Irrigation

Goal: Because war wounds are most often grossly contaminated, proper irrigation techniques should be implemented as early as possible after wounding to reduce the possibility of infection. Pressure, fluid choice, and fluid amount are the tenants of irrigation: the solution to pollution is dilution.

  • Best: Irrigate wounds with Dakin’s solution or sterile isotonic solution.
  • Better: Irrigate wounds with clean, potable tap water.
  • Minimum: Irrigate wounds with the cleanest water available (nonpotable water should be boiled for a minimum of 3 minutes and then cooled to body temperature).

 

Irrigation notes:

  • Cleansing the entire patient (shower or cloth bath) will reduce the risk of infection.
  • Bacterial loads drop significantly with increases in wound irrigation fluid volumes.2
  • Evaluate the wound size and contamination level to determine the optimal amount of irrigation: 1–3L for small or clean wounds, 4–8L for intermediate or dirty wounds, and ≥9L for large or very dirty wounds.
  • Dakin’s solution (0.025%) may be used for irrigation of large, very dirty, or infected wounds to help treat wound infection and prevent fungal infection. A diluted concentration of one-tenth the strength of “half-strength” Dakin’s solution has been shown to be toxic to microorganisms without damaging tissues. The recipe is given below.3–5

Half-strength Dakin’s Solution

  1. 1L water, sterile or boiled
  2. 5mL household bleach (5.25% hypochlorite solution, unscented)
  3. Sodium bicarbonate: 1.5mL (1/2 tsp) of baking soda or 4 ampules (200mL) of 8.5% sodium bicarbonate injection (preferred, but can leave out if not available)
  4. Once mixed, Dakin’s solution can be stored. The half-strength solution should be diluted 1:10 with water for wound irrigation solution.
  • Additives such as iodine, bacitracin, or alcohol are not associated with reduced infection.6
  • Very high-pressure (>15 psi) irrigation is not associated with reduced infection and has been associated with tissue damage and injection of bacteria deeper into the tissues.7 For smaller wounds, a large-bore catheter on the end of a syringe will provide high-pressure (6–15 psi) flow and is the ideal pressure for maintaining tissue viability and irrigation in a contaminated wound.8 A 19-gauge catheter with a 35mL syringe will deliver approximately 8 psi. For moderate sized wounds, a bulb syringe or bottle with puncture holes in the top can be used for low pressure (<6 psi) irrigation. For large wounds, bags of IV fluids can be connected to IV tubing to facilitate large-volume irrigation or any large container may be used to pour water onto the wound while gently scrubbing the wound.9

Debris made of wood, vegetative material, clothing, and any debris in the foot should be excised and/or removed if possible; however, foreign bodies penetrating into vital structures, including the eye, should be left in place until the patient can reach a surgical capability. Most retained metal fragments do not need to be removed, particularly if doing so creates additional tissue damage.