Chapter 18: WOUNDS AND SOFT TISSUE INJURIES

INTRODUCTION

WOUND CLEANING AND IRRIGATION

Clinical Summary

The goals of minor wound care are to achieve optimal wound aesthetics and infection prevention. For most uncomplicated wounds, irrigation is the most effective means of reducing bacterial count. However, debridement may be necessary in contaminated wounds since devitalized tissue may impair the wound’s ability to resist infection.

Management and Disposition

Preliminary wound management begins with assessment, adequate hemostasis, foreign-body removal, and irrigation. Provide adequate analgesia prior to wound cleansing. In simple well-vascularized wounds, tap water is as effective as normal saline or sterile water. In contaminated wounds, povidone-iodine diluted 1:10 with normal saline may help with disinfection. Bacterial-static solutions, such as nonionic surfactant cleaner, may also reduce bacterial inoculum. Solutions containing ionic detergents (eg, Betadine surgical scrub) should not be used as it is toxic to wound tissue. If necessary, wound scrubbing should be done gently to avoid damaging viable tissue.

Irrigation is the most effective means of reducing bacterial inoculum; 500 to 1000 mL of fluid or 60 mL/cm of wound length is adequate for most uncomplicated wounds. The recommended irrigation pressure of 5 to 8 lb per square inch (PSI) can be accomplished by attaching an 18- or 19-gauge intravenous (IV) catheter sheath, or a commercially available splash shield, to a 20- or 30-mL syringe. A bulb system is suboptimal; it generates only 0.5 to 1 PSI. Debris that cannot be irrigated can be scrubbed or sharply debrided. The tissue should appear pink and viable; a scant amount of fresh bleeding indicates good vascular supply. High-pressure irrigation (≥25 PSI) may be necessary in highly contaminated or complicated wounds requiring operating room washout. However, it offers no advantage for routine wounds.

Pearls

1. Universal precautions, including gloves and face shield, should always be observed.

2. Antibiotics are no substitute for thorough wound cleansing and irrigation.

3. Shaving the eyebrow for wound repair is contraindicated due to the unpredictable pattern of ...