Wound hygiene (eg, cleansing, irrigation, and debridement), including thorough examination of the wound and surrounding tissues, promotes uncomplicated healing of traumatic skin wounds and is required prior to wound closure.
Wound healing is impaired by various factors (eg, bacterial contamination, foreign bodies, wound ischemia, host factors). All traumatic wounds are assumed to be contaminated. The goal of wound hygiene is to reduce the contaminant burden without causing further tissue damage or introducing more contaminants.
Diagnosis and management of foreign bodies in wounds are a critical part of wound hygiene. Occasionally, identified or suspected foreign bodies are deeply seated, requiring referral to a surgical specialist.
Factors That Interfere With Wound Healing
Tissue ischemia (due to features of the wound or locally poor circulation)
Disorders affecting peripheral vasculature (eg, diabetes, arterial insufficiency)
Type of injury (eg, a crush-type injury, which damages the microvasculature)
Repair techniques (eg, overly tight sutures)
Use of cautery
Foreign material (including deep dermal suture material)
Delayed treatment (eg, > 6 hours for lower-extremity injuries; > 12 to 24 hours for face and scalp injuries)
Significant wound contamination (as typically occurs in bite wounds)
Antiplatelet drugs and anticoagulants
Drugs that suppress inflammation (eg, corticosteroids, immunosuppressants)
Disorders that suppress the immune system or impair healing (eg, chronic kidney disease)
Undernutrition (eg, protein-calorie undernutrition, deficiencies of specific nutrients such as vitamin C)
(See also Lacerations. )
- Traumatic skin wounds
- Wounds of highly vascularized skin (eg, scalp and face) may not need irrigation.
- Deep wounds or those with sinuses or fistulas should be carefully evaluated* before irrigation to avoid causing deeper seeding of bacteria or foreign material.
- Puncture wounds should be irrigated and debrided at the surface, particularly if secondary to cat bites given their high likelihood of infection. However, the value of deep probing, irrigation, and coring is not certain.
- Actively bleeding wounds should not be irrigated, because irrigation may disturb clot formation; hemostasis must precede irrigation.
- Wounds involving deep structures (eg, nerves, blood vessels, ducts, joints, tendons, bones) and those covering large areas require specific repair techniques that may necessitate referral to a surgical specialist. Hand lacerations or injuries, particularly high-pressure injections or those requiring microscopic repair procedures, need surgical evaluation. Facial lacerations, deep or complex wounds, or wounds involving the eyelids also need specialist consultation or evaluation.
* Imaging studies (eg, x-rays and ultrasonography) should be obtained for deep wounds, puncture wounds, and other wounds that potentially involve a fracture or may contain foreign bodies (eg, teeth, glass, or splinters). CT as well as MRI can help locate foreign bodies, particularly when their location in relation to underlying structures is important.
- Infection, the risk of which is increased by insufficient cleansing or debridement, foreign body retention (especially wood splinters or other organic material), or overly aggressive debridement of viable tissue
- Further tissue damage or deeper inoculation of bacteria and foreign material due to overly aggressive wound hygiene
Wound hygiene and closure techniques need not be sterile procedures. Although instruments that touch the wound (eg, forceps, needles, suture) must be sterile, clean nonsterile gloves as well as clean but not sterile water may be used in immunocompetent patients. Some operators prefer the better fit and better barrier protection of sterile gloves.
Clean procedure, barrier protection
- Face mask and safety glasses (or a face shield), head cap, gown, gloves (sterile if preferred, but these are nonsterile procedures)
- Sterile drapes, towels (for wound debridement and suturing)
Wound cleansing, inspection, debridement (not all items are required for simple repairs)
- Overhead procedure light
- Antiseptic solution (eg, chlorhexidine, povidone-iodine)
- Sterile gauze squares (eg, 10 cm ×10 cm [4 inch × 4 inch])
- Pneumatic tourniquet (or blood pressure cuff), commercial hemostatic agent, as needed to assist hemostasis
- Local anesthetic (eg, 1% lidocaine with epinephrine 1:100,000, 25-gauge needle): Do not use epinephrine in extremities affected by peripheral vascular disease, in digits, the penis, or tip of the nose, or at distal sites when a compression tourniquet is also being used. Local anesthetics are discussed in Lacerations.
- For certain patients (eg, children), topical anesthetic (eg, proprietary emulsions of 2.5% lidocaine plus 2.5% prilocaine)
- Sterile saline for irrigation (sterile water or clean, potable water are permissible substitutes)
- 35-mL and/or 60-mL syringes
- Irrigation shield (syringe attachment to block splashing)
- Plastic catheter (eg, 18- or 19-gauge standard catheter) or commercially available splash guard device
- Fine-pore sponge (eg, 90 pores per inch)
- Tissue forceps (eg, Adson forceps), tissue hook, probe, hemostat, splinter forceps (fine-tipped), and suture scissors (single blunt-tip, double sharp edge)
- Scalpel (#10 for large incisions, #15 for precise incisions, #11 for small stab incisions), iris scissors, or curette
- Antibiotic ointment: Topical antibiotic ointments continue to be recommended for sutured wounds because they help keep wound edges moist and prevent dressings from sticking. However, they have not been proven to reduce infection or enhance healing.
- Sterile nonadherent, absorbent, and/or occlusive dressing
- Gauze roll and tape or gauze sleeve
- Sometimes splints or other materials to restrict motion or skin tension that may pull on the wound
- Adequate anesthesia is important because these procedures may be painful, and insufficient anesthesia may result in insufficient cleansing, inspection, and debridement. Always do the neurovascular examination (distal to the wound) before giving anesthesia.
- Intradermal anesthetic injection itself is painful. Subdermal (subcutaneous) injection causes less pain and is preferred.
- Nerve blocks and procedural sedation and analgesia should be used as needed for wounds that are difficult to anesthetize using local anesthesia (eg, very painful or large wounds) and for agitated or uncooperative patients.
- Hair removal is generally not recommended, except when closure using adhesive strips is anticipated. To remove hair, clip rather than shave it. Eyebrows must remain intact to achieve accurate alignment of wound edges during suturing.
- Wound tissue can be vulnerable to further injury during cleansing and closure. Do not use excessive force during irrigation and scrubbing. To avoid crushing tissue, never grasp it with a hemostat.
- A retained foreign body in a wound is suggested by pain or foreign-body sensation (enhanced by motion) in the absence of infection.
- Suspected foreign bodies can often be identified using ultrasonography.
- Some foreign bodies (eg, small fragments of glass or metal in a puncture wound) may be allowed to remain in a wound if removal would incur additional tissue damage and further impair healing. Patients should be told that a retained foreign body is possible and given wound care instructions that include watching for signs of infection.
- Dressings should keep wounds moist—but not too moist. Typically, a nonstick porous dressing is placed directly over the wound, followed sometimes by an absorbent dressing sufficient to absorb the wound's secretions, followed lastly by an occlusive dressing. The dressing contacting the wound must not dry and adhere to the wound because fragile granulation tissue would be ripped from the healing wound bed when the dressing is removed for changing.
- Tetanus vaccination and immune globulin may be needed depending on the wound type and patient's vaccination history (see table Tetanus Prophylaxis in Routine Wound Management).
- Position the patient comfortably reclined or supine. Allow space for a basin to be placed under the wound during irrigation.
- Adjust the stretcher height so that you will be comfortable either sitting or standing at the bedside.
- The wound should be well lit, preferably with an overhead procedure light.
Step-by-Step Description of Procedure
(See Lacerations for detailed discussions of the treatment and healing of skin wounds.)
- Place all equipment on a tray within your—but not the patient's—reach.
- Wear gloves and a face shield or protective eyewear and a mask.
- Initially wash heavily contaminated wounds, eg, using tap water and a gentle hand soap. Depending on wound location, patients can do this themselves; local anesthesia may be needed.
- Hemostasis: Direct pressure to the site is the primary technique. Use finger pressure or gauze pads (may be moistened with sterile saline) to hold external pressure on the wound. Elevate the area if possible, and, if needed, use other means (eg, inflated blood pressure cuff, brief application of a proximal tourniquet, injected or topical 1% epinephrine with lidocaine) to attain hemostasis. Elevation and use of a proximally placed compression tourniquet are often helpful in achieving hemostasis of hand wounds. Avoid clamping blood vessels to avoid inadvertently clamping tendons, nerves, or other important structures.
- Wound evaluation: Document the wound's history, location, size, degree of contamination, foreign bodies, associated injuries (eg, fractures and muscle and tendon disruptions), and neurovascular status distal to the wound. Check range of motion in all appropriate joints, particularly if a tendon injury is possible.
- Imaging studies: Do imaging studies for all wounds involving glass and for wounds if the history or clinical findings suggest a foreign body (eg, puncture wounds of the foot, any puncture deeper than 5 mm, or animal or human bites). Plain x-rays are sensitive for glass (≥1 mm) and most inorganic material (eg, stones). Most organic materials (eg, wood splinters, plastic) are radiolucent but can be detected by ultrasonography or CT or MRI.
- Skin cleansing: Proceed from the wound edges outward, wiping in concentric circles with chlorhexidine or povidone-iodine solution followed by alcohol solution. Do not introduce a cleansing agent directly into the wound because many are toxic to tissues and may interfere with wound healing.
Local infiltration anesthesia
- Hold the local anesthetic syringe at a shallow angle to the skin. Insert the needle directly into the exposed subdermal layer of the wound edge (ie, do not insert the needle percutaneously) and advance the needle to the hub. Pull back on the plunger to exclude intravascular placement. Then inject the anesthetic, minimizing the pressure of injection while slowly withdrawing the needle.
- Continue to anesthetize the circumference of the wound, subdermally inserting the needle into regions already anesthetized, advancing the needle into contiguous unanesthetized tissue, and injecting while withdrawing the needle. Repeat around the entire wound.
Dirty wounds may require scrubbing (as described below) before irrigation.
- Irrigate the laceration using sterile saline in a 35- or 60-mL syringe (preferably with a splash guard attached but otherwise via a plastic catheter).
- Use a tissue forceps or probe to expose the tissue, and irrigate the entire depth and full extent of the wound.
- Press down on the plunger with the thumbs of both hands in order to produce enough pressure to remove particulate matter and bacteria. The volume of the fluid required varies with the size of the wound and the degree of contamination. Typically, 50 to 100 mL per centimeter of wound length is used, but for relatively clean wounds, 30 to 50 mL per centimeter is usually adequate.
- Continue irrigation until the wound is visibly clean. If irrigation is ineffective in removing visible particles, scrubbing (described below) is required.
- Scrub gently, using a fine-pore sponge (if available) to minimize tissue abrasion.
- Use a portion of the sponge to first scrub the skin surface around the wound to remove foreign material that could enter the wound.
- Use the remaining sponge to scrub the internal surface of the wound. Use care when scrubbing because the sponge may damage the internal tissues and provoke inflammation.
- After scrubbing, irrigate the wound as described above.
- Place a fenestrated drape over the wound.
- Examine the wound under good lighting and after bleeding has been controlled.
- Use a tissue forceps or probe to expose the wound tissue, and explore the entire depth and full extent of the wound to locate foreign bodies, particulate matter, bone fragments, and injuries to underlying structures. Do not explore the wound with your finger, because sharp foreign bodies may cause injury.
- Use the forceps or #15 scalpel to remove visible objects from the wound. Use gauze to remove particulate matter.
- Sometimes you may need to extend the wound edges or occasionally its depth to see adequately.
- After inspecting and removing matter from the wound, irrigate the wound.
- Debride all devitalized and necrotic tissue: Stabilize the wound edge with forceps, then cut away the devitalized tissue with a scalpel or iris scissors. Make the cuts perpendicular to the skin surface, not on an angle (to maximize dermal apposition during closure).
- Wound edge contamination that cannot be removed by irrigation and scrubbing (eg, grease and grit from power tool injury) may need to be removed by debridement.
- To debride a fistula or through-and-through puncture wound, moisten some gauze and gently pull it through the tract in the direction opposite to the puncture using a forceps or hemostat.
- After debridement, irrigate the wound again to remove any remaining debris.
The wound is now prepared for closure and dressing. (See Lacerations regarding which wounds may benefit from delayed closure or no closure.) For wounds that require closure, the closure can be done using simple interrupted sutures, buried deep dermal sutures, horizontal mattress sutures, vertical mattress sutures, a subcuticular running suture, glue, or stapling, depending on the nature of the wound.
- Gently wipe away any remaining cleansing agent and dried blood or skin debris using moistened gauze.
- If the wound has been closed with sutures, many operators apply topical antibiotic to keep the sutures from adhering to the dressing.
- Place a nonadherent dressing on the wound.
- If significant oozing or bleeding seems possible, apply a sterile absorbent dressing over the nonadherent dressing. Use a thick layer if considerable drainage is anticipated. Follow wounds at risk of heavy bleeding closely.
- For wounds in locations subject to significant soilage, apply a sterile occlusive dressing.
- Apply adhesive tape or a circumferential gauze wrap to keep the dressing in place. Be careful not to place circumferential wraps too tightly, which may lead to excessive compression and subsequent ischemia.
* Some wounds typically are not dressed (eg, facial lacerations and those within areas that have hair).
- Instruct the patient to keep the dressing dry and in place and to return in 2 days for a wound check or, if delayed closure is anticipated, in 3 to 5 days.
- Prophylactic oral antibiotics may be given to prevent infection of dirty (especially organically contaminated) wounds, particularly for diabetic and immunocompromised patients.
Warnings and Common Errors
- Proper wound care must include thorough examination regardless of anticipated closure method; a common error is to do cursory exploration and no debridement because a noninvasive closure not requiring local anesthesia is planned.
- Wounds with possible retained foreign bodies, joint penetration, or damage to underlying structures such as tendons require full wound exploration and observation through the range of motion of adjoining joints.
Drugs Mentioned In This Article
|Drug Name||Select Trade|
|immune globulin||Gammagard S/D|