13 open-wound management mistakes to avoidIf you follow these basic principles, healing will be faster, costs will be lower, and both your client and your patient will be happier June 2, 2020 By Phil Zeltzman, DVM, DACVS, CVJ, Fear Free CertifiedA Penrose drain should not exit dorsal to a wound, only distally or ventrally.Photo courtesy Phil Zeltzman Open wounds are a common presentation, whether in day practice or at emergency clinics. Your treatment success rate can increase dramatically if you don’t make any of the following 13 mistakes. 1) Don’t neglect pain management Wounds are painful. Address pain immediately and continuously. Encourage your entire team to pain-score patients at every visit. A patient’s aggressive behavior may be related to guarding a painful area. Treat the pain, and Cujo may magically become Sweetie. 2) Don’t be shy about finances Fees can quickly escalate when you treat open wounds. Don’t surprise pet owners with costs. Be very transparent about what they’re getting into before you start pursuing treatment. The cost of multiple sedation episodes, debridement sessions, and bandage changes can add up. Explain the treatment plan can change. For example, amputation may be required in some extreme cases. 3) Don’t close open wounds Few open wounds can be closed on presentation, unless, that is, you are pretty certain all bacteria have been removed and only healthy tissues remain. If you close an open wound prematurely, you are trapping bacteria under the skin, which can potentially lead to an abscess or infection. If you are dealing with a very large wound and you are concerned about skin edges drifting apart, consider bringing them closer together with a few loose sutures. 4) Don’t misuse a Penrose You can sometimes violate the previous rule by using a drain. Unfortunately, Penrose drains are often placed incorrectly. Here are a few reminders for proper positioning: A drain should not be placed through an existing opening or wound. Instead, create a new, healthy opening. Said opening should be located distal or ventral to the wound. A Penrose drain is passive, requiring gravity to work. This means the drainage naturally flows distally or ventrally. Allowing a drain to exit proximally or dorsally to the wound completely defeats the purpose. It also creates an additional entry for bacteria. Cover open wounds and drains with a sterile bandage. It should be changed frequently based on the amount of drainage. 5) Don’t break asepsis One common misconception is that because a wound is grossly contaminated, you can relax on following asepsis rules. Nothing could be further from the truth—it is quite the opposite. An open wound is a perfect way to introduce more bacteria in tissue that is immunocompromised, poorly vascularized, and possibly heavily traumatized. This is not the time to be flippant about asepsis: Follow 2020 surgical standards Ensure your workspace (e.g. wet sink, treatment table, etc.) is clean Clip hair generously with a clean blade Aseptically scrub the skin around the wound, but not the wound itself Use instruments and supplies—including gloves—that are sterile Wear a cap and a mask Wear a gown, which may or may not need to be sterile depending on the situation Use a properly sized drape. This prevents suture material from dragging all over the table or touching the patient’s hair, your forearms, or the towel under the patient 6) Don’t disregard lavage It’s an immutable law: “The solution to pollution is dilution.” Lavage is a wound’s best friend. You need both enough volume and sufficient pressure. It is perfectly acceptable to flush a highly contaminated wound with tap water in a wet sink upon presentation. When the wound is cleaner, switch to sterile fluids. The best system has been shown to be an IV fluid bag placed in a pressure bag—the fluid bag is connected to an IV line and an injection needle. In one study, “the most consistent delivery method to generate 7 to 8 psi was use of a 1-L plastic bag within a cuff pressurized to 300 mmHg.”1 7) Don’t worship goo Most practices have their “goo” of choice: sugar Betadine (a.k.a. “sugardine”), silver sulfadiazine, antibiotic ointment, steroid cream, zinc oxide, trypsin ointment… Most are merely supported by the voodoo-esque belief they stimulate healing. Yet, applying the wrong ointment at the wrong phase of wound-healing can act as a foreign body, attract debris, and delay the very thing you’re trying to accomplish. One notable exception is honey. It is cheap, safe, and effective. It deodorizes the wound, promotes granulation, and has antibacterial properties. Importantly, use raw honey (unpasteurized is acceptable), as a pasteurized product is devoid of all the helpful components. 8) Don’t overlook using Epsom salt Epsom salt soaks are easy to use: simply follow the “recipe” on the back of the container and soak the wound. This helps reduce inflammation, decrease infection, and speed up healing. 9) Don’t let necrotic tissue increase healing time Serial debridement is important. Tissue should be evaluated daily and multiple debridement sessions may be necessary. If there is questionable tissue, it can be temporarily left in place. Reassess the next day. 10) Don’t skimp on heat Open-wound patients may be otherwise healthy or severely compromised. Either way, always provide heat support. These patients usually require repeated sedation or anesthesia, which will lower their body temperature. Adding cold fluids to flush the wound and aseptically prepping the skin may cause the patient’s temperature to drop even more. Animals with open wounds require heat support like any other surgery patient. 11) Don’t skip the E-collar Wound management is labor-intensive and expensive enough without extra bandage changes or the need for additional surgeries because the patient caused self-trauma. An E-collar—or some kind of protective device—should be used for the treatment’s duration. 12) Don’t get stuck on wet-to-dry bandages These days, wet-to-dry bandages are rarely recommended by wound-management specialists, as they cause pain and severe tissue damage when removed. Instead, nurture the wound by using the gentler techniques described in this article. 13) Don’t forget Halsted’s principles Human surgeon William Halsted (1852 to1922) described seven basic surgical principles. You can conveniently remember them thanks to the acronym that spells his name: H – Handle tissues gently A – Arrest all bleeding L – Leave blood supply intact S – Strict asepsis T – Tension minimized E – Edges together nicely (apposition) D – Dead space minimized These principles are just as relevant today as they were in the 19th century. Violate them at your own risk or at your patient’s expense. If you follow these 13 basic principles, healing will be faster, costs will be lower, and both your client and your patient will be happier. And these are great reasons to celebrate your success. Phil Zeltzman, DVM, DACVS, CVJ, Fear Free Certified, is a board-certified veterinary surgeon and serial entrepreneur whose traveling surgery practice takes him all over Eastern Pennsylvania and Western New Jersey. You can visit his website at www.DrPhilZeltzman.com. He also is cofounder of Veterinary Financial Summit, an online community and conference dedicated to personal and practice finance (www.vetfinancialsummit.com). AJ Debiasse, a technician in Blairstown, N.J., contributed to this article. References 1 TT Gall et al. “Evaluation of fluid pressures of common wound-flushing techniques.” AJVR 2010, Vol. 71, N. 11, p. 1384-1386.