Wound Irrigation


Article Author:
Kevin Lewis


Article Editor:
Jeffrey Pay


Editors In Chief:
Rhonda Coffman
Lindsay Iverson
Heather Templin


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Pritesh Sheth
Hassam Zulfiqar
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes
Kavin Sugumar


Updated:
3/23/2019 2:32:49 AM

Introduction

Wounds and lacerations are common complaints bringing patients both to urgent and emergent care centers. Emergency departments in the United States see an estimated 12.2 million patients for wound closure and wound management per year.[1] The most common complication of wound care is an infection of the wound, with severe infection occurring in 2.47% of wounds sutured in the emergency department.[2] Wound irrigation is an essential part of wound management and is the single greatest intervention in wound care that can reduce the risk of infection.[3] The goal of wound irrigation is to remove foreign material, decrease bacterial contamination of the wound, and to remove cellular debris or exudate from the surface of the wound. Wound irrigation must be vigorous enough to perform the above goals but gentle enough to avoid further tissue trauma or passage of bacteria and foreign material deeper into the wound. Wound irrigation involves body fluids which may splash and spray due to the use of pressure; therefore, proper personal protective equipment is essential to the safety of wound care providers performing wound irrigation. The essential steps of wound irrigation include assessing the wound, wound anesthesia, wound periphery cleansing, and irrigation with the solution under pressure.

Anatomy

The two main layers of the skin are the epidermis and the dermis. The epidermis is composed up of epithelial cells, and the dermis is composed of dense, irregular connective tissue where blood vessels, hair follicles, sweat glands, and other structures reside. The hypodermis situates beneath the dermis and is composed mostly of loose connective and fatty tissues. Muscle, tendons, ligaments, bone, and cartilage are all located below the hypodermis.[4]

Indications

Wound irrigation is indicated in the management of both acute and chronic wounds, and especially those that will be undergoing suturing, surgical repair, or debridement.  

Contraindications

Irrigation may not be necessary for certain highly vascular areas such as the scalp.[5] Wounds with fistulas or sinuses with unknown depth should undergo careful evaluation before irrigation is performed to avoid forcing bacteria and debris containing fluids further into the wound or other body spaces.

Equipment

Multiple methods of irrigation delivery have been described using a variety of equipment. A 35 to 50mL piston syringe with an eye irrigation cup attached to the end may be used to irrigate and reduce splashing back of irrigation fluid. A 35mL syringe with a 19G catheter placed on its end generates the pressure necessary to remove debris and reduce bacterial burden in the wound. Other tricks of the trade include placing a liter of isotonic fluid in a pressure bag on an IV pole and attaching an 18 gauge catheter to the end which can provide a continuous stream of irrigation fluid under similar pressure.  You may also use an 18-gauge needle, puncture 3 or 4 holes in the cap of a bottle of irrigation, and this will create the pressure needed by squeezing the bottle for short increments. Manufacturers have now created devices that replace the cap of the irrigation bottle that acts similarly.

Personal protective gear should always be utilized when cleaning and irrigating a wound. Wound irrigation is an aseptic procedure so washing hands, donning gloves, face mask, and eye protection help avoid contamination of the wound and also protect the provider from body fluid exposure. 

Wound anesthesia is achievable with lidocaine 1% injection, lidocaine 1% or 2% with epi injection, or bupivacaine 0.5% injection around the wound site.  One may also use a topical application of a LET (lidocaine-epinephrine- tetracaine) preparation. 

Multiple wound cleansing agents are available as described below:

  • Povidone-iodine Solution- strong, broad bactericidal action against gram-positive and gram-negative bacteria; mildly toxic to healthy cells and granulating tissues.
  • Chlorhexidine - Strongly bactericidal against gram-positive bacteria, less bactericidal against gram-negative bacteria
  • Poloxamer 188 - No bactericidal effect; soap-like action to remove dirt and oil

Multiple irrigation solutions are available for wound irrigation as described below:

  • Normal Saline - non-toxic to tissues and similar in tonicity to physiologic fluids; most commonly used
  • Sterile Water - non-toxic to tissues but is hypotonic and may cause cell lysis
  • Potable Water - used in austere environments where sterile water or saline is not available; no difference found in the use of potable water vs. sterile water in wound infection rates

Personnel

Wound irrigation is readily performable by a single person. For large or difficult to reach wounds, a second person may be necessary to help position the patient or manipulate the wound for better visualization. Medics, nurses, medical students, mid-level providers, and physicians can all successfully perform wound irrigation. Wounds with fistulas or wound tracts of unknown depth or course should be evaluated and irrigated by advanced providers.

Preparation

The patient should consent to have the wound inspected, anesthetized, cleansed, and irrigated after discussion of the risks and benefits. The patient’s allergies should undergo review before the application or injection of any medications. Patient positioning should be such that both the patient and provider are comfortable during the procedure. The operator should wash his or her hands before the procedure. While complete anesthesia of the wound is usually not possible, local anesthesia should be performed prior to irrigation as it contributes to better toleration of irrigation. The periphery of the wound should be cleansed beginning at the wound and then moving out in concentric circles. Absorbent pads should be placed under the patient to minimize fluid run-off to the floor and exam bed. The operator should make use of personal protective equipment including eye/face shields, gowns, and gloves to minimize exposure risk to bloodborne pathogens.

Technique

Described in detail below is the piston syringe technique which can be performed in almost all environments with equipment that is universal to most medical clinics.

A 35 to 50mL syringe may be attached to an eye cup (to prevent splash back) or an 18 gauge plastic catheter. The syringe may be filled with the operator’s choice of irrigation solution as discussed above. An assembly consisting of a 19-gauge plastic attached to a 35 to 50mL syringe produces a pressure of 25 to 40 PSI when pushing the barrel of the syringe with both hands.[6] The upper limit of pressure where injury to tissues may occur is 70 PSI. Studies have used 250mL of irrigation fluid per 5cm of wound length or approximately 50mL per centimeter of wound length.[7] Once the operator believes that the wound has been sufficiently irrigated and that no foreign material remains the clinician may proceed to either wound dressing or primary repair depending upon the situation.

Clinical Significance

Proper wound management includes wound irrigation as it leads to better wound healing, decreased risk of infection, and decreased risk of hospital admission.

Enhancing Healthcare Team Outcomes

Wound infection is one of the most significant risks of wound management and wound closure. Wound Irrigation is an integral part of managing both chronic and acute wounds. It may be carried out by any member of the healthcare team and contributes to decreasing the infection risk. Wound irrigation is an excellent example of a procedure in which any member of the healthcare team can play a vital role in reducing risk and improving outcomes for patients.


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Wound Irrigation - Questions

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Which of the following solution is not recommended for the irrigation of wounds?



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Which of the following would be the most appropriate wound cleansing agent for a dirty wound?



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What is true about the use of normal saline to irrigate an open wound? Select all that apply.



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A 21-year-old male presents to the emergency department with a chief complaint of a laceration to his hand while using a knife to open a box one hour prior to arrival. The patient reports his tetanus vaccination series was completed with his last dose four years ago. He has no allergies and no significant past medical history. The involved extremity is neurovascularly intact, and tendon function is grossly intact. Which of the following do you do first?



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What is the ideal volume of irrigation fluid per centimeter of laceration?



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A 5-year-old male presents to the emergency department with a simple laceration to his forehead that occurred thirty minutes prior to arrival. There are no other injuries, and the mechanism does not suggest a risk of clinically significant traumatic brain injury. You intend to suture the wound for the best cosmetic result. Which of the following solutions should not be used directly in the wound while preparing for repair?



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Wound Irrigation - References

References

Ly N,McCaig LF, National Hospital Ambulatory Medical Care Survey: 2000 outpatient department summary. Advance data. 2002 Jun 4;     [PubMed]
Rutherford WH,Spence RA, Infection in wounds sutured in the accident and emergency department. Annals of emergency medicine. 1980 Jul;     [PubMed]
Edlich RF,Rodeheaver GT,Morgan RF,Berman DE,Thacker JG, Principles of emergency wound management. Annals of emergency medicine. 1988 Dec;     [PubMed]
Manna B,Morrison CA, Wound Debridement 2018 Jan;     [PubMed]
Hollander JE,Singer AJ, Laceration management. Annals of emergency medicine. 1999 Sep;     [PubMed]
Singer AJ,Hollander JE,Subramanian S,Malhotra AK,Villez PA, Pressure dynamics of various irrigation techniques commonly used in the emergency department. Annals of emergency medicine. 1994 Jul;     [PubMed]
Chisholm CD,Cordell WH,Rogers K,Woods JR, Comparison of a new pressurized saline canister versus syringe irrigation for laceration cleansing in the emergency department. Annals of emergency medicine. 1992 Nov;     [PubMed]

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