Protocol 2 - Wound Cleaning & Debridement

In the management of all wounds, bleeding must be controlled using well-aimed direct pressure with whatever means are necessary. Controlling all severe bleeding (Stop The Bleed) is a higher priority than cleaning out a wound, regardless of how deep or wide the wound is. This is to be accomplished via well-aimed direct pressure, followed by the use of either a hemostatic agent or with the use of a TCCC-approved Tourniquet.

Once bleeding has been controlled:

Open Wounds

1. Cleaning a wound will involve a combination of the following procedures in an order that seems appropriate:

   1. Explore the wound and remove foreign material as completely as possible.

   2. Wash the surrounding skin with soap and water or other specified cleanser.

   3. Irrigate the wound with water clean enough to drink. Water preparation can be accomplished by filter, chemical, ultraviolet, or reverse osmosis. Water of questionable quality should be sterilized by creating a 1% povidone-iodine solution.

2. High-risk wounds (embedded debris, devitalized tissue, bites, open fractures, deep structure involvement) should be irrigated with large amounts of water under pressure (e.g.: using a 30 or 60-cc syringe with an 18-gauge catheter). If the wound cannot be completely cleansed of foreign material or the quantity of irrigation water is insufficient, rinse the wound with 1% povidone-iodine solution. DO NOT use pressure irrigation on puncture wounds where irrigation fluid cannot easily drain away.

3. Cover the wound with a sterile bandage but allow for drainage. Splint or otherwise immobilize high-risk wounds if safe to do so. Do not close a high-risk wound with sutures or tape.

4. Change the bandage and clean the wound at least daily.

5. If an infection develops (e.g., red, tender, swollen, drainage of pus), irrigate with clean water, allow for drainage, and apply warm compresses. Infected wounds should be evacuated to medical care promptly.

6. High-risk wounds require tetanus prophylaxis every five years, all others every ten.

7. Animal bite wounds require a risk assessment for rabies exposure. The probability of rabies varies by geographic location. Check with state or local health agencies for recommendations. Prophylaxis should be administered as soon as possible, but a period of several days between the bite and immunization is considered safe. Antibiotic prophylaxis may also be indicated.

Shallow Wounds (Abrasions + Burns)

1. Clean the wound with soap and the cleanest water available.

2. Apply an antibacterial ointment or cream and cover with a sterile bandage.

3. Immobilize the wound area if possible.

4. Inspect the wound and change the bandage daily.

Impaled Objects

When it comes to wound cleaning, impaled objects should be removed in the field first before being — however should be cleaned as soon as practical. Exceptions to removal include objects in the globe of the eye and situations in which removal would result in significant tissue damage, intractable pain, or bleeding that cannot be controlled.

Discussion

Field providers are often rushed to evacuate an open wound because of the perception that wound closure (sutures) must be accomplished within six or eight hours of injury. In the EMS context with short transport times, it makes sense to bandage and transport an open wound for care in the clean and controlled environment of a hospital or clinic.

However, it is not so much the time to closure that matters, as it is the time to wound cleaning. Early and complete wound cleaning substantially reduces the chance of later infection.

In a remote environment where definitive care will be delayed, thorough irrigation and debridement of an open wound reduces the urgency of evacuation and leads to a better long-term outcome.