# Disinfection of wounds



## Foxbat (Nov 28, 2008)

One of the things that surprised me in EMT class was virlually no information on wound disinfection; I understand that when you deal with severe hemorrage (or pt. with other life-threatening condition), disinfection is 1)not a first priority 2)hard to perform on profusely bleeding wound.
But what about patients where it can be done?
Do you think there should be more education/emphasis on this aspect of infection control? What do you use for this purpose - iodine, alcohol wipes, hydrogen peroxide?
P.S. Yes, I did the search.


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## Code 3 (Nov 28, 2008)

In school, we were always taught to irrigate the wounds as best as possible with sterile water. I believe the idea behind this is that presumably you're going to be transporting this person to the hospital where they will receive a very thorough wound cleaning.


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## SpudCrushr (Nov 28, 2008)

For scrapes and minor cuts:

I prefer to clean the wound with hydrogen peroxide then apply neosporin (antiseptic). Then slap a band-aid over the wound...or use gauze/tape

EDIT: This is what I do when a buddy gets hurt..  If your transporting the patient to a hospital, the above would probably be a better idea

I avoid iodine because you have to wash off the excess...and alcohol stings more than hydrogen peroxide


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## Ridryder911 (Nov 28, 2008)

Foxbat said:


> One of the things that surprised me in EMT class was virlually no information on wound disinfection; I understand that when you deal with severe hemorrage (or pt. with other life-threatening condition), disinfection is 1)not a first priority 2)hard to perform on profusely bleeding wound.
> But what about patients where it can be done?
> Do you think there should be more education/emphasis on this aspect of infection control? What do you use for this purpose - iodine, alcohol wipes, hydrogen peroxide?
> P.S. Yes, I did the search.



The reason wound irrigation is not discussed is because *it is  NOT practical nor effective *in the field setting. 

It takes a *large* amount of saline or sterile water along with time and effective irrigating tools. 

I also want to inform *HYDROGEN PEROXIDE* is *NOT* a good agent to irrigate and wash skin with. It causes irritation and removal of the epidermis and new growth of skin. Iodine, alcohol are not effective disinfectants and in some studies promote bacterial growth. 

The best treatment is to cover the wounds to prevent further contamination and allow the ED, to start the initial irrigation as some requires more in-depth irrigation in surgical theatres, and even post surgical care. 

R/r 911


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## KEVD18 (Nov 28, 2008)

basically what it boils down to is that, in the prehospital environment(and research is becoming apparent in the perihospital environment as well), preventing infection is pretty much a joke. the only place your ever going to be able to maintain a constant semblance of sterility(or medical cleanliness for that matter) is in the or. other than that its a crap shoot.

to facilitate the understanding of that point, think about the imbalance of products in the prevention of infection and the treatment of it. we have a hundred different types of antibiotics to treat infection, but what do we have to prevent it? the cleanest ambulance on the road is filthy with bacteria. we use non sterile gloves in our procedures. the best emt on the job makes only a cursory effort to prevent infection. 

R/r(per usual) nailed it. we're ill equipped to actually prevent and treat infection in the field. we can try, but we can also wish in one hand and defecate in the other and see which fills up first.


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## VentMedic (Nov 28, 2008)

Ridryder911 said:


> The reason wound irrigation is not discussed is because *it is NOT practical nor effective *in the field setting.
> 
> It takes a *large* amount of saline or sterile water along with time and effective irrigating tools.
> 
> ...


 


KEVD18 said:


> the cleanest ambulance on the road is filthy with bacteria. we use non sterile gloves in our procedures. the best emt on the job makes only a cursory effort to prevent infection.


 

I have got to emphasize KED18 and Rid's posts. In the field, you may further contaminate the wound by washing more contaminants into or deeper into the wound if not done correctly. H202 is not a popular agent for use as a disinfectant except for a few specific cases that usually involve colonization of certain bacteria.


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## RailFan77 (Nov 28, 2008)

I've always been told to bandage and transport to the hospital where the ER staff can properly disinfect and clean the wound.  We are not allowed here to put any type of Neosporin on the wound.

The exception to the "just bandage" rule is if the wound is extremely dirty (i.e. covered in mud).  We will usually use sterile water to clean it just to get those contaminants out.

Jim


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## ffemt8978 (Nov 28, 2008)

How many rigs actually carry Hydrogen Peroxide anymore?  I know we don't.


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## RailFan77 (Nov 28, 2008)

We don't either.  Just sterile water and saline.


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## Foxbat (Nov 29, 2008)

We carry peroxide but I have never seen anyone using it.

Another question on the same topic: I heard that in case of animal bites it is better not to stop the bleeding (unless it's severe) for a few minutes to let the bloodstream carry some of the saliva/poison away. Comments?


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## JPINFV (Nov 29, 2008)

When I was working first aid we had H2O2 bottles with spray tops. I was never fond of using it, but a few people did. In general, I just cleaned off wounds and then used neosporin, a band aid, and lots of tape. There simply wasn't that much of a point in trying to really clean out a wound if they were just going to go back into the water.


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## akflightmedic (Nov 29, 2008)

We carried hydrogen peroxide because it is really good at immediately removing blood stains.


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## RailFan77 (Nov 29, 2008)

akflightmedic said:


> We carried hydrogen peroxide because it is really good at immediately removing blood stains.



I was just thinking the same thing.  Works good for cleaning blood off your uniform.


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## Brooks416 (Nov 29, 2008)

In the wilderness setting we have extensive training in wound cleaning. We carry as protocol provodone iodine and mix for use with sterile saline and use a 16 or 18 ga needle to irrigate.


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## RailFan77 (Nov 29, 2008)

Wilderness EMS though is very different from what is done in most BLS settings.  

Have always been interested in learning more about wilderness EMS and the techniques used, but unfortunately we don't have a need for it where I am now.


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## mycrofft (Nov 29, 2008)

*I'm shaking my head. And not because it feels good.*


To quote Van Halen, it's a matter of balance.
Hipshots at prior comments:
1. Urban stabilize-and/while-go EMS is different than boondocks/disaster stuff or home care. When we receive pts from the urban field we don't want to have to get through clots and creams and, worse yet, greasy/oily stuff to see,  clean and treat a wound. Especially eyes. Delayed definitve care: weigh supply levels to urgency, use least supply-expending means. If you are a couple days out you had _better_ think about sepsis, local and maybe systemic. Home care: read up on that separately for what to do after the emergency's over.

2. Peroxide : good first cleaning treatment for instruments clothes etc. Not so good for initial EMS tx on large wounds, unless it needs bleaching. Tetanus and staph hate peroxide, as do most anaerobes, but you can potentially damage tissues as well. It's a matter of balance, but in any case rinse it off after the initial application, and consider using it 50/50 with SNS. 

3. If you can't clean it, place a layer of gauze with SNS in it with edges protruding for easy extrication, then your lifesaving overbandage. This will remove many contaminants when it is removed, as well as some of the clot with surprisingly little bleeding since the clot that _really_ counts is the one in the vessel not in the wound void. Much easier to visualize and then debride later. ASK YOUR RECEIVING ER WHAT THEY PREFER.

4. Slivers go well with a drop of betadine, easier to locate and it will tend to wick along fiberous slivers and kill local bacteria.

5. And for those pessimistic lab reports, the test tube johnnies don't mean that it is futile to try to kill germs short of a pic line or neutron irradiation, they mean to show that we are part of a swarming ocean of microbial and sub (prion) microbial life. 

A perfectly sterile wound is impossible in a living subject and would offer a Darwinian dragrace between the fastest and most virulent critters. By reducing the microbial load and perhaps tending to lean a little heavier on the anaerobic "dark siders", we give the body a chance to marshal its immune resources and start healing.

Keep on cleaning the units, hands, equip etc, disrupting the substrate quite often kills the organism;  leaving the goo in place but shooting it with this-years' "holy water" disinfectant will not. Soap, water and elbow grease, not "hand sanitizer" every time.

Just food for thought. Ask me about my miracle heel blister treatment some time!.


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## VentMedic (Nov 29, 2008)

Since H2O2 has specific therapeutic uses, it also should be regarded as any med even though it is OTC. Aspirin is OTC and yet it is used only in a specific protocol. As mentioned before, it is not used on all wounds and can be harmful to some. EMTs should check their protocols to see if it specifies the type of wound and the type of irrigation solution to be used. 



mycrofft said:


> (That said, I have many times seen patients, who dropped out of dressing change treatment of moderate-sized healing wounds, who healed faster than similar pts whose dressings we kept changing everyday).


 
You should also know there is a BIG difference in the classification of some wounds. Hence, some wounds with certain bacteria growing require even a hyperbaric chamber to heal. Some wounds may just require a clean dressing and some will heal regardless of what one does. Some dressings need to even be changed every 8 or 12 hours. *One can not make a blanket statement for infection control and cleaning without taking the type of wound, type of microbe infecting the wound and the condition of the patient's health into consideration. *

The patient's overall health status or disease processes and nuitritional status play a big role in the treatment of some wounds. Patient's with diabetes require very specific attention to even the smallest wound and patients that have low albumin levels will be slow to heal.


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## VentMedic (Nov 29, 2008)

Apologies to you *mycrofft. *

I see you edited while I was typing or just after.

Your post does contain a lot of good information. 

Also, when taking a patient to a NH or hospital, pay attention to what type of disinfectant they are using on the infection control cart outside of some rooms. Some bacteria require different products than others. Clostridium difficile (C. Diff) is a good example and unfortunately is now very common mostly due to lax infection control. Take note and advantage of the products since what you might be using in the ambulance will be ineffective on that microbe. 

Elderly people with even the slightest skin tears caused by moving can easily pick up any infection, especially MRSA, from a poorly cleaned ambulance or gloves worn by an EMT that had been stuffed into the contaminated pockets of their uniform.


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## mycrofft (Nov 29, 2008)

*Absolutely, Vent! Agreed, good point. (Add: no apology needed!)*

The EMT and most MD's don't have the luxury (so to speak) of seeing wounds progress or decline day afer day. (If they did, they would ban Teflon coated dressing for most applications).

Absolutely, when you see wounds, the patient's condition is going to affect the outcome and the receiver will want to know (ought to want to know) about meds, alcohol, diet, etc. as well as the obvious gapes, tears, and craters. What did the pt or his bystanders do to self-treat? (Like packing with toothpaste, or with toilet paper, the "poor man's Gelfoam").

Look to your SOP's, talk to your receiving facilities, in most settings creativity will not count more than preventing shock and getting them in with their ABC's. As I said, food for thought.

Aren't you glad I didn't mention turpentine and spider webs?

(haha, yes I cut the post greatly, but you made good points)

Oh, and by the way, in our line of work, about 30% ofus are carrying pathogenic staph in our noses, and everyone has staph growing on their skin. It just gets a llittle frisky when it gets underneath


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## VentMedic (Nov 29, 2008)

I guess I should also make some statements about the amount of training and education it takes RNs to get their wound care certification. 

http://www.wocncb.org/become-certified/how_to_choose.pdf

The requirements are extensive and recertification is required every 5 years. 

Sidenote: Some health professions are now requiring their practitioners to retest for their specialty or licensure cert or both every five years to ensure quality.

mycroft wrote:


> Oh, and by the way, in our line of work, about 30% ofus are carrying pathogenic staph in our noses,


Netty pot


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## FF894 (Nov 29, 2008)

VentMedic said:


> http://www.wocncb.org/become-certified/how_to_choose.pdf
> 
> The requirements are extensive and recertification is required every 5 years.
> 
> ...




Wow, that is actually impressive.  Is this something all nurses certify in and stay current with?  (ICU, ED, Transport, etc. nurses)  Is it something that EMS profoessionals could attend and certify in as well?  More for ED techs though, I would agree with covering and saving the irrigation for the controlled environment.


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## VentMedic (Nov 29, 2008)

FF894 said:


> Wow, that is actually impressive. Is this something all nurses certify in and stay current with? (ICU, ED, Transport, etc. nurses) Is it something that EMS profoessionals could attend and certify in as well? More for ED techs though, I would agree with covering and saving the irrigation for the controlled environment.


 
Wound care is a specialty. RNs (or others) are trained in broad general terms to manage wounds or identify ones that require special attention from a wound nurse. For the treatment to be a covered therapy, doctors will just write "per the wound specialist". 

There are also specialists in infection control.
http://www.cbic.org/Becoming_Certified.asp


Infection Control Today: Excellent magazine with lots of info.
http://www.infectioncontroltoday.com/

Some good reading for infection control. You can read for free if you don't want the CEUs.
http://www.nurse.com/ce/InfectionControl/

The hospitals and colleges usually offer several courses for infection control and wound care in their continuing ed department. I also advise taking a class about the various vascular access devices such as PICCs and Porto-Caths.


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## BossyCow (Nov 29, 2008)

There is a lot more information on wound care in Wilderness EMS because we can be with the pt for a much longer period of time. While a 15 minute ambulance ride isn't long enough for signs of infection to develop, a two day pack out certainly is. Plus, in wilderness EMS, you are generally working with injuries that occur in dirty places. 

If you are working on a primarily urban ambulance system, your wound care shouldn't go much beyond cleaning off the big chunks, being able to visualize the wound intially and then stop the bleeding and stop any further dirtiness from getting into it. Infection is the reason antibiotics were invented. Let the RNs and the Docs do that part.


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## Ridryder911 (Nov 29, 2008)

At one time, I was Director of a Home Health Agency (yeah shocking) and went partially went through an ostomy nurse course. I agree it is a speciality upon its own and wound healing and irrigation has to be done specifically and *NO* its not always H2S or NSS, Iodine or simple techniques. 

There are several types of wounds. Much more than we have time or interest discussing. For example stages of decubitus ulcers are alike burns, only such wounds may have a "tunnelling effect". These wounds takes months to years to heal or what is considered a success is formation of scar tissue. 

It has been over ten years since I reviewed any current literature on long term wounds and I am sure there has been much changes. I admit I was more a pencil pusher and I hired an ostomy nurse consultant and had her train my nursing staff for daily care and aggressive treatment. The physicians would co-sign her orders to make it legitimate as most well inform you that they are not abreast on wound care and the specifics of irrigation solutions, packing, dressing, etc....


R/r 911


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## FF894 (Nov 29, 2008)

This is really interesting, didn't know wound care was a specialty.  Always thought each nurse had basic training and developed their own style.

Bossy- you have probably answered this before but how long are the transport times where you are?


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## mycrofft (Nov 29, 2008)

*HAHA! Nurses need to do what to keep doing which?*

There are wound care specialists among nurses, but the run of the mill registered nurse is supposed to be capable of at least carrying out a MD order for dressings, observe and record wound status, and get the doc's attention when things aren't going well. At least in this state, LVN's can do the actual dressing, but unless they have some sort of extraordinary certificate or something they are not allowed to observe and record wound status themselves.

I've seen some vague MD orders result in every different nurse taking a different approach within the boundaries of the order. "DSD"'s  (dry sterile dressings) I have seen ranged from whole-roll 4 inch fluffed Kerlix over two ABD's mummy affairs, to a large bandaid, on the same pt at different shifts. (Of course mine are always pefect!). I keep incident reports in my desk just for those.


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## VentMedic (Nov 29, 2008)

BossyCow said:


> Infection is the reason antibiotics were invented.


 
Often the hospitals will try everything in their tool box of knowledge to keep from using antibiotics on wounds especially in the elderly. Their immune systems are too fragile as are the many organs that will be affected by the antibiotics. Too many people end up on dialysis permanently (that can also include young people) after an infection which had to be treated aggressively with the big gun antibiotics. C. Diff also runs amok because of antibiotic over use coupled with poor infection control techniques. It is a vicious circle or cycle that can be easily broken if people would pay attention to a few very basic steps when handling patients or their own possessions and hands.


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## zippyRN (Nov 29, 2008)

OK folks , ridryder and ventmedic have talked a lot of sense  in this thread 

topical ABx   forget it if you want to stick anything in the wound  stick some honey in ! or the shavings off a silver dollar !  because  long before topical ABX - dressings containing honey or silver will be used ....

iodine has it's place but there are risks associated with topicla iptake if you use too much too often on open wounds ... 

THE SOLUTION TO POLLUTION IS DILUTION !!!!! if a wound needs cleaning it needs cleaning with lots of of water either potable water straight from the tap or sterile water or NS for irrigation if you don't have a convenient source of potable mains water... 

you are not going to achieve a sterile wound unless you create the wound yourself in surgical conditions 



here in rightpondia  topical Abx are used extremely rarely  apart from topical metronidazole in when you have a fungating tumour  and the use of neosporin would be considered malpractice ( if you can even get it .)


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## BossyCow (Dec 2, 2008)

We include honey in our wilderness protocols, but anyone shaving a silver dollar into a wound better be prepared to face disciplinary action.


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## EMT271WNY (Dec 2, 2008)

Foxbat said:


> We carry peroxide but I have never seen anyone using it.
> 
> Another question on the same topic: I heard that in case of animal bites it is better not to stop the bleeding (unless it's severe) for a few minutes to let the bloodstream carry some of the saliva/poison away. Comments?



BLS -  "Keep the red stuff in"  So control the bleeding, let the Docs worry about infection.  :unsure:


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## VentMedic (Dec 3, 2008)

BossyCow said:


> We include honey in our wilderness protocols, but anyone shaving a* silver dollar into a wound* better be prepared to face disciplinary action.


 
Wow! Guess we're both old enough to remember when silver trachs were the norm and copper mesh was use in heated water "kettles" for devices such as vent or room humidifiers. 

The male WWII vets had their war medallions placed on their trach tubes and the women had their precious stones set on them. 

Since silver's use has a long, long history...Happy Birthday!

For interesting pics:
http://www.tracheostomy.com/resources/history/antiques.htm


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## JPINFV (Dec 3, 2008)

EMT271WNY said:


> BLS -  "Keep the red stuff in"  So control the bleeding, let the Docs worry about infection.  :unsure:



While I'm not 100% sure on the validity of the 'let animal bites bleed' statement, if you can do something that can help prevent infection without compromising the patient's health, why not? Not all bleeds are life threatening.


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## Ridryder911 (Dec 3, 2008)

Animal and human bites are NOT recommended to be sutured if possible since (especially humans) contain large number of bacteria. Irrigation and cleansing of these wounds along with prophylactic antibiotics is administered. 

R/r 911


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## emtashleyb (Dec 3, 2008)

We were told in my class just to put a bandage over it, the hospital will irrigate. Not to mention with iodine some people are allergic to it and I would not want to use on someone who didnt know they were or someone who was not able to tell us and create another emergency


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## Scout (Dec 3, 2008)

http://www.gpkmotivations.com/images/DSCN4515-cut.jpg


When you say wound as we talking about some thing like this, or something thats going to make me dirty my shirt???


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