Interesting Medscape Article:

If you are a memeber:

Drinkable Tap Water May Be Suitable for Wound Cleansing


Summary for those who are not:

"This Cochrane review identified no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it. For chronic wounds cleansed with tap water vs saline, the RR for infection was 0.16. Tap water vs saline was more effective in reducing the infection rate in adults with acute wounds. For children with acute wounds, infection rates were not statistically significantly different with tap water vs saline. Infection rate for open fractures was not statistically significantly different for cleansing with isotonic saline, distilled water, or boiled water.
Wounds cleansed with tap water vs wounds not cleansed at all did not differ in infection rates, and episiotomy wounds cleansed with water or with procaine spirit did not differ in infection rate."


Pete

Am I taking that out of context, or otherwise misunderstanding? Does that mean exactly what it says?

I once read that the pressure and the length of time a wound is cleaned has more to do with how clean it gets than how clean the water is.

And I've heard of studies that show water does not have to be super clean to effectively clean a wound.

Here are more of the details from Medscape:

"Of 11 included trials, 7 compared rates of infection and healing in wounds cleansed with water vs normal saline, 3 trials compared cleansing vs no cleansing, and 1 trial compared procaine spirit vs water. Procaine spirit is a mixture of procaine HCl 2% with spirit 70% and is commonly prescribed for wound cleansing following surgery. Ability to pool the data was limited because there were no standard criteria across the trials for evaluating wound infection. The predominant comparisons were water vs normal saline and tap water vs no cleansing.

When chronic wounds were cleansed with tap water vs normal saline, the relative risk (RR) of developing an infection was 0.16 (95% confidence interval [CI], 0.01 - 2.96). Compared with saline, tap water was more effective in reducing the infection rate in adults with acute wounds (RR, 0.63; 95% CI, 0.40 - 0.99). In children, the use of tap water to cleanse acute wounds was not associated with a statistically significant difference in infection vs saline (RR, 1.07; 95% CI, 0.43 - 2.64).

When wounds were cleansed with tap water or not cleansed at all, there was no statistically significant difference in infection rates (RR, 1.06; 95% CI, 0.07 - 16.50). In a similar fashion, episiotomy wounds cleansed with water or with procaine spirit did not differ in infection rate. For cleansing open fractures, use of isotonic saline, distilled water, and boiled water was not statistically significantly different in the number of fractures that became infected.

"There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it," the review authors write. "However there is not strong evidence that cleansing wounds per se increases healing or reduces infection. In the absence of potable tap water, boiled and cooled water as well as distilled water can be used as wound cleansing agents. . . . The decision to use tap water to cleanse wounds should take into account the quality of water, nature of wounds and the patient's general condition, including the presence of comorbid conditions."

Keep in mind these are limited studies and it is often difficult to compare field received wounds, which by their very nature will vary in degrees of possible contamination.

I think the take home message is not to take things to an extreme, if all you have is drinkable water (vs. sterile saline) that should suffice for most incidences.

Pete

Doesn't surprise me.

Mostly because sterility is more a scalar then an absolute. Very few things are ever absolutely sterile and if they ever get to that level they seldom stay that way for long.

Also some consideration has to be given toward the difference between non-sterile and non-infective. A material can be loaded with microbes but as long as those microbes are species that the body can handle and/or do not cause disease then being non-sterile is not a problem.

More on-point, the 'cleaning' of a wound using any particular solution would seem to be at least somewhat more effective the more sterile and less infective it is. Sterile water being at least notionally better than non-sterile water.

But there are at least three other factors that come to mind: First, exactly how much less sterile, or more importantly more infective, was the non-sterile solution. Tap water is not sterile but exactly how much more infective is it? Is the difference between tap water and sterile solution meaningless, or at least less important, on a bacteriological and infective level?

The second thought that comes to mind is: How does time play into this? Would an immediate irrigation with less clean water be better than waiting for more clean water? The answer would seem to be affirmative for the longer haul. You certainly wouldn't wait a week for an IV bag of NS to arrive by mail if the water available was relatively clean.

But would waiting thirty minutes to get to a supply of sterile water be justified? Would it be better to irrigate with potable water immediately and removing the worse of the dirt in the wound now or do you take the time to set up provisions for boiling water? Would it be better to do both? Or is the second rinse just more trauma to the already damaged tissue?

The third thought is that in this, and so many other situations, your going to run into the law of diminishing returns. The difference between raw sewage and safe potable water is pretty big. The difference between: 'Wouldn't use it on a bet' and 'We go with what we got'.

With this in mind it doesn't surprise me that the difference between tap water, presumably pretty clean and chlorinated, boiled water and commercial sterile solution would be pretty small.

The study I would like to see is irrigation with water versus irrigation with soap and water followed by a rinse.

Not very. I couldn't find the notes on permitted numbers from three semesters ago for e. coli but allowable for Giardia is removal of 99.9% and viruses is 99.99%.

I've heard that there was a study of regular soap vs anti-bacterial and it made only a very small difference.

That debate is one of my favorites. Soap IS antibacterial.

"Soap IS antibacterial."

I don't think so. Soap is more of a dispersal agent that allows bacteria to be washed away. Something that is 'antibacterial' is something that kills bacterial, isn't it?

Sue

Not sure about the terminology, but I have read reports that compared soap that was and was not antibacterial. The comparison dealt with the amount of bacteria left after hand washing, and if I recall correctly, there was little or no difference between the two types of soap.

Correct, soap is a surfactant--raises stuff up so it can be rinsed away.

"The solution to pollution is dilution"

As I understand it soap, generically (and somewhat incorrectly) defined as what you wash with is both an agent that allows microorganisms to be better washed away and, to some small extent, an anti-microbial agent. Granted its main action is to dissolve the oily film that naturally coats skin and to aid the bodily removal of microorganisms but the same action does, to some extent, damage the cell walls of bacteria.

The most widely used anti-microbial cleaning agents in hospitals are termed "quats" , short for quaternary detergents. Essentially a synergistic mix of four related detergents. These attack microorganisms by chemically destroying the integrity of their cell membranes. It is hard to stay alive when your guts keep leaking out. Even more so when your microscopic.

I've read similar things before. I also gather that use of antiseptic in wounds is now frowned upon. It's too generic - it kills some bugs, but also damages the human tissue and so reduces healing. (Antibiotics are another matter, and antiseptics can be used for cleaning around the wound, just not in it.)

I think that the discussion is not asking all the possible questions. First of all, what is the projected timeline to definitive medical care? As an example, as a combat medic I was trained to use tourniquets, and that is something that in most civilian situations, or remote /long delay treatment, you would never use, except perhaps in traumatic amputations. It is a function of evacuation time, which since the days of Vietnam has gotten pretty short. So I think wound irrigation should consider this same timeline issue. Coming on a car accident, primary issues are stopping the bleed, and infection is not a concern. On a blue water cruise, in a remote area with little help available via evacuation in 24 hours or less, it is a different world. Of course anyone in these situations would want to have Rx antibiotic and pain meds with them as part of their kit or they are in my mind heading out prepared inadequately. In many wilderness situations after bleeding is controlled infection is highly likely by day two or three. These wounds should never be closed by any permanent means such as suturing as they need the ability to drain purulent materials. Closure will only allow the infection to spread deeper into surrounding tissues. So while the topic is irrigation, closure ( or choosing to pack the wound with no adherent and removable material and not close) is another important component to consider.

Second issue, is where is the wound located anatomically? There are some areas that you are likely to cause more problems if you irrigate. Deep abdominal wounds fall into this group. Also letting deep, narrow punctures bleed for a period is considered appropriate, as they cannot easily be irrigated poperly, and this will help clean the wound to some extent.

How about what caused the wound? I've temporarily closed many wounds with zero irrigation and no long term complications. Irrigation with a large bore syringe is important, but not always possible. If you do not carry a large bore syringe to pressurize the irrigation stream, rinsing/irrigation is far less effective unless you have copious flooding of the wound, and there is seldom that much flushing medium available. So think of other ways to irrigate. A plastic bag with a hole in it can be squeezed to create that high pressure stream to remove debris.

But what if you have serious reasons to believe that the wound is not only contaminated with debris, (much of which you may mechanically remove) but is potentially created by something that you definitely know has infectious potential.... think animal bite, etc. In those cases sterile saline irrigation (even if available) is only of minor help. Wounds are never completely clean even after sterile saline irrigation, and routinely contain some bacteria. Minor bacterials in small numbers might be dealt with by the bodies natural immune processes and systems. Anything more is a whole 'nuther deal. This is where antibiotic therapy has to be part of your "long term" far from care kit.

People have tried to clean them in a first responder situation at home for instance with things that seem to them logical, but are significantly damaging to the tissues. Antiseptics like alcohol, tincture of iodine, or old fashioned mercurial preparations should be avoided at all costs, and even diluted never put in wounds.

There are only a couple of antiseptics that might be considered appropriate. Benzalkonium chloride (Zephiran) or povidone iodine (Betadyne) are, but even these have to be carefully diluted. Zephiran at 1:750 aqueous solution, and for Povidone, ten to one in undisinfected water, and 20 to one in disinfected water. These are available OTC.

If you have reason to believe that the wound was created by an object or animal or something that may have infectious potential, these two antiseptics for irrigation are the ticket, and if in a long term situation, antibiotic therapy prophylactically started. Otherwise I personally would prefer not to irrigate with an unknown that might introduce additional problems, especially if I am unprepared for infection. A cut from your survival knife etc, as long as it doesn't happen while you are cleaning an animal, but cutting wood, line etc., leaves a fairly clean wound. I am thinking out in the field. At home I would be using tap water if nothing else were available. Tap water that has been chlorinated is surprisingly clean. If you are in a third world country, this is not the case... but here in the states, if you believe it is that bad, you shouldn't even be brushing your teeth with it. Should anyone think that these severe cuts that go unirrigated are a huge problem, just think about the kid that self amputated part of his arm to extract himself from between two rocks.... no irrigation and a couple of days without any antiseptic or antibiotic treatment.

I got pretty far off topic here, but thought that the discussion could be opened up to other possibilities, issues, and trains of thought.

Hilllaguna, that was a great post. Thanks. I'll relate an experience with a hunting buddy who is a respected surgeon, but outside of the O.R. is a total klutz. On one of our trips he cut his palm deeply on a piece of dirty tin. He was satisfied with irrigation (plastic bag pressure) with drinking water, pressure to stop the bleeding, no closure.. then soaked in betadyne solution for perhaps 15-20min. while we got him to an E.R. where they sutured.If we were not going to be able to get to the E.R. in 1/2 a day, he states he would have closed with steri-strips under 4x4, NO topical antibiotic. He did start an oral antibiotic (Augmentin, actually).

His hands are pretty important to him. We had a very complete emergency medical kit, but the above is what he did, for his injury.

Things like that is why I carry a 15 day supply of Augmentin in my FAK.

NAro - Your surgeon obviously is someone that nows what's what, and I think that he did it by the numbers. One of the things that always surprises me, (except in arterial bleeds) is how quickly direct pressure and the body's own clotting mechanisms will bring things under control even in significant wounds. Once that has taken place, clean cuts that are not a result of something that tears the tissues, have a tendency to just fall together, in what is a surprisingly nice fit. I always have Steri-strips around. They hold like crazy, the closure is easily reopened by removing them, (to examine for the beginnings of infection, or if treatment was done in haste to get out of danger, to reopen, finish debris removal, and clean the wound properly) and in a body part that will be in motion, keep the would closed.

While on this subject, clotting agents are now available over the counter like CELOX granules and Quick Clot sponges. I like the CELOX product better as it does not create any heat, and is easily removed in the definitive care setting. Clotting agents like this stuff are part of our front line combat kits, and it is pretty remarkable, with an clotting time of around 30 seconds for even a fairly large arterial bleed. If you use this in the civilian world, I like to take the empty package and wrap it in the bandage so the person who gets the patient in the ER etc. knows what's in the wound. This stuff is not technique sensitive... you just tear open the pouch and dump it in the wound, then pack, apply pressure, and bandage. No measuring, no issues. People with arterial bleeds, particularly large vessels such as the femoral artery, can go south in less than 5 minutes. This stuff will save a life. Again off topic, but thought it worth mentioning.