Sean Nordt, MD PharmD and Stuart Swadron, MD

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Sean and Stuart review literature to give up to date evidence based recommendations for wound care. A sort of audio- journal club! Take a listen!

PEARLS:
  • The majority of soft tissue injuries can be dealt with in the Urgent Care (UC) setting.  Consider referring wounds to a surgeon or hospital if the wound is very old, dirty, has underlying damage to vital structures, or a high suspicion of foreign bodies in the wound.  

  • Soaking and scrubbing are not beneficial and may be harmful.  

  • Tap water is safe and less expensive and pressure irrigation is necessary to break down biofilm and wash bacteria away.

  • We see countless wounds and lacerations in the Urgent Care (UC) setting.  We need to be skilled and comfortable with repairing most of these.  

  • We also need to be able to recognize those wounds that require a surgical or an advanced approach that need to be referred.  Consider referring if a wound is particularly contaminated or complicated with a partial or complete tendon laceration, is very extensive and may require grafting or is likely to have foreign bodies not easily washed away with irrigation.

  • The 2 biggest legal concerns when it comes to wound care are missed injuries to joints, tendons, etc. and retained foreign bodies.  

  • Good lighting, adequate exposure, and an bloodless field are the key to an adequate wound examination.  

Wound Care Don’ts:

  • No soaking: It offers no infection reduction and makes the wound soggy, macerated and difficult to deal with.

Lammers RL, et al. Effect of povidone-iodine and saline soaking on bacterial counts in acute, traumatic, contaminated wounds. Ann Emerg Med. 1990 Jun;19(6):709-14. [PMID 2344090]

  • Looked at 29 patients presenting with acute contaminated wounds and randomized them into 1 of 3 groups.  Group 1 wounds were covered with gauze, group 2 wounds were soaked in saline, and group 3 wounds were soaked in a diluted povidone-iodine (Betadine) solution.

  • Examined blocks of tissue and counted the number of bacteria present before and after treatment.  Soaking in saline increased the bacterial count, Betadine made no change in the bacterial count.  We no longer soak wounds.  

  • No scrubbing: Dead and devitalized tissue increases the risk of wound infection, but the literature suggests that scrubbing causes local tissue damage that results in inflammation and can be a nidus for infection.  We need to get the dead stuff out without causing additional injury to the tissue that decreases its ability to heal.

Wound Care Dos:

  • Prep the skin around the wound with a 10% povidone-iodine solution to prevent bringing bacteria from the surrounding skin into the wound.  

  • Irrigate: Bacteria have biofilm that allows for wound adherence.  Irrigation breaks up the biofilm and allows the bacteria to be washed away.  

  • Irrigate with water or sterile saline.

Moscati RM, et al. A multicenter comparison of tap water versus sterile saline for wound irrigation.  Acad Emerg Med. 2007 May;14(5):404-9. [Free open access link]

  • Looked at 715 adults who presented with simple lacerations requiring either sutures or staples.  Patients were randomized to either tap water irrigation at a sink or with normal saline using a sterile syringe.  Wounds were then closed and brought back to ED for suture removal.

  • Among the 634 patients who returned to the ED for follow up, there was no difference in rate of wound infections.  12/300 in the tap water group developed a wound infection and 11/334 in the sterile saline group developed wound infections.

Weiss EA, et al. Water is a safe and effective alternative to sterile normal saline for wound irrigation prior to suturing: a prospective, double-blind, randomised, controlled clinical trial. BMJ Open. 2013 Jan 16;3(1). [Free open access link]

  • A single center study that looked at 663 patients who presented to the ED  with soft tissue lacerations requiring repair.  The patients were randomized and both the caregivers and patients were blinded as to the treatment solution used: tap water or sterile saline.

  • Wounds were irrigated with 500mL of the selected solution using a 35mL syringe with an 18 gauge needle.  There was no difference in infection rates between the groups.

  • Irrigate under pressure.

Stevenson TR, et al. Cleansing the traumatic wound by high pressure syringe irrigation. JACEP. 1976 Jan;5(1):17-21. [PMID 933383]

  • Landmark article that established the practice of wound irrigation.

  • Demonstrated that using a 19g needle and a 35mL syringe generates 8psi of pressure and that a minimum of 8psi is required to reduce bacterial load and wound infection rates.

Singer AJ, et al. Pressure dynamics of various irrigation techniques commonly used in the emergency department. Ann Emerg Med. 1994 Jul;24(1):36-40. [PMID 8010547]

  • An in vitro study that examined amount of pressure generated by several commonly used irrigation techniques including:

  • 19g needle on a 35mL syringe

  • 19g needle on a 65mL syringe

  • IV bag pierced with a 19g needle

  • holes poked into the cap of a bottle of saline

  • IV bag with BP cuff at 400mmHg.

  • The winning technique was a 19g needle on a 35mL syringe.  Demonstrated that this technique creates 25-40psi.  None of the other techniques generated pressures above 8psi, and 8psi appeared to be the magic number required to break down the biofilm.