傷口清洗 傷口處置 傷口清理 傷口清潔 wound management

2024-07-31 今天遇到一個被自家狗咬傷兩次的病患. 所以打開疾管署網頁. 找到狂犬病臨床處置指引. 教導民眾如何正確處理狗咬傷的傷口

肥皂及大量流動清水清洗傷口 15 分鐘. 

2019-01-06 EDIT 可使用於傷口的消毒殺菌藥物. 多處局部塗抹的殺菌製劑對於傷口都有刺激性, 有部分細胞毒性, 會延遲傷口癒合. 且可能導致局部過敏. 但某些東西對於傷口是有好處的. 例如. iodosorb. 銀基藥物. 蜂蜜

含銀敷料好處似乎不是很顯著. 在一篇系統性回溯研究找到三篇相關的實驗, 共 847 位參與者. 使用各式各樣銀敷料對於慢性潰瘍性傷口的療效. 經過四周之後, 含銀的敷料並沒有明顯改善傷口癒合. 但很多醫師仍使用含銀敷料以降低傷口表面的細菌

蜂蜜: 蜂蜜的高滲透壓與高二氧化氫濃度可用於抑制細菌, 醫療級的蜂蜜目前以各種型態販售(凝膠,貼片, 海藻酸鈉), 但目前的研究資料無法證實蜂蜜能促進傷口癒合. 某些形式的傷口, 例如燙傷, 使用蜂蜜有好處, 而蜂蜜對於靜脈潰瘍性傷口則沒有用. 

 Antiseptics and antimicrobial agents — Most topically applied antiseptic and antimicrobial products are irritating; are partially cytotoxic, leading to delayed healing; and can cause contact sensitization. However, some of these agents may be associated with potential benefits in selected populations:

 Iodine-based — Cadexomer iodine (eg, Iodosorb) is an antimicrobial that reduces bacterial load within the wound and stimulates healing by providing a moist wound environment [71]. Cadexomer iodine is bacteriocidal to all gram-positive and gram-negative bacteria. For topical preparations, there is some evidence to suggest that cadexomer iodine generates higher healing rates than standard care.

Silver-based — Although silver is toxic to bacteria, silver-containing dressings have not demonstrated significant benefits [72-74]. A systematic review evaluating topical silver in infected wounds identified three trials that treated 847 participants with various silver-containing dressings [75]. One trial compared silver-containing foam (Contreet) with hydrocellular foam (Allevyn) in patients with leg ulcers. The second compared a silver-containing alginate (Silvercel) with an alginate alone (Algosteril). The third trial compared a silver-containing foam dressing (Contreet) with best local practice in patients with chronic wounds. Silver-containing foam dressings were not found to significantly improve ulcer healing at four weeks compared with non-silver-containing dressings for best local practices. Nevertheless, silver dressings are used by many clinicians to decrease the heavy bacterial surface contamination [76].

Honey — Honey has been used since ancient times for the management of wounds. Honey has broad-spectrum antimicrobial activity due to its high osmolarity and high concentration of hydrogen peroxide [77]. Medical-grade honey products are now available as a gel, paste, and impregnated into adhesive, alginate, and colloid dressings [78,79]. Based upon the results of systematic reviews evaluating honey to aid healing in a variety of wounds, there are insufficient data to provide any recommendations for the routine use of honey for all wound types; specific wound types, such as burns, may benefit, whereas others, such as chronic venous ulcers, may not

2017-11-02 Edit

from TINTINALLI'S EMERGENCY MEDICINE 8th Edition

傷口沖洗是傷口處置最重要步驟. 能降地細菌數量. 移除壞死組織及異物, 降低傷口感染率. 

多處醫療場所使用無菌生理食鹽水沖洗傷口, 但自來水可能比無菌生理食鹽水更方便經濟且效果相似, 沖洗的液體加入稀釋的優碘, 雙氧水. 並沒有比較好. 含有 polyhexanide 氯己定聚合物 的沖洗液, 在污染性傷口使用. 可降低術後傷口感染 (優於 Ringer's lactate. 優碘. 雙氧水) 

In most medical settings, wound irrigation is performed with sterile normal saline, but potable tap water is as effective and may be superior when taking into account time, resources, cost, and the potential for occupational exposures during clinician-performed irrigation techniques. 12-17 Limited studies indicate that dilute solutions containing povidone-iodine or hydrogen peroxide do not appear to confer greater benefit than water alone.18-20Polyhexanide (a chlorhexidine polymer) is an antiseptic that, when used for wound irrigation of dirty and contaminated soft tissue wounds, reduced the rate of postrepair wound infections compared to Ringer’s lactate, povidone-iodine, or hydrogen peroxide irrigation.21-23 One small clinical trial suggests that warmed solution may be more comfortable than room temperature irrigant.

下圖是含有 Polyhexanide 成分的商品 (a polymer of chlorhexidine 氯己定)

氯己定（或稱洗必泰）為外用抗菌劑及陽離子表面活性劑，對多數革蘭氏陽性菌和革蘭氏陰性菌具殺滅作用（雖然對革蘭氏陰性菌作用較弱）。除可抑菌外，也可殺滅一般細菌。

氯己定是一種消毒劑和抗菌劑，用於手術前的皮膚消毒和消毒手術器械。 它可以用於消毒患者的皮膚和醫療衛生提供者的手部。它還用於清潔傷口，防止牙菌斑，治療口腔酵母感染，並預防導尿管阻塞。它以作為液體或粉末使用。副作用可能包括皮膚刺激，牙齒變色和過敏反應。如果發生直接接觸眼睛，可能會導致眼睛問題。在懷孕期間使用似乎是安全的。氯己定可混入酒精，水或表面活性劑溶液中。它對一定範圍的微生物是有效的，雖然不殺滅活孢子。氯己定在1950年代成為醫療用途。在世界衛生組織的基本藥物清單中，是衛生系統所需的最有效和最安全的藥物。開發中國家的批發成本約為5％溶液每升2.20至4.10美元。在英國約4.80英鎊。

Prontosan® Wound Irrigation Solution The solution for acute, chronic and burn wounds 商品. 用於清洗傷口. 

高壓沖洗. 定義是 7 PSI以上. 低壓沖洗. 定義是 0.5 PSI以下

High-pressure irrigation is defined as approximately 7 psi (50 kPa) or greater, and is achieved using any combination of a 30- to 65-mL syringe and a 19-gauge catheter or needle hub, or commercially available splashguard, with forceful depression of the syringe piston.3,25-28
Low-pressure irrigation is defined as approximately 0.5 psi (3.5 kPa)  or lower, and is achieved with a slow, gentle wash.29 Low-pressure irrigation may be sufficient for cleansing simple, nonbite, uncontaminated wounds in highly vascular areas such as the scalp and face.30 40

浸泡傷口是無效的. 反而可能增加細菌數量, 例行性使用海綿刷洗傷口也是無效的. 可能造成進一步傷害, 降低組織抵抗感染能力.

Wound soaking is not effective in cleansing contaminated wounds and may actually increase wound bacterial counts.32 Routine scrubbing of traumatic wounds with a sponge is also ineffective, inflicting trauma and impairing resistance to infection.

關於傷口沖洗要使用多少沖洗液, 目前資料不足. 常識告訴我們, 沖洗越徹底越不易感染, 一般建議對於乾淨的傷口. 每公分傷口使用 25-100 CC 沖洗液, 再來根據不同部位, 受傷機轉, 汙染程度, 病患本身因素, 可能需要加量

Many wounds and lacerations seen in the ED have little visible contamination, and there is no strong evidence regarding the amount of irrigation effective to minimize postrepair infection. Common sense dictates that the higher the volume of irrigation, the more thoroughly cleansed the wound and the less likely infection will ensue. Typical recommendations by wound care experts range from 25 to 100 mL/cm of wound length for “clean”-appearing wounds.11 Additional volumes should be based on anatomic location, mechanism of injury, degree of contamination, and patient factors that lower resistance to infection. 

高壓沖洗會增加醫護人員黏膜暴露於汙染的體液的風險. 應例行做好自我防護. 

High-pressure wound irrigation risks mucous membrane exposure of the healthcare worker to contaminated body fluids. Irrigation shields provide some measure of safety,28 but universal precautions, including barrier protection with face mask/shield, should be employed as a matter of routine.

2016-05-25 05:08 修改

參考資料  uptodate  Minor wound preparation and irrigation 2014 May 14 

乾淨的傷口, 用流動的自來水清洗, 跟生理食鹽水效果類似, 污染性傷口, 或動物/人 咬傷的傷口, 用稀釋十倍的優碘溶液清洗.  

Irrigation solution — Isotonic (normal) saline is frequently used for uncomplicated wounds, although tap water may be an acceptable alternative. Meta-analyses of three studies in adults and two studies in children compared irrigation with normal saline or tap water for preparation of acute lacerations [32]. No clinically significant differences in wound infection rates were seen. Thus, running tap water may be an acceptable alternative to isotonic saline, at least in healthy patients with clean wounds and in settings where water quality is assured. In addition, when easily available, warmed saline may offer a comfort advantage to room-temperature irrigation [33].

A dilute (ie, 1:10 mixture of povidone/iodine solution [Betadine®]) and isotonic saline may provide useful antiseptic activity for contaminated wounds. Betadine® surgical scrub solution should not be used for this purpose because it contains ionic detergent that may be toxic to wound tissue. Other antiseptic solutions (eg, chlorhexidine and hydrogen peroxide) sometimes are used to reduce bacterial contamination. However, some of these solutions may be toxic to wound tissue, have little action against bacteria, impede wound healing, or have other adverse effects [2,34,35].

The author uses tap water irrigation for the irrigation of clean uncomplicated wounds and uses dilute povidone/iodine for dirty or bite wounds.

http://www.uptodate.com/contents/basic-principles-of-wound-management

傷口清洗是減少細菌和移除異物的重要步驟, 溫熱的生理食鹽水是常用的溶液, 但也有很多研究發現, 自來水清潔傷口的效果跟生理食鹽水類似,  另外, 加入稀釋的優碘或其他抗菌劑, 通常是不必要的. 

Irrigation — Irrigation is important for decreasing bacterial load and removing loose material, and should be a part of routine wound management [1,17,18]. Warm, isotonic (normal) saline is typically used; however, systematic reviews have found no significant differences in rates of infection for tap water compared with saline for wound cleansing [19,20]. The addition of dilute iodine or other antiseptic solutions (eg, chlorhexidine and hydrogen peroxide) is generally unnecessary. These solutions have minimal action against bacteria and could potentially impede wound healing through toxic effects on normal tissue [21-23]. (See 'Antiseptics and antimicrobial agents' below.)

低壓沖洗 (15 PSI)通常足以移除多數傷口上的物質. 在高汙染性傷口, 高壓清洗減少細菌的效果, 會蓋過高壓對鄰近組織的傷害, 但沒有研究證實, 多高的壓力會讓組織傷害的結果, 延遲傷口癒合. 

Low pressure irrigation (eg, <15 pounds per square inch [psi]) is usually adequate to remove material from the surface of most wounds. Decreased bacterial load has been documented clinically with the use of pulsed irrigation in lower extremity chronic wounds [24]. Bacteria do not appear to accompany the irrigation fluid into adjacent tissues in animal studies even at higher pressure levels [25]. In an experimental model, high-pressure irrigation decreased bacterial levels more than bulb irrigation (average reduction, 70 versus 44 percent) with no increase in the rate of bacteremia [26]. For highly contaminated wounds, the benefits of reducing bacterial load may outweigh the risk of speculative adjacent tissue damage associated with the use of higher irrigating pressures. Although higher pressure irrigators may lead to local tissue damage and increased tissue edema, there are no specific data available to suggest a specific cutoff pressure above which tissue damage or impaired, rather than improved, wound healing will occur.

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2014年4月9日 18:27 

1. 在野外，沖洗傷口比較實際，在傷口倒入抗生素藥膏藥粉、浸泡優碘，都不是很好的選擇

2. 直接加壓是最好的止血法，比止血帶實用

3. 止血帶是萬不得以才考慮的方式(大腿截斷、手臂截斷，如不處理，病患可能快速死亡)

4. 斷肢保存方式，使用無菌濕紗布包裹，放入無菌塑膠袋後密閉，再放入冰塊中保持低溫。斷肢需要空氣和水分，斷肢不要直接接觸冰塊，不要泡在生理食鹽水裡面，也不要泡在抗生素藥水內。濕紗布最好是使用生理食鹽水。萬一沒有無菌塑膠袋，則使用清潔的塑膠袋或容器

理想的傷口清理材料, 應該要有廣效性抗菌性, 作用快速, 對組織無傷害, 不會降低組織抵抗感染的能力, 不會延遲癒合, 不會降低傷口強度

(優碘、雙氧水都會殺死細胞)

0.9% 的生理食鹽水和乾淨的自來水, 使用於高壓針筒沖洗, 可以有效清潔傷口, 傳統上是使用生理食鹽水, 但自來水清洗傷口的感染率和美觀程度也相當, 自來水對於沖洗頭皮和上肢的傷口很方便 

Wound Cleansing

An ideal wound cleanser has broad antimicrobial activity with a rapid onset. It is nontoxic to the tissue and does not reduce tissue resistance to infection, delay healing, or decrease the tensile strength of the healing wound. Many antiseptic solutions have been used clinically and studied in great detail ( Table 59-1 ). Much debate exists regarding which agent comes closest to possessing these qualities. Povidone-iodine in various concentrations, saline, and, more recently, tap water have received the most attention.

Evidence suggests that a 0.9% normal saline solution or tap water are effective irrigants when used with high-pressure syringe irrigation. 35 36 Saline is the traditional wound-irrigating fluid of choice. However, tap water has consistently produced equivalent rates of infection and cosmetic outcomes. Tap-water irrigation allows a large volume of irrigation rapidly and inexpensively and is especially suited to upper extremity and scalp injuries.

碘有很強的殺菌力, 但是對於組織的毒性太大, 會降低組織抵抗力, 常用的碘製劑是 POVIDONE-IODINE, 載體是POVIDONE, 通常是 10% 溶液, 含有 1% 游離碘, 但 podivone-iodine 對於多核球有毒性, 即使是 5% podivone-iodine 也會降低PMN活動力, 而增加感染率.

1% 優碘溶液比較安全,能有效殺菌,對於細胞的毒性比較小. 含有洗滌劑的消毒液, 對於組織的毒性太大, 不可用於開放性傷口(見血的都不要用). 

povidone= 多分子聚合物：polyvinylpyrrolidone，一種類似人體血漿的物質， 

Iodophor（碘仿） 

Free iodine, although possessing broad, rapid antimicrobial activity, is too toxic to tissue and its defenses to have therapeutic value in the open wound. An iodophor is a complex of iodine with a carrier to increase its solubility and decrease the availability of free iodine. The most widely used iodophor is povidone-iodine, in which the carrier molecule is povidone (formerly polyvinylpyrrolidone). It is generally available in a 10% solution, which is 1% free iodine. The clinical benefit of this complex is a solution that maintains broad antimicrobial activity and eliminates most local and systemic toxicity. It is well documented that even a 5% povidone-iodine solution is toxic to polymorphonuclear neutrophil leukocyte activity and may increase the infection rate. A 1% solution is safe and effective with little or no toxicity. 29 34 Detergent-containing cleansers, such as povidone-iodine scrub, may be excellent for skin preparation but are toxic to tissue defenses and should never be allowed to contaminate open wounds. 

雖然有各種不同成分的消毒劑可以選, 但清潔傷口主要關鍵在於使用高壓水柱沖洗, 而非選擇的溶劑種類, 使用自來水沖洗傷口可能在未來會成為優先選項, 自來水安全、有效、 不須事前準備 、便宜。 

Although many different irrigation solutions may be beneficial, it seems that the key to cleansing is high-pressure irrigation rather than the type of solution used. Tap-water irrigation soon may become the preferred method of irrigation because it is safe, is effective, requires no preparation, and is less expensive. 

傷口沖洗

影響傷口預後最重要的因素是有沒有好好的沖洗傷口, 沖洗傷口最有效的方式是高壓水柱沖洗, 壓力要大於 7psi, 可減少細菌數量及感染率. 最簡便的方式是使用 18 號針頭, 搭配 35CC 針筒, 可以製造出 7-8 PSI 的水柱, 商品化的洗牙器可以產生 50-70 PSI 的水柱, 高壓水柱雖然會造成一些組織傷害, 但相較於減少傷口細菌和清除壞死組織, 好處遠大於壞處. 單純將傷口浸泡在抗菌溶液並沒有效用, 且可能有害, 使用比較粗的海綿清洗傷口可能造成組織傷害, 且會降地抵抗細菌的能力, 建議可以使用比較細緻的海綿清洗傷口, 使用大量低壓的水清洗傷口, 不管使用任何溶液, 並不會降低感染率.

Irrigation

The quality of mechanical cleansing is one of the most important determinants of wound prognosis. The most effective form of wound cleansing is high-pressure irrigation. Irrigating with pressures greater than 7 pounds per square inch (psi) significantly decreases the number of bacteria and the incidence of infection. 37 38 Although several commercial devices are available, attaching an 18-gauge needle to a 35-mL syringe yields a force of 7 or 8 psi. High pressures of 50 to 70 psi may be obtained with a commercial water pick. These pressures may cause some tissue damage, but the beneficial effect of ridding the wound of bacteria and debris outweighs this risk. Simply soaking the wound in an antiseptic solution is not beneficial and may be harmful. Scrubbing the wound with a sponge with large-pore cells inflicts tissue trauma and impairs the ability to resist infection. Tissue damage can be decreased by use of a sponge with a fine size of pore cell. Adding a surfactant further minimizes the mechanical trauma inflicted by the sponge. Flooding the wound under low pressure via a bulb syringe or gravity alone does not reduce the incidence of infection, regardless of the agent used. 

臉部和頭皮的傷口通常不太需要沖洗(簡單消毒乾淨即可), 不影響感染率和美觀 

At least one study has shown little benefit to any irrigation in facial and scalp lacerations. This study prospectively compared outcomes of almost 2000 immunocompetent patients. Infection rates and cosmetic outcomes were similar in the irrigation and the nonirrigation groups. 39

(ROSEN是急診醫師的教科書)

正常濃度優碘不建議使用於任何開放性傷口  rosen 5th edition page 742:

刷手用優碘不建議使用於任何開放性傷口，濃度約 7.5％

detergent-containing cleansers, such as povidone-iodine scrub, may be excellent for skin preparation but are toxic to tissue defenses and should never be allowed to contaminate open wounds.
但是 1% 濃度的POVIDINE IODINE SOLUTION 可以消毒傷口