CLINICAL PRACTICE
GUIDELINE:
Wound Preparation
What method of wound preparation is most effective
for promoting wound healing and reducing rates of
infection for patients in the emergency department
with acute lacerations?
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Table of Contents
Background and Significance__________________________________________________________________3
Methodology_______________________________________________________________________________3
Summary of Literature Review________________________________________________________________5
Description of Decision Options/Interventions and the Level of Recommendation_________________________6
References_________________________________________________________________________________7
Authors___________________________________________________________________________________8
Acknowledgments___________________________________________________________________________8
Appendix 1: Evidence Table___________________________________________________________________9
Appendix 2: Other Resources Table____________________________________________________________13
Appendix 3: Study Selection Flowchart and Inclusion/Exclusion Criteria_______________________________15
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Background and Significance
Each year millions of patients with acute lacerations present to emergency departments for treatment. Management of these
wounds will vary by practitioner, emergency department, and geographic location but the goal is the same: proper preparation
of the wound to reduce the risk of infection and promote wound healing in order to achieve optimal results for the patient (Nicks,
2010; Dulecki, 2005).
Wound cleansing and irrigation for acute lacerations is one of the most frequent procedures performed to remove loose devitalized
tissue, bacteria, and foreign bodies (Nicks, 2010). The standard of care for wound cleaning and irrigation of acute wounds in
reducing the risk of infection and promoting optimum healing has been the subject of evolving research over the past several
decades. Chatterjee (2005) reviewed several studies looking at the benefits of different irrigation techniques and concluded that there
was a lack of substantial evidence to support one technique over another. There are multiple considerations in wound management
including type, location, age, and size of the wound, as well as patient factors such as age and co-morbidities (Hollander et al. 2001).
Hollander et al. identified that wound infection rates increased with patient age, diabetes, and jagged edge wounds.
This Clinical Practice Guideline (CPG) evaluates the scientific evidence for laceration preparation in regards to type of cleansing
fluid, irrigating pressures optimal for cleaning a wound without damaging tissue, and patient satisfaction and comfort with
cleansing technique.
Methodology
This CPG was created based on a thorough review and critical analysis of the literature following ENA’s Requirements for the
Development of Clinical Practice Guidelines. Via a comprehensive literature search, all articles relevant to the topic were identified.
The articles reviewed to formulate the recommendations in this CPG are described in Appendix 1. The following databases were
searched: PubMed, Google Scholar, CINAHL, Cochrane Library, Agency for Healthcare Research and Quality, and the National
Guideline Clearinghouse. Searches were conducted using various combinations of the key words including wound cleansing, wound
irrigation, acute wound care, and traumatic wound care. Initial searches were limited to English language articles from January
2005 – October 2011. This six-year search limit was found to be inadequate due to the limited number of relevant articles found
and, therefore, the time frame was removed. A new search was conducted in 2015, following the same guidelines used for the initial
search, and included the time frame of October 2011 to July 2015. Only three new articles were found to be relevant in the literature
search, and these articles showed no change in clinical practice of wound preparation (Appendix 3). In addition, the reference lists
in the selected articles were scanned for pertinent research articles. Research articles from emergency department settings, nonemergency department settings, position statements and guidelines from other sources were also reviewed. Clinical findings and
levels of recommendations regarding patient management were made by the Clinical Practice Guideline Committee according to
ENA’s classification of levels of recommendation for practice (Table 1).
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Table 1. Levels of Recommendation for Practice
Level A recommendations: High
• Reflects a high degree of clinical certainty
• Based on availability of high quality level I, II and/or III evidence available using Melnyk & Fineout-Overholt grading system
(Melnyk & Fineout-Overholt, 2005)
• Based on consistent and good quality evidence; has relevance and applicability to emergency nursing practice
• Is beneficial
Level B recommendations: Moderate
• Reflects moderate clinical certainty
• Based on availability of Level III and/or Level IV and V evidence using Melnyk & Fineout-Overholt grading system
(Melnyk & Fineout-Overholt, 2005)
• There are some minor or inconsistencies in quality evidence; has relevance and applicability to emergency nursing practice
• Is likely to be beneficial
Level C recommendations: Weak
• Level V, VI and/or VII evidence available using Melnyk & Fineout-Overholt grading system (Melnyk & Fineout-Overholt,
2005) - Based on consensus, usual practice, evidence, case series for studies of treatment or screening, anecdotal evidence
and/or opinion
• There is limited or low quality patient-oriented evidence; has relevance and applicability to emergency nursing practice
• Has limited or unknown effectiveness
Not recommended for practice
• No objective evidence or only anecdotal evidence available; or the supportive evidence is from poorly controlled or
uncontrolled studies
• Other indications for not recommending evidence for practice may include:
◦◦ Conflicting evidence
◦◦ Harmfulness has been demonstrated
◦◦ Cost or burden necessary for intervention exceeds anticipated benefit
◦◦ Does not have relevance or applicability to emergency nursing practice
• There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as
highly as the individual studies on which they are based. For example:
◦◦ Heterogeneity of results
◦◦ Uncertainty about effect magnitude and consequences,
◦◦ Strength of prior beliefs
◦◦ Publication bias
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Summary of Literature Review
Wound Cleansing and Irrigation Methods
In order for wound irrigation to be effective, the force of the irrigation must be great enough to remove debris and organic material
(bacteria, viruses) from the surface of the wound without causing harm to surrounding tissues (Luedtke-Hoffman & Schafer, 2000).
Wound cleansing and irrigation may be accomplished using a variety of methods including syringes with intravenous (IV) catheters
or needles attached, or specialty irrigation devices.
Wound irrigation research has been carried out on various models including in vitro, live animal, and human. Stevenson, Thacker,
Rodeheaver, Bacchetta, Edgerton, and Edlich (1976) conducted research on both fluid irrigation dynamics and the effectiveness of
irrigation on experimental wounds. They found that delivering irrigation fluid through a 19-gauge needle produced higher pressure
than that produced using a 21, 23, or 25 gauge needle. When using a 19 gauge needle the researchers found pressures of 7 pounds
per square inch when delivered through a 35 ml syringe and 20 pounds per square inch when delivered through a 12ml syringe.
Fluid delivered through a bulb syringe produced an irrigation pressure of 0.05 pounds per square inch. Additionally, Stevenson and
colleagues (1976) tested the syringe combination on contaminated wounds in a live rabbit model. High-pressure irrigation with
both the 35ml syringe and 12ml syringe with a 19-gauge needle decreased bacterial contamination significantly and unequivocally.
A bulb syringe was not effective in removing bacteria from wounds. High-pressure syringe irrigation significantly reduced the rates
of infection in the wounds compared with the controls and the bulb syringe. The rates of inflammation did not significantly differ.
Longmire and Broom (1987) completed a similar study using a human model comparing infection and inflammation rates
in those who received bulb syringe irrigation and those who received high-pressure syringe irrigation. Those subjects who received
high-pressure syringe irrigation had a significant decrease in infection and inflammation compared to those subjects who received
bulb syringe irrigation. Of the subjects who received bulb syringe irrigation, 27.8% had evidence of wound inflammation and 6.9%
had evidence of wound infection. Of those subjects who received high-pressure syringe irrigation, 16.8% had evidence of wound
inflammation and 1.3% had evidence of wound infection at the time of wound assessment.
Compared to high-pressure syringe irrigation, high-pressure pulsatile lavage (HPPL) irrigation produces markedly increased
pressures ranging from 50 to 80 pounds per square inch. The primary purpose of HPPL is for irrigation of wounds during
surgical procedures; however, some emergency departments use HPPL for wound cleansing and irrigation. Draeger and Dahners
(2006) conducted an in vitro study using flank steak contaminated with inorganic and organic debris to compare the efficacy of
HPPL irrigation to bulb syringe irrigation combined with suction. Tissue samples irrigated with HPPL had more qualitative and
quantitative degrees of tissue damage than suction irrigation or bulb irrigation. HPPL was also less efficacious at the removal of
inorganic material. However, these data have yet to be extrapolated to in vivo or human models.
Saline versus Other Solutions
Saline has traditionally been utilized for wound cleansing and irrigation in the emergency department setting. Dire (1990) compared
normal saline, 1% povodine iodine, and pluronic F-68 (Shur-Clens®) to determine which was the most efficacious in reducing the
risk of wound infections in patients with soft tissue lacerations. Among the three solutions studied, the author found no significant
differences in infection rates (p=0.571). Normal saline was found to be the most cost-effective. The authors noted that povodineiodine has been found to be cytotoxic in non-human studies and that pluronic F-68 can be cost prohibitive. Moreira & Markovchick
(2012) recommend avoidance of detergents in wound cleansing to minimize tissue damage.
Tap Water Versus Other Solutions
Tap water is commonly used in community settings for wound cleansing and has the advantages of being cost effective and readily
available (Fernandez, Griffiths, & Ussia, 2010). Fernandez and colleagues (2010) completed a Cochrane Review to address the
comparative effects of healing and infection in wounds cleansed with potable tap water compared to other solutions. Pooled data
from three studies (Angeras, 1992; Godinez , 2002; Moscati, 2007) identified a 37% reduction in the rate of infection in wounds
cleansed with tap water compared to wounds cleansed with normal saline. Fernandez et al. (2010) point out that data from one study
showed a significantly higher rate of infection in the group that received normal saline; however, this could have been attributed to
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
difference in the temperature of the irrigation solution. Moscati (2007) concluded that with the use of tap water and the decrease in
infection rates, supplies for irrigation and saline, an estimated $65 million would be saved annually in the United States if wounds
were irrigated with tap water as opposed to normal saline. The review also included data from two studies that included infection
rates in children (Bansal, 2002; Valente, 2003). Data from the studies including children showed no difference in the infection rate
between tap water and saline.
Irrigation and Pain
Wound cleansing and irrigation is an often uncomfortable and sometimes painful procedure for patients. A review of the literature
revealed a noticeable lack of research related to wound preparation and pain, and the efficacy of using local anesthesia before
cleansing and irrigation. The researchers in multiple studies compared the effect of warm versus room temperature normal saline
on patient comfort during cleansing and irrigation. Ernst, Gershoff, Miller, Tilden, and Weiss (2003) conducted a randomized single
blind crossover trial with 38 subjects using both warm (90-100°F; 32.2-37.8°C) and room temperature (70°F; 21.1°C) saline with a
10-minute rest period in between the two solutions. Sixty three percent of subjects preferred the warmed solutions and 47% found
the warm solution soothing whereas, 29% preferred the room temperature and 16% found the room temperature solution soothing.
Twenty four percent found the warmed solution caused more discomfort, 53% found the room temperature solutions caused more
discomfort. Overall, warm solution was considered more comfortable by a greater number of subjects (Lloyd, 2012).
Irrigation versus No Irrigation
Wound cleansing and irrigation is the standard of care for acute soft tissue lacerations. Clean wounds to the face and scalp pose a
lower infection risk than other areas of the body. Hollander, Richman, Werblud, Miller, and Huggler (1998) compared the infection
rates and cosmetic outcomes for facial and scalp lacerations for subjects who received irrigation and those who did not. The
researchers included subjects who presented less than six hours after injury and had no history of diabetes mellitus, renal disease
or immune compromise. The authors found no differences in the rates of infection between those subjects who did not receive
irrigation and those who did receive irrigation (p=0.28). Additionally, the authors found no difference in cosmetic appearance at the
time of suture removal. However, there was a trend towards worse cosmetic outcome in subjects who received irrigation (95% CI
for the difference between groups).
Description of Decision Options/Interventions and the Level of Recommendation
1. Irrigation with a syringe and needle/catheter is more effective than bulb syringe irrigation for laceration cleansing
and irrigation across the lifespan. Level A - High (Stevenson, et. al, 1976 ; Longmire & Broom, 1987)
2. Cleansing or irrigation may not be required for low-risk patients (patients with clean, non-contaminated lacerations
and without signi.cant co-morbidities (e.g. diabetes, renal disease, or immunocompromised) with clean facial/scalp
lacerations of less than six hours in both adult and pediatric patients. Level B - Moderate (Hollander, et. al, 1998)
3.
Potable tap water is equivalent and may be superior to normal saline for laceration cleansing and irrigation in patients
across the lifespan. Level A - High (Fernandez, et. al, 2010).
4. Warmed irrigation solution (90-100°F; 32.2-37.8°C) may be more comfortable and soothing than room temperature
(70°F; 21.1°C) irrigation solution in adult patients. Level C - Weak (Ernst, 2003)
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
References
1.
Angeras, M., Brandberg, A., Falk, A., & Seeman, T. (1992). Comparison between sterile saline and tap water for the cleaning of acute traumatic
soft tissue wounds. Eur J Surg, 158(6-7): 347-50.
2.
Beam, J.W. (2006). Wound cleansing: Water or saline? J Athl Train, 41(2):196-7.
3.
Chaterjee, J. (2005). A critical review of irrigation techniques in acute wounds. International Wound Journal, 2, 258-265.
4.
Dire, D.J., & Welsh, A.P. (1990). A comparison of wound irrigation solutions used in the emergency department. Ann Emerg Med, 19(6):7048.
5.
Draeger, R., & Dahners, L. (2006). Traumatic wound debridement: a comparison of irrigation methods. J Orthop Trauma, 20(2):83-8. doi:10.1097/01.
bot.0000197700.19826.db
6.
Dulecki, M., & Pieper, B. (2005). Irrigating simple acute traumatic wounds: a review of the current literature. J Emerg Nurs, 31(2):156-60.
7.
Ernst., A. Gershoff, L., Miller, P., Tilden, E., & Weiss, S. (2003). Warmed versus room temperature saline for laceration irrigation: a randomized
clinical trial. South Med J, 96(5):436-9.
8.
Fernandez, R., Griffiths, R., & Ussia, C. (2010). Water for wound cleansing (review). Cochrane Database of Systematic Reviews, Issue 2.
doi:10.1002/14651858.CD003861.pub2
9.
Gravett, A., Sterner, S., Clinton, J., & Ruiz. E. (1987). A trial of povidone–iodine in the prevention of infection in sutured lacerations. Ann Emerg Med,
16(2):167-71.
10. Godinez, F., Grant-Levy, T., McGuirk, T., Letterle, S., Eich, M., & O’Malley, G. (2002). Comparison of normal saline vs tap water for irrigation of
minor lacerations in the emergency department. Acad Emerg Med, 9(5):396-7. doi:10.1197/aemj.9.5.396-b
11. Hollander, J.E., Richman, P.B., Werblud, M., Miller, T., Huggler, J., Singer, A.J. (1998). Irrigation in facial and scalp lacerations: does it alter outcome?
Ann Emerg Med, 31(1):73-7.
12. Hollander, J., Singer, A., Valentine, S., & Shofer, F. (2001). Risk factors for infection in patients with traumatic lacerations.
Acad Emerg Med, 8(7):716-20.
13. Longmire, A., & Broom, L. (1987). Wound infection following high-pressure syringe and needle irrigation. Am J Emerg Med, 5(2):179-81.
14. Lloyd-Jones, M. (2012). Wound cleansing: Has it become a ritual or is it a necessity? British J Community Nurs, 17(12):S22-26. doi:10.12968/
bjcn.2012.17.Sup12.S22
15. Luedtke-Hoffman, K., & Schafer, D. (2000). Pulsed lavage in wound cleansing. Physical Therapy, 80, 292-300.
16. Moreira, M., & Markovchick, V. (2012). Wound management. Crit Care Nurs Clin North Am, 24(2):215-37. doi:10.1016/j.ccell.2012.03.008
17. Moscati, R., Mayrose, J., Reardon, R., Janicke, D., & Jehle, F. (2007). A multicentre comparison of tap water versus sterile saline for wound irrigation.
Acad Emerg Med, 14(5):404–10.
18. Nicks, B. A., Ayello, E. A., Woo, K., Nitzki-George, D., & Sibbald, R. G. (2010). Acute wound management: revisiting the approach to assessment,
irrigation, and closure considerations. Int J Emerg Med, 3(?):399-407. doi: 10.1007/s12245-010-0217-5
19. Stevenson, T., Thacker, J., Rodeheaver, G., Bacchetta, C., Edgerton, M., & Edlich, R. (1976). Cleansing the traumatic wound by high pressure syringe
irrigation. JACEP, 5(1):17-21.
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Authors
2015 ENA Clinical Practice Guideline Committee:
Nancy Erin Reeve, MSN, RN, CEN
Anne Renaker, DNP, RN, CNS, CPEN
Marylou Killian, DNP, MS, RN, CEN, FNP-BC, FAEN, Chairperson
Anna Maria Valdez, PhD, MSN, RN, CEN, CFRN, CNE, FAEN
Alysa Reynolds, RN
Mary Alice Vanhoy, MSN, RN, CEN, CPEN, NREMT-P, FAEN
Marsha Cooper, MSN, RN, CEN
Karen Gates, DNP, RN, NE-BC
Mary Kamienski, PhD, APRN, CEN, FAEN, FAAN
David McDonald, MSN, RN, APRN, CEN, CCNS
Janis Farnholtz Provinse, MS, RN, CNS, CEN
Stephen Stapleton, PhD, MSN, MS, RN, CEN, FAEN
Patricia Sturt, MSN, MBA, RN, CEN, CPEN
Mary Ellen Zaleski, MSN, RN, CEN
ENA 2015 Board of Directors Liaison:
Jean A. Proehl, MN, RN, CEN, CPEN, FAEN
ENA Staff Liaisons:
Lisa Wolf, PhD, RN, CEN, FAEN
Altair Delao, MPH
Acknowledgments
ENA would like to acknowledge the following member of the 2015 Institute for Emergency Nursing Research (IENR) Advisory
Council for her review of this document:
Martha McDonald, PhD, RN, CEN, CCNS, CCRN, CNE
Developed: December 2011
Revised: October 2015
© Emergency Nurses Association, 2015.
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Appendix 1: Evidence Table
Reference
Research/Purpose
Questions/Hypothesis
Dire, D. J., & Welsh, A.
P. (1990). A comparison
of wound irrigation
solutions used in the
emergency department.
Ann Emerg Med,
19(6):7048
To examine which of three
irrigation solutions (normal
saline, 1% povodine iodine,
or plutonic F-68 [ShurClens®]) used in the ED is the
most efficacious in reducing
the risk of wound infections
in patients with soft tissue
lacerations.
Draeger, R. W., &
Dahners, L. E. (2006).
Traumatic wound debridement: A comparison
of irrigation methods.
J Orthop Trauma,
20(2):83-8. doi:10.1097/01.
bot.0000197700.19826.db
To examine which of three
irrigation solutions (normal
saline, 1% povodine iodine,
or plutonic F-68 [ShurClens®]) used in the ED is
the most efficacious in
reducing the risk of wound
infections in patients with
soft tissue lacerations.
To compare the efficacy
of high-pressure pulsatile
lavage (HPPL), suction
irrigation, and bulb syringe
irrigation in the removal
of wound contaminants
as well as to evaluate the
possible soft tissue damage
that they may produce.
Gentle irrigation combined
with suction may be as
effective asHPPL for soft
tissue debridement without
causing soft tissue damage.
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
Prospective, non-randomized,
controlled trial IRB approved
Community military ED
531 patients with minor, soft-tissue
lacerations divided into 3 groups.
189 Normal saline
184 povodine-iodine
184 Shur-Clens
Patients returned to ED
for suture removal by
study authors. Subjective
and objective measures of
infection were assessed
including abscess formation,
cellulitis, lymphangitis ,
adenophathy, and systemic
symptoms. Overall infection
rates amongst three solutions
not significant (p=.571).
There were no significant differences
found between infection rates and the
three irrigation solutions.
Normal saline is the most cost-effective.
Povodine-iodine is cyto-toxic and carries
risks and Shur-Clens can be
cost prohibitive.
I
III
Quantitative, In Vitro Research
8 samples of flank steak divided into
8 groups. 4 groups not contaminated
and irrigated as follows:
1. Not irrigated (control)
2. Bulb syringe
3. HPPL irrigation
4. Suction irrigation
The other 4 groups were contaminated
with 2 grams rock dust and irrigated
as above 1-4
MRunoff from tissue
irrigation was collected,
filtered, lyophilized, and
ashed to quantitatively
measure removal of organic
and inorganic material
from the wound by each
irrigation method.
Digital photos of tissue
samples were subjected to
blinded grading of
soft tissue damage (scale
1-5) Study team utilized
one-way ANOVA analysis
to determine group
differences. Tissue samples
treated with HPPL had
more tissue damage than
suction irrigation or bulb
irrigation (p=<0.001).
HPPL was also less
efficacious at the removal
of inorganic material
(p= 0.003).
Qualitative Soft Tissue Damage
Qualitative results for tissue samples
treated with HPPL appeared to be more
physically damaged that with bulb
syringe or suction irrigation.
Quantitative Soft Tissue Damage
Samples from the contaminated
group treated with HPPL removed
significantly more organic material
(ANOVA, P < 0.001).
Debridement Efficacy
HPPL removed significantly
less inorganic material (ANOVA,
P= 0.003), making it less efficacious.
I
IV
9
CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Appendix 1: Evidence Table
Reference
Ernst, A. A.,
Gershoff, L., Miller,
P., Tilden, E., &
Weiss, S. J. (2003).
Warmed versus room
temperature saline for
laceration irrigation:
A randomized clinical
trial. South Med J,
96(5):436-9.
Fernandez, R., Griffiths, R.,
& Ussia, C. (2010). Water for
wound cleansing (review).
Cochrane Database of
Systematic Reviews, Issue 2.
doi:10.1002/
14651858.CD003861.
pub2annemergmed.
2004.12.026jannemergm
ed.2004.12.026
Research/Purpose
Questions/Hypothesis
To compare warmed versus
room temperature saline for
wound irrigation
To assess the effects of tap
water compared to other
solutions for wound cleansing.
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
Randomized single blind cross over
trial. IRB approved.
38 patients in an academic ED
All patients received both
solutions with a 10-minute
wash out in between.
Study end-points included
preferred solution, soothing
effect, and solution with
most discomfort. Secondary
measure was amount of
bleeding. Comfort was
measured with a 100mm
Visual Analog Scale; wound
bleeding measured with
5-point Likert scale (nonvalidated). 95% CI
63% of patients preferred the warmed
solutions, 29% preferred the room
temperature solution, and 8% preferred
neither solution. 47% found the warm
solution soothing, 16% found the room
temperature solution soothing, and 32%
found neither solution soothing. 24%
found the warmed solution caused more
discomfort, 53% found the cold solutions
caused more discomfort, and 24% found
the solutions the same. Overall, warm
solution was more comfortable.
I
II
Review of Literature included
randomized and quasi-randomized
controlled trials that compared wound
healing outcomes or infection rates in
wounds cleansed with water or with
normal saline or any other solution.
Trials with subjective measurements
of infection (erythema, purulent
drainage, or edema) were also included
but analyzed separately.
11 Trials were included in the review.
7 trials compared rates of infection,
wound healing in wounds cleansed
with water or saline, 3 trials compared
cleansing, and no cleansing, and one trial
compared procaine spirit with water.
7 studies utilized the
medical or nursing staff to
cleanse to wound. Only one
trial specified the duration of
wound cleansing. Duration
of follow-up ranged from 1
to 6 weeks. Comparison of
Tap Water to Normal Saline
Pooled Results Infection Rates:
(RR 0.63, 95% CI 0.40 to
0.99; p =0.05). Two Pediatric
studies showed no difference
in infection rates (RR1.07, 95%
CI 0.43 to 2.64; p=0.88). One
trial reported wound healing
no statistical difference (RR
0.57, 95% CI 0.30 to 1.07).
Objective measurement of
infection (wound culture or
biopsy) and objective measure
of healing (change in surface
area or depth). Eleven articles
included in review. Seven
compared rates of infection in
wounds cleansed with water
versus saline, three compared
cleansing with no cleansing,
and one compared procainic
spirit with water.
Comparison of Tap Water with Normal
Saline: Three trials compared infection
rates in acute soft tissue wounds
cleansed with tap water versus saline.
There was a 37% decrease in the
incidence in wound infection associated
with the use of tap water. One trial
reported a significantly higher rate
of infection in the saline group. Two
additional trials measured infection
rates in children and results show no
difference in infection rates between
normal saline and tap water. One trial
reported wound healing and found
no difference between tap water and
normal saline. Tap water was found to
have a cost analysis savings. Data was
extrapolated an adjusted annual savings
of $65.6 million US dollars per year
with the use of tap water for irrigation
of lacerations could be expected.
Comparison of distilled or cooled boiled
water with normal saline: Study lacked
statistical significance to detect clinical
difference between distilled/boiled
water and saline regarding differences
in infection.
II
IV
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Appendix 1: Evidence Table
Reference
Hollander, J. E.,
Richman, P. B.,
Werblud, M., Miller,
T., Huggler, J., &
Singer, A. J. (1998).
Irrigation in facial and
scalp lacerations: Does
it alter outcome? Ann
Emerg Med, 31(1):73-7.
Longmire, A., &
Broom, L. (1987).
Wound infection
following high-pressure
syringe and needle
irrigation. Am J Emerg
Med, 5(2):179-81.
Research/Purpose
Questions/Hypothesis
Design/Sample
Setting
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
To compare the outcomes of
facial and scalp outcomes with
of facial and scalp lacerations
who receive irrigation and
those who do not
Prospective, cross-sectional study IRB
approved. 1,923 subjects in an urban
academic ED
Healing (Outcome
Measures): Stepoff borders, Contour
irregularities, Wound
Margin Separation, Edge
Inversion, and Overall
Appearance. Statistical
Analysis: Infection Rates
did not differ between
groups (p=.28).
No difference in rates of infection
between those who did not receive
irrigation and those who did receive
irrigation, no difference in “optimal”
cosmetically appearance between
groups at the time of suture removal,
however a trend towards worse
cosmetic outcome in patients who
received irrigation
II
IV
To compare high pressure
to low pressure irrigation
for acute traumatic wounds
and its impact on wound
infections.
Prospective, randomized, controlled
trial IRB status not stated.
All subjects had wounds anesthetized
with 1% lidocaine without epinephrine
and cleansed with povodine-iodine
immediately prior to irrigation.
Control Group (N=158) received wound
irrigation with 350 mL of normal saline
by bulb syringe method.
The experimental group (N=177)
received high-pressure syringe
irrigation (12 ml syringe and 22 gauge
needle) with 72 ml of normal saline.
Additional saline was utilized in the
experimental group if the repair was not
immediately completed.
N=335 subjects with acute soft tissue
lacerations of less than 24 hours
duration requiring closure in an ED.
Subjects returned to the ED
2 days after irrigation and
closure to assess for signs of
wound infection. Infection
was considered present if
any of the following were
present: redness, drainage,
tenderness, swelling,
or warmth.
If subjects did not return
at two days, they were
assessed on the fifth or
seventh day at the time of
suture removal. Decreased
inflammation (p=0.034)
and infection (p=0.017)
were found in the group
who received high-pressure
syringe irrigation.
Those subjects who received highpressure syringe irrigation had a
significant decrease in infection and
inflammation compared those subjects
who received bulb syringe irrigation.
Of the subjects who received bulb
syringe irrigation, 27.8% had evidence
of wound inflammation and 6.9% had
evidence of wound infection.
Of those subjects who received highpressure syringe irrigation 16.8% had
evidence of wound inflammation and
1.3% had evidence of wound infection
at the time of wound assessment.
I
II
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Appendix 1: Evidence Table
Reference
Stevenson, T. R., Thacker,
J. G., Rodeheaver, G. T.,
Bacchetta, C., Edgerton,
M. T., & Edlich, R. F.
(1976). Cleansing the
traumatic wound by highpressure syringe irrigation.
JACEP, 5(1):17-21.
Research/Purpose
Questions/Hypothesis
Purpose: To examine the
f luid dynamics of various
combinations of needles
and plastic disposable
syringes as well as an asepto
glass bulb syringe on the
efficacy of wound irrigation
and infection rates in
experimental wounds.
Design/Sample
Setting
Animal sample of New Zealand white
rabbits weighing 2-3 kg. Prior to
preparing the incision, the hair on each
animal back was shaved off with an
electric razor.
Variables/Measures
Analysis
Findings/Implications
Quality of
Evidence
Level of
Evidence
Inflammatory response
measured by indurations
of wound in millimeters.
Infection was measured by
excising wound and wound
edges and measuring the
number of bacteria.
Irrigation fluid delivered through a
19-gauge needle produced higher
pressure than any other needle 7 lbs/
sq inch when delivered through a 35
ml syringe and 20lbs/ sq inch when
delivered through a 12 ml syringe.
Fluid delivered through an asepto
syringe produced an irrigation
pressure of 0.05 lb/ sq inch. Highpressure irrigation with both the 35
ml syringe and 12 ml syringe with a
19-gauge needle decreased bacterial
contamination significantly and
equivocally. An asepto syringe was
not effective in removing bacteria
from wounds. High pressure syringe
irrigation was effective at significantly
reducing the rates of infection in the
wounds compared with the controls
I
III
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Appendix 2: Other Resources Table
Reference
Research Purpose
Conclusions
Anderson K. (2012). Factors that impair wound healing. J of Am College
of Clin Wound Spec, 4(4):84-91. doi:10.1016/j.jccw.2014.03.001
Presentation of factors that impede wound healing
Identification of comorbidities and their pathophysiologic effect on wound healing.
Generalizable: NO. Relevance to practice: YES
Crowley, D., Kanakaris, N., & Giannoudis, P. (2007). Irrigation of the
wounds in open fractures. J Bone Joint Surg Br, 89(5): 580-5.
Review of articles with additives to saline: Three
human studies utilized iodine and two found no
benefit while one found that it killed all bacteria,
fungi, and viruses however it was toxic to fibroblasts at an effective level. Negatively one study
found that it increased infection rates.
No human studies on wound care that is relevant to soft tissue wounds or
lacerations on irrigation methods.
Chisholm, C., Cordell, W., Rogers, K., & Woods, J. (1992). Comparison of
a new pressurized saline canister versus syringe irrigation for laceration
cleansing in the emergency department. Ann Emerg Med, 21(11):1364-7.
To compare irrigation times and infection rates
for wounds cleansed with normal saline utilizing
syringe irrigation versus a single-use pressurized
canister (Dey-Wash®). Prospective, randomized,
controlled. Unsure if IRB controlled but patients
were consented.
No significant difference between infection rates and wound healing between
those who had syringe irrigation and canister irrigation. Canister irrigation has the
advantage of not being operator dependent but is no longer commercially available.
Dulecki, M., & Pieper, B. (2005). Irrigating simple acute traumatic
wounds: a review of the current literature. J Emerg Nurs, 31(2):156-60.
Review current literature regarding irrigating
solutions, techniques and irrigation
vs. no irrigation of wounds
4 studies comparing irrigating solutions
2 studies comparing irrigation techniques
3 studies comparing irrigation vs. no irrigation
of wounds
Comparison of irrigating solutions (saline vs. water) showed no significant
differences in infection rates. Comparison of irrigation techniques suggested that
5 to 8 psi is the amount of pressure needed to irrigate a wound without destruction
of vital tissue. Comparison of irrigating vs. no irrigation demonstrated that irrigation
before primary closure of clean, non-contaminated wounds of the face and scalp
did not significantly change the rate of infection.
Edlich, R. F., Rodeheaver, G. T., Thacker, J. G., Lin, K. Y., Drake, D.
B., Mason, S. S., ...Vissers, R. J. (2010). Revolutionary advances in the
management of traumatic wounds in the emergency department during
the last 40 years: Part I. J Emerg Med,38(1):40-50.
doi: 10.1016/j.jemermed.2008.09.029
Discussion of advances in wound repair devised by
the research team over 4 decades looking at predictors of outcomes. Report of life-threatening trauma,
thorough history, wound examination with aseptic
technique, anesthetize wound before cleansing, hair
removal, skin disinfection, hemostasis, surgical debridement, mechanical cleansing, antibiotics, drains
and open wound management
Low-pressure irrigation can be used for clean wounds. High-pressure irrigation
should be reserved for dirty or heavily contaminated wounds.
High pressure is defined as 7 psi (19 gauge needle and 35 ml syringe)
Low pressure is defined as 0.5 psi
High pressure irrigation is effective in removing 80% of soil
infection-potentiating factors
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Appendix 2: Other Resources Table
Reference
Description
Conclusions
Moreira, M., & Markovchick, V. (2012). Wound management. Crit Care
Nurs Clin North Am, 24(2):215-37. doi:10.1016/j.ccell.2012.03.008
Research review of best practice management of
wounds in the emergency department
Findings are consistent with other current wound care management regarding wound
cleansing. Factors discussed are patient comorbidiites, as well as the use of NS
versus tap water, use of pressure behind the irrigant, temperature of the irrigant, and
avoidance of detergents to prevent wound injury. One new aspect to consider was
the recommendation of 50-100ml of irrigant per centimeter of the laceration
for effective cleansing.
Nicks, B. A., Ayello, E. A., Woo, K., Nitzki-George, D., & Sibbald, R. G.
(2010). Acute Wound Management: revisiting the approach to assessment,
irrigation, and closure considerations. Int J Emerg Med, 3(?):399-407.
doi: 10.1007/s12245-010-0217-5
Provide an overview of current evidence of acute
wound management and wound healing.
No single approach to wound management will work for all wounds due to variability
in location and characteristics. A comprehensive systematic approach that integrates the
evidence and best practices for acute wound management should be applied.
Discuss the history of wound care
The first wound treatments were described 5 millennia ago. Since then, various
principles of wound care have been passed on from generation to generation. It is
essential to know the historical aspects of wound treatment (both successes and
failures) in order to continue this progress and provide future direction. Importance
to look at historical treatments when evaluating proposed new treatments.
Shah, J.B. (2011). The history of wound care. J Am Col Certif Wound
Spec, 3(3):65-6. doi: 10.1016/j.jcws.2012.04.002
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CLINICAL PRACTICE GUIDELINE:
Wound Preparation
Appendix 3: Study Selection Flowchart and Inclusion/Exclusion Criteria
Potentially relevant publications identified by
electronic search
(n=176)
Publications excluded as they did not meet
the selected timeframe
(n=114)
Publications reviewed in full text
(n=62)
Publications excluded as they were not
peer reviewed
(n=49)
Publications reviewed in full text
(n=6)
Publications excluded (did not meet
evidence analysis criteria)
(n=3)
Publications that met criteria to be included
in evidence analysis (sound and relevant studies)
(n=3)
Inclusion Criteria
Exclusion Criteria
Studies published in English
Studies involving human subjects
October 2010- July 2015
Studies addressing the PICOT question
Studies not published in English
Non-human studies
Studies not in the timeframe listed
Studies not addressing the PICOT questions
The following databases were searched: PubMed, Google Scholar, CINAHL, Cochrane - British Medical Journal, Agency for Healthcare Research and Quality (AHRQ;
www.ahrq.gov), and the National Guideline Clearinghouse (www.guidelines.gov).
Search terms included: “difficult intravenous access,” “tools intravenous access,” “heat,” “nitroglycerin,” “tourniquet,” “ultrasound,” “light,” “illumination,” “subcutaneous
rehydration therapy,” and “hypodermoclysis,” “interosseous”, “infrared”, and “ultrasound guided”, using a variety of different search combinations.
15