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<< Wound Care: Modern Evidence In The Treatment Of Man’s Age-Old Injuries
Risk Management
1. Failing to irrigate with the proper technique.
Proper irrigation requires a wound impact pressure of around 8 psi. This is accomplished with a syringe and catheter technique or the equivalent. Don’t allow your technicians or lower-level providers to use a bulb syringe or “needle hole in IV bag” technique.
2. Failure to consider delayed primary closure.
If a wound is dirty and contaminated, it will become infected, even if you clean it well. Use delayed primary closure on all heavily contaminated wounds. The patient will need to come back for closure, but that’s easier than being admitted for a wound infection and having a poor cosmetic outcome.
3. Using cyanoacrylates on high-tension areas.
Skin glue is designed for areas of low tension where a 5-0 suture would be used. It has a tendency to fail, allowing the wound to dehisce in high-tension areas. Either place a dermal suture to reduce the tension, or don’t use glue.
4. Using improper aftercare dressings.
Bacitracin reduces the infection rate in sutured wounds, but it should not be used on a cyanoacrylate-closed wound. It will dissolve the glue and dehisce the wound.
5. Using antibiotics to make up for poor wound cleaning.
Prophylactic antibiotics are of little use in most wounds. Failure to properly clean the wound is what leads to infection, not failure to use antibiotics.
6. Failure to use clinical judgment when considering “golden periods” for wound closure.
A child with a clean facial laceration will likely do well with primary closure, even if he presents 22 hours after sustaining it. On the other hand, a diabetic with lupus who sustains a clean cut to their hand and presents 30 minutes later should probably still be closed by delayed primary closure.
7. Failure to find a foreign body.
A retained foreign body is not only a frequent cause of malpractice lawsuits, but it magnifies manyfold the risk of wound infection and bad outcomes. Thoroughly examine every wound and, if it is around a joint, put it through a full range of motion. If your exam turns up no foreign body, but the history suggests it, get a radiographic study. Use US, CT, or MRI to look for wood, plastic, or vegetable matter.
8. Using povidone iodine or other irrigation solutions to clean wounds.
The standard for irrigation is sterile saline, though potable tap water appears to be just as effective. If povidone iodine is used, it should be diluted to 1% — anything stronger is tissue-toxic and can actually increase the incidence of wound infection. Most other irrigation solutions are either of no benefit or worse (ie, tissue-toxic).
9. Failure to warn patients of infection risk and scarring.
All wounds have a risk of infection, even with proper care, so let your patients know this and explain what you have done to minimize the risk. All wounds heal by scarring, therefore you should not tell your patient there will be no scar; rather, explain what you have done to minimize its size, but reiterate that there will also be at least a minimal scar.
10. Failure to align the vermillion border in lip lacerations.
A misalignment of more than 1 mm can make a lip scar very obvious to the viewer. Take meticulous care in alignment of the vermillion border in lip lacerations.
11. Failure to suture a bisecting, anterior tongue laceration.
One tongue laceration that always requires repair is an anterior, “bisecting” laceration. Failure to suture this wound can result in a scar in the form of a “reptilian tongue.”
Proper irrigation requires a wound impact pressure of around 8 psi. This is accomplished with a syringe and catheter technique or the equivalent. Don’t allow your technicians or lower-level providers to use a bulb syringe or “needle hole in IV bag” technique.
2. Failure to consider delayed primary closure.
If a wound is dirty and contaminated, it will become infected, even if you clean it well. Use delayed primary closure on all heavily contaminated wounds. The patient will need to come back for closure, but that’s easier than being admitted for a wound infection and having a poor cosmetic outcome.
3. Using cyanoacrylates on high-tension areas.
Skin glue is designed for areas of low tension where a 5-0 suture would be used. It has a tendency to fail, allowing the wound to dehisce in high-tension areas. Either place a dermal suture to reduce the tension, or don’t use glue.
4. Using improper aftercare dressings.
Bacitracin reduces the infection rate in sutured wounds, but it should not be used on a cyanoacrylate-closed wound. It will dissolve the glue and dehisce the wound.
5. Using antibiotics to make up for poor wound cleaning.
Prophylactic antibiotics are of little use in most wounds. Failure to properly clean the wound is what leads to infection, not failure to use antibiotics.
6. Failure to use clinical judgment when considering “golden periods” for wound closure.
A child with a clean facial laceration will likely do well with primary closure, even if he presents 22 hours after sustaining it. On the other hand, a diabetic with lupus who sustains a clean cut to their hand and presents 30 minutes later should probably still be closed by delayed primary closure.
7. Failure to find a foreign body.
A retained foreign body is not only a frequent cause of malpractice lawsuits, but it magnifies manyfold the risk of wound infection and bad outcomes. Thoroughly examine every wound and, if it is around a joint, put it through a full range of motion. If your exam turns up no foreign body, but the history suggests it, get a radiographic study. Use US, CT, or MRI to look for wood, plastic, or vegetable matter.
8. Using povidone iodine or other irrigation solutions to clean wounds.
The standard for irrigation is sterile saline, though potable tap water appears to be just as effective. If povidone iodine is used, it should be diluted to 1% — anything stronger is tissue-toxic and can actually increase the incidence of wound infection. Most other irrigation solutions are either of no benefit or worse (ie, tissue-toxic).
9. Failure to warn patients of infection risk and scarring.
All wounds have a risk of infection, even with proper care, so let your patients know this and explain what you have done to minimize the risk. All wounds heal by scarring, therefore you should not tell your patient there will be no scar; rather, explain what you have done to minimize its size, but reiterate that there will also be at least a minimal scar.
10. Failure to align the vermillion border in lip lacerations.
A misalignment of more than 1 mm can make a lip scar very obvious to the viewer. Take meticulous care in alignment of the vermillion border in lip lacerations.
11. Failure to suture a bisecting, anterior tongue laceration.
One tongue laceration that always requires repair is an anterior, “bisecting” laceration. Failure to suture this wound can result in a scar in the form of a “reptilian tongue.”
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