Continuing Education Activity

Wounds and lacerations are common complaints. Each year in the United States, roughly 12.2 million patients are seen in emergency departments for wound closure and wound management. The most common complication of a wound is an infection, with severe infection occurring in 2.47 percent of wounds sutured in the emergency department. Wound irrigation is an essential part of wound management and is the single greatest intervention in wound care to reduce the risk of infection. This activity illustrates the importance of wound irrigation and highlights the role of the interprofessional team in the management of patients with dirty or contaminated wounds.

Objectives:

• Identify the indications for wound irrigation.
• Describe the technique involved in wound irrigation.
• Describe the contraindications to wound irrigation.
• Outline the strategies of the interprofessional team for enhancing care coordination and communication to advance the management of contaminated wounds and attain the best possible standard of care for patients with wounds and lacerations.

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 and Physiology

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 or Treatment

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.

Complications

Wound irrigation should not be performed if the wound is actively bleeding, as irrigation may dislodge any clots that are forming. Incomplete wound irrigation can lead to the persistence of debris or purulent discharge left inside the wound, especially in abscesses that may end up in sinus formation. When using povidone-iodine, care must be exercised not to pour it profusely inside the wound however, it should be used on the wound edges. 

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.[8] Wound Irrigation is an integral part of managing both chronic and acute wounds[9]. The optimal care for patients with wounds and/or lacerations is best achieved by interprofessional collaboration among healthcare professionals. 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[10]. The nurse plays a very important role in the care of patients with wounds and/or lacerations. The nurse needs to assist the clinician during the pre-operative preparation of the patient. During the wound irrigation procedure, the nurse assists the provider in the proper positioning of the patient and ensures that all required equipment is readily available. After the procedure, the nurse monitors the patient and should be vigilant for any untoward changes in the vital signs of the patient. Any changes in the status of the wound and/or laceration should be immediately reported to the provider. The best standard of care to wound patients could only be achieved through harmonious collaboration among the interprofessional team.

Nursing, Allied Health, and Interprofessional Team Monitoring

• Vital signs
• Pain scores
• Symptoms and/or signs of wound infection
• Symptoms and/or signs of wound dehiscence
• Symptoms and/or signs of anaphylaxis or allergy to the irrigating solutions