Cleaning and irrigating a wound before closure

What it is

Irrigation is the most important step in preventing infection of a traumatic wound. A stream of fluid at moderate pressure lifts bacteria, soil and small debris out of the wound without damaging living tissue. Sterile normal saline is the usual fluid, but clean drinkable tap water works as well for most simple lacerations and is cheap and available everywhere. The pressure is produced by pushing a large syringe through a splash shield or a fine cannula held just above the wound, or by a pressurised bag or running tap; very low-pressure pouring and soaking clean poorly, and very high pressure drives bacteria into tissue. The volume is scaled to the size and contamination of the wound, with more for dirtier and larger wounds. Strong antiseptics belong on the intact skin around the wound, not inside it, because they damage the cells that heal it. Irrigation is done after local anaesthesia, together with removal of foreign bodies and trimming of dead tissue, and the person doing it wears eye protection against splashes.

Indications

• Every traumatic wound before closure, whatever method is used to close it.
• Contaminated wounds (soil, faeces, saliva, bites) need more volume and more careful debridement.
• Wounds left open for delayed closure or secondary intention are irrigated at each review.
• Abscess cavities after drainage are irrigated to wash out the remaining pus.
• Very clean, small facial or scalp wounds with an excellent blood supply may need only gentle irrigation.

Contraindications and precautions

• Give local anaesthesia first: proper irrigation and scrubbing hurt and the patient will not tolerate it otherwise.
• Wear eye protection and a mask or face shield; splashback carries blood and contaminated fluid.
• High-pressure jets on loose tissue (eyelids, genitals, flaps) can spread fluid into tissue planes; use gentle flow there.
• Do not soak wounds in antiseptic solutions or fill them with hydrogen peroxide; they kill fibroblasts and delay healing.
• Deep, heavily contaminated or crush wounds may need washout in theatre rather than at the bedside.

Equipment

• Gloves, gown, eye protection and an absorbent sheet or basin under the wound.
• Sterile saline or clean drinkable tap water at body or room temperature.
• A large syringe with a splash shield or a fine intravenous cannula, or a pressurised irrigation bag.
• Gauze, sterile toothed forceps and scissors or a scalpel for debridement.
• Antiseptic solution for the surrounding intact skin and hair clippers if needed.

Step by step (and why)

1. Explain, position the patient and protect yourself with gloves and eye protection — splashback is the main exposure risk.
2. Anaesthetise the wound — irrigation and scrubbing are painful and would be incomplete otherwise.
3. Clip hair at the edges if it gets in the way, never shave — shaving cuts the skin and raises infection.
4. Clean the intact skin around the wound with antiseptic, keeping it out of the wound — antiseptics injure healing cells.
5. Irrigate with the syringe tip just above the wound, moving across all of it — a moving jet at moderate pressure lifts debris.
6. Open the wound edges gently and irrigate every recess — bacteria hide in pockets and under flaps.
7. Remove visible dirt and foreign bodies with forceps — particles left in cause infection and tattooing.
8. Trim clearly dead tissue and irrigate again — devitalised tissue is a medium for bacteria.
9. Dry the skin and proceed to closure or a dressing — a clean, dry surface helps strips, adhesive and dressings stick.

Complications

• Wound infection when irrigation was too brief or debris was left behind.
• Traumatic tattooing when road grit or soot is not removed in the first days.
• Tissue oedema or fluid tracking if high pressure is used on loose tissue.
• Splash exposure of the operator to blood or contaminated fluid without eye protection.
• Pain and an incomplete wash when anaesthesia was not given first.

Next step

• Proceed to closure or choose delayed closure or secondary intention according to the wound assessment.
• Check and update tetanus prophylaxis for any wound that broke the skin.
• Call a senior or surgeon if the wound cannot be cleaned at the bedside or embedded material cannot be removed.
• Contaminated or open wounds: review in about 48 hours and irrigate again if needed.
• Teach the patient to wash gently once the first day or two have passed and to return with signs of infection.

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Elsewhere in DurgiPedia

• Wound care and dressings: cleaning and choosing a dressing
• Clean and sterile technique: medical and surgical asepsis
• Hand hygiene: the five moments and the technique

Connections

← All clinical skills

Educational content; it does not replace supervised hands-on training, your institution's protocols or a prescriber's order. A procedure is learnt with a teacher and done only once you are trained to do it.

Sources: Wound Irrigation (StatPearls (NCBI Bookshelf), 2023).

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