Which solution should be used when irrigating lacerated tissue over a wound on the arm?

• Place all equipment on a tray within your—but not the patient's—reach.

• Wear gloves and a face shield or protective eyewear and a mask.

• Initially wash heavily contaminated wounds, eg, using tap water and a gentle hand soap. Depending on wound location, patients can do this themselves; local anesthesia may be needed.

• Hemostasis: Direct pressure to the site is the primary technique. Use finger pressure or gauze pads (may be moistened with sterile saline) to hold external pressure on the wound. Elevate the area if possible, and, if needed, use other means (eg, inflated blood pressure cuff, brief application of a proximal tourniquet, injected or topical 1% epinephrine with lidocaine) to attain hemostasis. Elevation and use of a proximally placed compression tourniquet are often helpful in achieving hemostasis of hand wounds. Avoid clamping blood vessels to avoid inadvertently clamping tendons, nerves, or other important structures.

• Imaging studies: Do imaging studies for all wounds involving glass and for wounds if the history or clinical findings suggest a foreign body (eg, puncture wounds of the foot, any puncture deeper than 5 mm, or animal or human bites Human and Mammal Bites Human and other mammal bites (mostly dog and cat bites, but also squirrel, gerbil, rabbit, guinea pig, and monkey bites) are common and occasionally cause significant morbidity and disability... read more ). Plain x-rays are sensitive for glass (≥ 1 mm) and most inorganic material (eg, stones). Most organic materials (eg, wood splinters, plastic) are radiolucent but can be detected by ultrasonography or CT Computed Tomography CT shows a focal area of osteolysis (arrows) involving the right acetabulum that is consistent with particle disease. In CT, an x-ray source and x-ray detector housed in a doughnut-shaped assembly... read more

  
  or MRI Magnetic Resonance Imaging Sagittal T1-weighted image of the brain shows normal midline structures. Sagittal proton density–weighted 3-tesla magnetic resonance image of the right knee shows meniscocapsular separation... read more
  
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• Skin cleansing: Proceed from the wound edges outward, wiping in concentric circles with chlorhexidine or povidone-iodine solution followed by alcohol solution. Do not introduce a cleansing agent directly into the wound because many are toxic to tissues and may interfere with wound healing.

• Hold the local anesthetic syringe at a shallow angle to the skin. Insert the needle directly into the exposed subdermal layer of the wound edge (ie, do not insert the needle percutaneously) and advance the needle to the hub. Pull back on the plunger to exclude intravascular placement. Then inject the anesthetic, minimizing the pressure of injection while slowly withdrawing the needle.

• Continue to anesthetize the circumference of the wound, subdermally inserting the needle into regions already anesthetized, advancing the needle into contiguous unanesthetized tissue, and injecting while withdrawing the needle. Repeat around the entire wound.

Dirty wounds may require scrubbing (as described below) before irrigation.

Irrigation

• Irrigate the laceration using sterile saline in a 35- or 60-mL syringe (preferably with a splash guard attached but otherwise via a plastic catheter).

• Use a tissue forceps or probe to expose the tissue, and irrigate the entire depth and full extent of the wound.

• Press down on the plunger with the thumbs of both hands in order to produce enough pressure to remove particulate matter and bacteria. The volume of the fluid required varies with the size of the wound and the degree of contamination. Typically, 50 to 100 mL per centimeter of wound length is used, but for relatively clean wounds, 30 to 50 mL per centimeter is usually adequate.

• Continue irrigation until the wound is visibly clean. If irrigation is ineffective in removing visible particles, scrubbing (described below) is required.

Scrubbing

• Scrub gently, using a fine-pore sponge (if available) to minimize tissue abrasion.

• Use a portion of the sponge to first scrub the skin surface around the wound to remove foreign material that could enter the wound.

• Use the remaining sponge to scrub the internal surface of the wound. Use care when scrubbing because the sponge may damage the internal tissues and provoke inflammation.

• After scrubbing, irrigate the wound as described above.

• Place a fenestrated drape over the wound.

• Examine the wound under good lighting and after bleeding has been controlled.

• Use a tissue forceps or probe to expose the wound tissue, and explore the entire depth and full extent of the wound to locate foreign bodies, particulate matter, bone fragments, and injuries to underlying structures. Do not explore the wound with your finger, because sharp foreign bodies may cause injury.

• Use the forceps or #15 scalpel to remove visible objects from the wound. Use gauze to remove particulate matter.

• Sometimes you may need to extend the wound edges or occasionally its depth to see adequately.

• After inspecting and removing matter from the wound, irrigate the wound.

• Debride all devitalized and necrotic tissue: Stabilize the wound edge with forceps, then cut away the devitalized tissue with a scalpel or iris scissors. Make the cuts perpendicular to the skin surface, not on an angle (to maximize dermal apposition during closure).

• Wound edge contamination that cannot be removed by irrigation and scrubbing (eg, grease and grit from power tool injury) may need to be removed by debridement.

• To debride a fistula or through-and-through puncture wound, moisten some gauze and gently pull it through the tract in the direction opposite to the puncture using a forceps or hemostat.

• After debridement, irrigate the wound again to remove any remaining debris.

The wound is now prepared for closure and dressing. (See Lacerations Lacerations Lacerations are tears in soft body tissue. Care of lacerations Enables prompt healing Minimizes risk of infection Optimizes cosmetic results read more regarding which wounds may benefit from delayed closure or no closure.) For wounds that require closure, the closure can be done using simple interrupted sutures How To Repair a Laceration With Simple Interrupted Sutures Uncomplicated epidermal closure is most often done using simple interrupted sutures. Each suture consists of a single, roughly circular (ie, simple) loop of suture material, individually tied... read more , buried deep dermal sutures How To Do Plastic Surgical Repair With Buried Deep Dermal Sutures Deep dermal sutures (which begin and end at the bottom of the wound so that the knot is deeply buried) can be used to appose the dermis and hypodermis of wounds under tension in cosmetically... read more , horizontal mattress sutures How To Repair a Laceration With Horizontal Mattress Sutures The horizontal mattress suture uses a simple suture bite followed by a reverse bite adjacent to the first to create a single broad suture that achieves wound approximation and epidermal eversion... read more , vertical mattress sutures How To Repair a Laceration With Vertical Mattress Sutures The vertical mattress suture accomplishes, in a single suture, both dermal and subdermal approximation using a wide-deep (“far-far”) loop, followed by epidermal approximation and eversion using... read more , a subcuticular running suture How To Repair a Laceration With a Subcuticular Running Suture Placed intradermally, the subcuticular running-type suture is used for cosmetic closure of a straight, clean laceration under no tension, typically of the face or neck and using absorbable suture... read more , glue How To Repair a Laceration With Glue Wound glue or adhesives—or biodegradable bonding agents—can be used to close small, straight, superficial, low-tension wounds. Simple superficial wounds that do not require deep-layer closure... read more , or stapling How To Repair a Laceration With Stapling Stapling devices are used to rapidly close straight, sharp-edged lacerations when cosmetic closure is not needed. Relatively straight, sharp-edged lacerations of the trunk or an extremity, and... read more , depending on the nature of the wound.

• Gently wipe away any remaining cleansing agent and dried blood or skin debris using moistened gauze.

• If the wound has been closed with sutures, many operators apply topical antibiotic to keep the sutures from adhering to the dressing.

• Place a nonadherent dressing on the wound.

• If significant oozing or bleeding seems possible, apply a sterile absorbent dressing over the nonadherent dressing. Use a thick layer if considerable drainage is anticipated. Follow wounds at risk of heavy bleeding closely.

• For wounds in locations subject to significant soilage, apply a sterile occlusive dressing.

• Apply adhesive tape or a circumferential gauze wrap to keep the dressing in place. Be careful not to place circumferential wraps too tightly, which may lead to excessive compression and subsequent ischemia.

* Some wounds typically are not dressed (eg, facial lacerations and those within areas that have hair).