Wound irrigation

[Perrotfish]

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Just curious, what is y'all's practicing for cleaning wounds? I was always told old fashioned high intensity high volume irrigation, but I have had a few lectures recommending different methods. So:

1) What fo you use? Tap water, distilled water, or saline?

2) High or low volume?

3) High or low pressure?

4) Do you put on a topical antibiotic afterwards? If so what?

 

[KGflyboy]

I typically use sterile saline. Poke holes in the top with big needle and creat a squirt bottle. If it's on a hand or arm, I will numb it up and have them rinse it really well under the sink. If it doesn't look clean after a couple minutes, then I'll do a little additional irrigation with my saline bottle method until I'm satisfied. I'm hit or miss on topical abx. There is no rhyme or reason to when I use it and when I don't. I use bacitracin if anything at all.

 

[BoardingDoc]

Just curious, what is y'all's practicing for cleaning wounds? I was always told old fashioned high intensity high volume irrigation, but I have had a few lectures recommending different methods. So:

1) What fo you use? Tap water, distilled water, or saline?

2) High or low volume?

3) High or low pressure?

4) Do you put on a topical antibiotic afterwards? If so what?

1: Sterile saline instead of tap water because patients appreciate the medical theater, unless it's on a hand. Then I just tell the patient to scrub it with soap and water in the sink.

2: 50-100ccs or so unless it's filthy, then I use more. If it's really busy: however much my tech runs through the wound before I get to the patient.

3: Generally high pressure from a syringe unless it's a puncture wound.

4: No. I use topical antibiotics for skin tears, abrasions and superficial partial thickness burns where the blisters have popped.

 

[The White Coat Investor]

Just curious, what is y'all's practicing for cleaning wounds? I was always told old fashioned high intensity high volume irrigation, but I have had a few lectures recommending different methods. So:

1) What fo you use? Tap water, distilled water, or saline?

2) High or low volume?

3) High or low pressure?

4) Do you put on a topical antibiotic afterwards? If so what?

Tap sometimes but usually sterile saline

High (at least 200 cc for even small wounds, a liter for larger

High as I can get in a 60 cc syringe

Bacitracin

 

[Fox800]

1. Tap water is fine. Sometimes use sterile saline/water with a syringe with a splash guard. The pressure is what matters, not the solution.

2. 60 cc per cm is what I was taught. Not always what happens though.

3. High pressure.

4. Bacitracin

 

[Apollyon]

You need 7 psi. That can be done with the 30cc or 60cc syringe. You can do it with a smaller syringe, of course, but I would NEVER want to irrigate a wound 10mL at a time. Tap water is fine, but, as my esteemed colleague above says, it's part of the theatre.

I do topical antibiotics never (or nearly never). If the nurse wants them, fine.

 

[Angry Birds]

Urine. It's sterile.

 

[gro2001]

Agree with all of the above. Always high volume, usually saline recognizing that there is probably no difference. Sometimes, depending on logistics (how difficult it is to get space around the patient, where the wound is, where the nearest sink is) and my gestalt of the patient, I will have them run it under tap water in the sink.

I apply bacitracin when I really care about cosmetic outcome (usually just the face). While it hasn't been shown to really decrease the number of infected wounds, inflammation plays a significant role in scarring. I think applying a barrier ointment of any kind, but particularly an antibiotic one like bacitracin, decreases the amount of inflammation a wound experiences until it is fully epithelialized, and decreases scarring. But this is complete voodoo on my part.

 

[turkeyjerky]

Just wanted to drop in a cople of points that I wasn't always aware of.

1. The sink, unless your tap is seriously corroded, provides an adequate PSI. (It also provides far more volume than is feasible with a syringe)

2. Any antibiotic can cause contact dermatitis--I usually tell patients to use vasoline, which I believe has been shown to have the best cosmetic outcome.

I don't care so much about the medical theater--I prefer patient empowerment. I hate it when people come in with a wound and they tell me they didn't clean I under the sink because they thought it would make it worse.

 

[Perrotfish]

So it sounds like most of you are doing what I'm cureently doing. The lecture I just went to was arguing that lower pressures and volumes have better outcomes (both cosmetic and infection rate), that tap water is superior to NS, and that all topical antibacterial treatments (with the possible exception of medihoney) worsen outcomes. I'm trying to decide if he was convincing enough to change my practice.

 

[deleted206819]

I use tap water whenever it is appropriate but it is all about volume of water used and not so much pressure. I never use topical antibiotics for the same reason that @turkeyjerky mentioned.

 

[Rendar5]

I e treated thousands of lacerations and removed just as many sets of sutures. I use bacitracin ointment all the Time. I have seen exactly 0 cases of topical dermatitis from typical antibiotic ointments. I have seen several cases of topical dermatitis from ear drops and eye drops before and have actually experienced it myself when I used stuff for a case of pink eye during residency. But transdermal ointment never seen a case.

I think that not using it for that specific reason for typical lacerations is a little bit silly. I’d need to see it but data suggesting worse outcomes with antibiotics doesn’t quite pass the sniff challenge. I would believe data showing no superiority of antibiotics though if it were a good study.

 

[GonnaBeADoc2222]

Agree with all of the above. Always high volume, usually saline recognizing that there is probably no difference. Sometimes, depending on logistics (how difficult it is to get space around the patient, where the wound is, where the nearest sink is) and my gestalt of the patient, I will have them run it under tap water in the sink.

I apply bacitracin when I really care about cosmetic outcome (usually just the face). While it hasn't been shown to really decrease the number of infected wounds, inflammation plays a significant role in scarring. I think applying a barrier ointment of any kind, but particularly an antibiotic one like bacitracin, decreases the amount of inflammation a wound experiences until it is fully epithelialized, and decreases scarring. But this is complete voodoo on my part.

I think that some academics just like to watch dogma burn.

 

[gro2001]

I think that some academics just like to watch dogma burn.

Sorry, I think your joke wooshed over my head. Did I say something antidogmatic? I thought I was expressing commonly accepted points of view.

 

[TMP-SMX]

I e treated thousands of lacerations and removed just as many sets of sutures. I use bacitracin ointment all the Time. I have seen exactly 0 cases of topical dermatitis from typical antibiotic ointments. I have seen several cases of topical dermatitis from ear drops and eye drops before and have actually experienced it myself when I used stuff for a case of pink eye during residency. But transdermal ointment never seen a case.

I think that not using it for that specific reason for typical lacerations is a little bit silly. I’d need to see it but data suggesting worse outcomes with antibiotics doesn’t quite pass the sniff challenge. I would believe data showing no superiority of antibiotics though if it were a good study.

Yeah they all come to me in dermatology because when they go back to the ED they are told it is still infected and given antibiotics. We still use bacitracin because old habits die hard because we have packets of both petroleum jelly and bacitracin for surgery and biopsies. Bacitracin allergy isn't that common but it certainly happens and there are rare reports of anaphylaxis from bacitracin. It's just not worth it I try to use straight up vaseline or aquaphor for clean wounds. Unfortunately there's also a rare beast allergic to the lanolin in aquaphor.

 

[deleted109597]

Tapwater. It's got a drain built in and you can use much, much higher volumes.
Never irrigate the face unless there's like feces in the wound. It worsens cosmesis.
I use antibiotic ointment because it helps with scar appearance. Of course, that's not the antibiotic portion, but I don't have vaseline in the ER, and surgilube isn't as effective. If they get irritation from triple ABx I tell them to go down to bacitracin or just vaseline.
Sunscreen.
I generally use that time as well as the time repairing to explain why I'm doing what I'm doing, and they're welcome to look it up and disprove their other doctors.

 

[alpinism]

Tapwater FTW.

Haven't used saline for irrigation since med school.

Good overview of the current literature: Evidence Based Laceration Repair - SOCMOB Blog

 

[Groove]

1) NS or SW
2) High volume
3) High pressure
4) No topical abx

 

[RoyBasch]

I use tap water for anything that is practical to get under a sink (usually hand/upper extremity) because I think it gets more volume, more pressure, and way easier management of the effluent. The only reason I use NS on face/scalp/trunk wounds is because I cannot practically get the patient's face under the sink, so I either use the NS bottle with a hole punched in the cap if i'm going to irrigate more than 250 mL or a 30 mL syringe for less.

I try to follow the rule of 50-100 mL/cm of laceration total volume.

The plastic surgeons I work with say the best topical oinment for lacerations is plain vasoline, but since we dont' have that in our ER I use bacitracin because we have it. I try to avoid "triple" antibiotic ointment because it is not superior and has 3x the chance of a local allergic reaction. (anecdotally it seems the incidence of allergic reaction/local irritation for polymixin and neosporin is higher than bacitracin).

I advise the patient to use vasoline at home after their first dressing change.

 

[Perrotfish]

Tapwater FTW.

Haven't used saline for irrigation since med school.

Good overview of the current literature: Evidence Based Laceration Repair - SOCMOB Blog

I love that there is a SOCMOB Blog

 

[RustedFox]

I love that there is a SOCMOB Blog

Does anyone want to curate a list of all-star EM-related blogs?
Forgive me if this has already been done; I'm exhausted.