Disinfection of wounds

[Foxbat]

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.

 

[Code 3]

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.

 

[SpudCrushr]

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

 

[Ridryder911]

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

 

[KEVD18]

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.

 

[VentMedic]

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

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.

 

[RailFan77]

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

 

[ffemt8978]

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

 

[RailFan77]

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

 

[Foxbat]

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?

 

[JPINFV]

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.

 

[akflightmedic]

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

 

[RailFan77]

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.

 

[Brooks416]

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.

 

[RailFan77]

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.

 

[mycrofft]

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!.

 

[VentMedic]

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.

(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.

 

[VentMedic]

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.

 

[mycrofft]

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

 

[VentMedic]

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