Key Practice Points
Thorough wound cleansing and irrigation are the most important steps in repairing wounds and lacerations.
Povidone-iodine solution (not scrub preparation) is the most effective skin, or periphery, cleanser.
Either water or saline can be used as a wound irrigant to flush debris and bacteria from inside a laceration.
Hydrogen peroxide has more negative than positive effects on wounds and is not recommended for wound care.
Shaving hair over wounds can lead to dermal injuries and an increased infection rate. It can be cleaned the same as skin and left alone, clipped with scissors, or flattened away from the wound with lubricants.
Never shave an eyebrow. It can grow back abnormally or not at all.
Wound care exposes the caregiver to pathogens such as human immunodeficiency virus (HIV) and hepatitis B and C. Blood and body fluid precautions should be observed.
Anesthesia should precede wound preparation to minimize the pain of a thorough cleansing and irrigation.
Cleansing and irrigation are the foundations of good wound care. These steps can be time-consuming and tedious. It is essential, however, that all contaminants and devitalized tissue are removed before wound closure. If they are not, the risks of infection and of a cosmetically poor scar are greatly increased. Neither clever suturing technique nor the use of prophylactic antibiotics can replace meticulous cleansing and irrigation and, if needed, judicious débridement.
Wound Cleansing Solutions
Several skin-cleansing preparations are available commercially ( Table 7-1 ). Most of the clinical data that compare the efficacy of these agents come from studies of elective surgery patients or experiments on laboratory animals. Only in more recent years have there been reports detailing the use of skin-cleansing preparations for emergency use. Based on these studies and the properties of the cleansing solutions, guidelines for use in emergency wound care can be suggested.
|Skin Cleanser||Antibacterial Activity||Tissue Toxicity||Systemic Toxicity||Potential Uses|
|Povidone-iodine surgical scrub||Strongly bactericidal against gram-positive and gram-negative viruses||Detergent can be toxic to wound tissue||Painful to open wounds||Hand cleanser|
|Povidone-iodine solution||Same as providone-iodine scrub||Minimally toxic to wound tissue||Extremely rare||Wound-periphery cleanser|
|Chlorhexidine||Strongly bactericidal against gram-positives, less strong against gram-negatives||Detergent can be toxic to wound tissue||Extremely rare||Hand cleanser|
|Poloxamer 188||No antibacterial activity||None known||None known||Wound cleanser (useful on face) Alternative wound periphery cleanser|
|Saline||None known||None known||None known||Wound irrigant|
Povidone-iodine (Betadine) is a complex of the potent bactericidal agent iodine and the carrier molecule povidone. On contact with tissues, the carrier complex slowly releases free iodine. Gradual release decreases tissue irritation and reduces potential toxicity while preserving the agent’s germicidal activity. Povidone-iodine is effective against gram-positive and gram-negative bacteria, fungi, and viruses. In contrast to chlorhexidine, povidone-iodine has a shorter protective effect against bacterial buildup on the skin after hand washing and seems to be less effective than these agents for that purpose.
Povidone-iodine is manufactured as a solution by itself (povidone-iodine solution) or in conjunction with an ionic detergent (povidone-iodine scrub preparation). The detergent in the scrub preparation seems to be toxic to several normal tissues and to components of an open wound. Excessive exposure of open wounds to scrub solutions by wound scrubbing or soaking is not recommended. Scrub solutions were designed for preoperative preparation of intact skin before operative incisions.
Povidone-iodine, without the detergent, is distributed most commonly as a 10% solution. When diluted to a 1% concentration or lower, it can be applied safely to wounds, and it retains its bactericidal activity. It has no inherent negative effect on wound healing. The lack of clinical toxicity of povidone-iodine without detergent was shown with 225 patients undergoing ophthalmologic surgery. Povidone-iodine 10% solution, diluted with saline, was used to prepare the eye and its surrounding structures for surgery. There was no reported corneal, conjunctival, or skin toxicity. Adverse and allergic reactions are extremely rare, even when the solution is used in known iodine-allergic patients.
Chlorhexidine (Hibiclens) is an antibacterial biguanide that is effective against gram-positive bacteria. This agent also is effective against gram-negative bacteria but is less so than povidone -iodine. Its action against viruses is uncertain. Repeated use can lead to buildup on the skin and prolonged suppression of hand bacterial count. For this reason, it is an excellent hand-washing preparation. Under normal conditions of use, chlorhexidine has a low toxicity. The skin cleanser contains an ionic detergent similar to the povidone-iodine scrub preparation, and direct contact with an open wound is discouraged despite its low toxicity.
Potentially useful wound cleansers are the nonionic surfactants pluronic F-68 (Shur-Clens) and poloxamer 188 (Pharma Clens). These are surface-active agents with the cleansing properties of soap but virtually no tissue toxicity, including to the eye and cornea. There are no demonstrable adverse effects in wounds and lacerations. Poloxamer 188 has been used successfully in a trial of more than 3000 patients without serious side effects. The major drawback of the nonionic surfactants is that they have no antibacterial activity. For this reason, alternative cleansing agents, such as povidone-iodine, are preferable for contaminated wounds. Conversely, surfactants are well suited for use on the face because they are nontoxic to the eye, and the face is naturally resistant to infection.
Without a clear scientific basis, as if by tradition alone, hydrogen peroxide is used commonly in emergency wound care. As it comes into contact with blood and tissue peroxidase, hydrogen peroxide makes visible bubbles from liberated oxygen. The reaction causes foaming that is thought to dislodge bacteria, debris, and other contaminants from small crevices in tissues. This effect gives the appearance of cleansing activity, but this agent has many drawbacks. It is naturally hemolytic, and the oxygen bubbles have been shown to separate new epithelial cells from granulation tissue. The germicidal action of hydrogen peroxide is weak and brief at best. In a controlled study of appendectomies, hydrogen peroxide topically applied to the incision site before suture closure did not reduce the infection rate compared with the control. Under experimental wound conditions, it can delay healing. Because of its hemolytic effect, hydrogen peroxide is best limited to a role as an adjunctive agent for wounds encrusted with blood.
Preparation for Wound Cleansing
Before cleansing and irrigating a laceration or wound, several issues, including hand washing, personnel precautions, hair removal, anesthesia, foreign material, wound soaking, wound periphery cleansing, and irrigation, have to be considered.
Because of the unsterile nature of traumatic wounds, fixed-time hand washing with preoperative scrubbing techniques are not necessary. Although a simple, brief hand washing suffices before each procedure, it is necessary to ensure that the fingernails have been well cleaned because they harbor more bacteria than other parts of the hand. Chlorhexidine is a good choice for hand washing. As a skin cleanser, it is well tolerated by users. With repeated washings, it builds up in the skin, with an accompanying prolonged antibacterial effect, and it does not stain clothing the way povidone-iodine does. Compliance with hand washing among emergency personnel has been shown to be poor. Nurses have been observed to comply (hand washing after patient contact before proceeding to the next contact) after 58.2% of patient contacts, residents after 18.6%, and faculty after 17%. Hand washing is just one of the defenses against the risks.
An advance in hand washing has made it much easier to comply with this requirement. Newer alcohol-based products allow for rapid, self-drying application. These agents are equally efficacious as soap-based products are in reducing bacterial counts, and the agents have equivalent cleansing power.
Blood and Body Fluid Precautions
Because preparing and cleansing a wound brings wound care personnel into contact with blood and other secretions, it is recommended that appropriate protective gloves and eyewear are worn at all times. Gowns also are recommended but are not always practical.
The main infective agents that are of concern in the emergency department are hepatitis B and C and HIV. The prevalence of HIV in urban emergency-department patients has been reported to be as high as 4% to 5%. More important, 25% of these patients are unaware of their HIV-positive status on presentation. It is common for practitioners to be diligent about protecting themselves during major trauma resuscitations. The bleeding laceration is no less a threat when suture needles, tissue scissors, and scalpel blades are in use.
Wound Area Hair Removal
It is common practice to shave hair around lacerations and other wounds before repair. Although there are no studies concerning hair removal in the wound care setting, shaving has the potential to increase the wound infection rate. Close shaving of intact skin can cause small dermal wounds that can act as portals of entry for bacterial invasion and possible infection. Two studies of patients, shaved versus not shaved for elective surgery, showed an increase in postoperative wound infection rates in the shaved groups. Although hair shafts harbor bacteria, structures such as roots, glands, and follicles do not contain high bacterial counts under normal conditions. Hair can be cleansed easily and successfully using standard techniques for applying antiseptic solutions.
A case for hair removal can be made on technical grounds. In areas such as the scalp, it is much easier to close lacerations without having the suture material become entangled with hair. Hair that is inadvertently buried in wounds can result in wound infection. Clipping hair around the wound with scissors and shaving with a recessed blade razor are techniques for hair removal that avoid dermal damage.
Another technique to expose the wound surrounded by hair is to apply sterile exam lubricant to flatten the hair away from the wound. Antibiotic ointment can be used as well. However, the jelly lubricant is water soluble and easier to remove then the petroleum-based ointment.
The only site from which hair is absolutely not shaved or clipped is the eyebrow ( Fig.7-1 ). Hair regrowth of the brow is unpredictable in many patients, and return to the original appearance cannot be guaranteed. Eyebrow hair can be cleansed readily, and the brow borders provide excellent landmarks for laceration alignment during wound closure.