help in disinfecting the wound. Bacterial-static solution cleaners, such as nonionic surfactant cleaner, may also help in reducing the bacterial inoculum. Solutions containing ionic detergents such as Betadine surgical scrub should not be used for this purpose as it is toxic to the wound tissue. If necessary, scrubbing of wounds should be done carefully as to avoid damaging viable tissue.

Irrigation remains the most effective means of reducing the bacterial inoculum; Five hundred to 1000 mL of irrigation fluid or 60 mL/cm of wound length is usually adequate for most uncomplicated wounds. The recommended irrigation pressure of 5 to 8 lb per square inch (PSI) can easily be accomplished by attaching an 18- or 19-gauge intravenous catheter sheath, or a commercially available splash shield, to a 20 or 30 mL syringe. A typical bulb system is suboptimal as it generates only 0.5 to 1 PSI. Debris that cannot be irrigated from the wound should either be scrubbed or sharply debrided using iris scissors or a scalpel. The tissue should appear pink and viable, with a scant amount of fresh bleeding indicating good vascular supply. High-pressure irrigation (ie, >25 PSI) may be necessary in highly contaminated wounds or complicated wounds that require operating room wash out. However, it offers no advantage for routine wounds cared for in the emergency department.

###### Figure 18.1.

Wound Soaking. Soaking is an appropriate method for loosening debris and coagulated blood but is not a substitute for irrigation. (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)

###### Figure 18.2.

High-Pressure Irrigation Devices. The ideal pressure for routine wound irrigation is 5 to 8 PSI. This can be easily achieved through the use of a 30 syringe attached to a commercially available device with an 18- or 19-gauge intravenous catheter sheath (top) or splash shield (bottom) (Photo contributor: Matthew D. Sztajnkrycer, MD, PhD.)

###### Figure 18.3.

Wound Irrigation. After adequate ...

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