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Splatter during jet irrigation cleansing of a wound model: A comparison of three inexpensive devices
ORIGINAL CONTRIBUTION
occupational safety wound healing
platter During Jet Irrigation Cleansing of a Wound Model: A Comparison of Three Inexpensive Devices From the Department of Emergency Medicine* and the Collegeof Medicine,~ GeorgeWashington University, Washington,DC. Receivedfor publication September I0, I992. Revision received December28, I992. Acceptedfor publication February 23, 1993. Presented at the Societyfor Academic EmergencyMedicine Annual Meetingin Toronto, Ontario, Canada, May 1992.
Edwin C Pigman, MD* D Brynn Karch t James L Scott, MD*
Study objective: Pressurized jet irrigation
is commonly used to cleanse traumatic wounds but results in splatter of blood, a biohazard. Three inexpensive irrigation devices were compared to assess the degree of splatter produced: a 1.25-in. 18-gauge angiocath, an Irrijet Irrigation System with a 12.7-cm splash shield, and a Zerowet Splashield held directly against the wound (Zerowet-C) and held 4 to 10 cm from the wound, an incorrect technique (Zerowet-I). Design: A standard laceration was created in pieces of beef. This wound model was placed 1 m from the floor. Paper grid sheets were placed on the irrigator's face and chest. Six grid sheets were suspended at the 9:00, 12:00, and 3:00 positions 1 m from the wound model and 1 and 1.5 m from the floor to simulate exposure to nearby individuals. Two grid sheets were placed flat on the floor, at the 10:30 and 1:30 positions, 1 m from the base of the wound model stand. The study area was contained in a 3 x 2 x 2 m plastic sheet enclosure to prevent air drafts. Intervention: Ten irrigations were performed with the angiocath, Irrijet, Zerowet-I, and Zerowet-C. Each run used 200 mL methylene blue solution delivered with a 50-mL syringe by onehand pressure. The methylene blue splatter on each of the grids was counted by size (diameter, less than 1 mm, more than 1 mm and less than 5 mm, more than 5 mm and less than 10 mm, and more than 10 ram). Resuhs: There was significantly less splatter onto the irrigator's face and chest with Irrijet, Zerowet-I, and Zerowet-C. No facial splatter occurred with Zerowet-C. There was significantly less splatter at the 9:00 and 12:00 positions at both heights, and on the floor with Irrijet, Zerowet-I, and Zerowet-C. Less significant splatter difference was noted at the 3:00 position. Conclusion: Irrijet, Zerowet-I, and Zerowet-C were superior to the angiocath in preventing splatter during this wound model irrigation. The correct use of Zerowet (Zerowet-C) was particularly effective in preventing splatter onto the irrigator's face.
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JET IRRIGATION
Pigman, Karch& Scott
[Pigman EC, Karch DB, Scott JL: Splatter during jet irrigation cleansing of a wound model: A comparison of three inexpensive devices. Ann EmorgMed October 1993:22:1563-1567.] INTRODUCTION Traumatic wound care is a common and vital element of the spectrum of care provided by emergency departments. The devitalized tissue and bloody discharge from wounds pose a risk to health care workers and other patients. In a study of consecutive adult patients in an inner-city ED, there was a 5.2% incidence of HIV seropositivity. 1 The majority of these were unrecognized infections. In a similar study at the same inner-city ED, 24% of adult patients were seropositive for hepatitis B, hepatitis C, or HIV type 1.2 While pereutaneous contact with contaminated blood poses a clear risk to a health care worker, the risk of cutaneous or mucous membrane contact remains undefined. 3 Prudence would encourage using barrier devices that reduce contact with contaminated fluids, whether that exposure is percutaneous, cutaneous, or mucous membrane. High-pressure jet irrigation, using either a steady or pulsatile stream, is a technique used for the removal of devitalized tissue and debris and the reduction in the wound bacterial load without compromising the tissue's reparative and regenerative abilities. 4-7 Jet irrigation of wounds causes splatter of blood-contaminated liquid. This study evaluated whether two inexpensive irrigation shielding devices produced less splatter than that produced with an 18-gauge angiocath.
MATERIALS AND METHODS Four devices were evaluated. The first was an 18-gauge, 1.25-in. angiocath (Deseret Medical, Inc, Sandy, Utah) attached to a 50-mL syringe. The second was the Irrijet Irrigation System (Irrijet; Ackrad Laboratories, Cranford, New Jersey). This apparatus uses a 12.7-cm-diameter, rigid, clear plastic disk attached to a flange on the flexible plastic irrigation jet tube to reduce irrigator splashback. The spring-loaded 35-mL syringe that is provided with this system was replaced with a standard 50-mL syringe. This substitution was made to avoid bias created by the smaller barrel volume and the spring-loaded resistance on the plunger with the manufacturer's syringe. The tip of the angiocath and the tip of the Irrijet jet tube were held less than 10 cm away from the wound's surface during jet irrigation. The third device was the Zerowet Splashield ([Zerowet-C] Zerowet, Redondo Beach, California) attached also to a 50-mL syringe (Figure 2). This device is
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ANNALS OF EMERGENCY MEDICINE
a 3.8-cm-diameter, rigid, clear plastic dome with an aperture for the irrigation jet. One point of the dome's circumference remains in contact with the skin surface adjacent to the wound at all times during the irrigation. The fourth device (Zerowet-I) involved the incorrect use of the Zerowet Splashshield by holding "the dome 4 to 10 cm away from the skin's surface during jet irrigation. A standard linear wound 1 cm deep and 5 cm long was created with a surgical scalpel in pieces of fresh, nonfrozen beef rump roast. Ten irrigations were performed with each of the four devices. Each irrigation used 200 mL (four syringes) of a 0.003% aqueous solution of methylene blue (aqueous dilutions of Loeffler's formula: 0.3% methylene blue, 30% denatured alcohol, and 0.007% potassium hydroxide). The irrigation was delivered with maximal one-hand pressure against the plunger using the irrigator's dominant hand. With all devices, the irrigation jet was directed at all margins of the wound to thoroughly cleanse the interior of the wound, as well as the immediately adjacent surface. This was meant to duplicate the process of human wound cleansing. The study area was a plastic drape enclosure of 2 x 3 m. A schematic diagram is presented in Figure 1. The wound model was placed 1 m above the floor on the irrigation stand. The irrigator stood behind this irrigation stand. Grid sheets were suspended from the ceiling at the 9:00, 12:00, and 3:00 positions. These sheets measured 8 1/2 in. and were divided into eight 1-in. columns and ten 1-in. rows. Two grid sheets were suspended at each position. One grid sheet's center was 1 m above the floor, and a second grid sheet's center was 1.5 m above the floor. A grid sheet was placed flat on the floor at the 10:30 and the Figure 1.
Schematic diagram of study area Plastic drape enclosure
~, I ~/2rn
(on four sides)
12:00 Splash grids 10:30 Floor splash grid
1:30 Floor splash 9rid lm
9:00 Splash grids
y~'~27" I *
/rdgation stand
3:00 Splash grids
,m
0Irrigator
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1:30 positions, 1 m from the base of the irrigation stand. The irrigator wore two grid sheets--one centered over the irrigator's xiphoid process (chest) and the other over the irrigatoFs face, attached to an eyeglass harness (face). The splatter grid sheets were coded by position and irrigation technique. Each methylene blue solution splat was categorized by diameter and hand counted. Pour size groups were created based on the splat's diameter: less than 1, 1 to 5, more than 5 to 10, and more thanl0 mm. No magnification was used to assist counting. On any grid Figure 2.
sheet where a splat count reached 500 for a given size category, alternating rows were counted, and the result was multiplied by 2 to yield the total count for that grid sheet for that size category. A set of ten splatter grid sheets was generated for each of the ten irrigations with each study groulS. This study generated a total of 400 splatter grid sheets. Comparisons of splatter counts by position and size between groups were analyzed by one-way analysis of variance and the Newman-Keuls multiple-comparison technique. Calculations were performed with the EPISTATstatistical program. Figure 3,
In'igator splatter exposure by size
Nearby health care worker splatter exposure by size ~]
No. of Splats
[]1-5ram 10,000
~5-10mm II > 10ram
1,000
No. of Splats E]
1,000
m 1-5rnm 100
100
10
10
1
1
0.1
0.1 Angiocath Irrijet
Zerowet-I Zerowet-C
Angiocath Irrijet
Face
Zerowet-I Zerowet-C
[]5-10mm B > lOrnm
IH Angiocath Irrijet
Chest
Zerowet-I Zerowet-C
Angiocath
9:00, 1.5 m
Figure 4.
Irrijet
Zerowet-I Zerowet-C
12:00, 1.5 m
Figure 5.
Nearby patient splatter exposure by size
Floor splatter by size
No. of Splats
No. of Splats [~ < 1 rnm
I ~ < 1 mm
10,000
m 1-5turn m5-1Omm I I > lOmm
~l-5mrn 1,000
100
10
0.1 Angiocath Irrijet
Zerowet-I Zerowet-C
9:00, 1 m
64/1565
Angiocath
Zerowet-I Irrijet
12:00, 1 m
Angiocath Zerowet-C
Irrijet
Zerowet-I Angiocath Zerowet-C
10:30
ANNALS 0FEMERGENCY MEDICINE
Irrijet
Zerowet-I Zerowet-C
1:30
22:10
0CTOBER1993
JET I R R I G A T I O N
Pigman, Karch& Scott
RESULTS
DISCUSSION
The grid sheet counts of splatter were evaluated after being divided into four clinically relevant groups. The irrigator splatter exposure risk was evaluated by the face and chest grids. The health care worker exposure risk was evaluated by the grids placed 1.5 m off the floor at the 9:00, 12:00, and 3:00 positions. This arrangement was meant to represent mucous membrane exposure risk to other health care workers who may be standing nearby during wound jet irrigation. The other patient exposure risk was evaluated by the grids placed 1 m off the floor at the 9:00, 12:00, and 3:00 positions. This arrangement was meant to represent mucous membrane exposure risk to other patients who may be lying on nearby gurneys. The final grouping included the two floor grids at the 10:30 and 1:30 positions. Figure 2 indicates the splatter counts by size and by irrigating technique on a logarithmic scale for the face and chest grids. The angiocath caused sigmficantly more splatter on the face and chest (for diameters of less than 1 ram, P = .001; I to 5 ram, P = .00001; 5 to 10 ram, P = .0002; and more than 10 ram, P > .1). No facial splatter was produced during any of the ten irrigation runs with Zerowet-C. Figure 3 presents the same type of data on the same logarithmic scale for the 1.5-m grids at the 9:00 and 12:00 positions. The angiocath caused significantly more splatter on these grids (for diameters of less than 1 ram, P = .024; 1 to 5 ram, P = .00005; 5 to 10 ram, P = .001; and more than 10 ram, P > .1). There was no significant difference among Irrijet, Zerowet-I, and Zerowet-C. The splatter count for the 3:00 grid is not presented graphically While the total count was less than on the 9:00 and 12:00 grids, the relative distribution Was similar. Both irrigators were right-hand dominant and tended to direct the irrigation jet from the right. Figure ~ presents the data for the 1-m grids at the 9:00 and 12:00 positions. The angiocath caused significantly more splatter only with the smaller splatter (for diameters of less than 1 ram, P=.006; 1 to 5 ram, P=.0006). There was no significant difference among Irrijet, Zerowet-I, and Zerowe;-C. The 3:00 grid had less splatter, and the difference by technique was less marked. Figure 5 presents the data for the floor grids at the 10:30 and 1:30 positions. The angiocath resulted in significantly more splatter only on the 10:30 grid in the three smaller-diameter categories (P = .002 to .006). There was no significant difference among Irrijet, Zerowet-I, and Zerowet-C.
Jet irrigationcleansing is a messy procedure. W h e n an 18-gauge angiocath is used to produce jet stream irrigation to debride a wound, at least a 2-m-diameter area of contamination with bloody fluid splatter is produced about the irrigator. It is likely that most busy inner-city EDs do not have the space available to keep all wounded patients isolated. Cramped work spaces also require that fellow health care workers must traverse this sphere of bloody fluid splatter, either while administering to nearby patients or while simply passing through. This produces at least a mucous membrane bloody fluid exposure risk to these nearby patients and fellow health care workers. Even if an ED had sufficient space to isolate patients undergoing jet irrigation wound cleansing, there still would be risk of bloody fluid splatter to the irrigator. One technique would be to wear a face mask with additional eye protection so that mucous membrane contact with the splatter is limited. Although the risk for infectious disease transmission cutaneously probably is negligible, optimal protection would require the irrigator to wear a gown (a blood-splattered shirt would be unappealing to other patients, fellow health care workers, and spouses). This full-barrier protection would be effective if patient isolation could be achieved; however, the inconvenience of putting on this gear might discourage the potential irrigator from performing this effective wound-cleansing technique. This especially may be true if the wounded patient is known to be infected with or perceived as being at high risk for hepatitis B, hepatitis C, or HIV. Either of the two inexpensive devices tested in this s t u d y - - the Irrijet Irrigation System and the Xerowet Splashield--is effective at reducing the risk of bloody fluid splatter to nearby patients or health care workers. Both are easy to use and do not interfere with performance of the irrigation. The greatest protection for the irrigator is achieved with the Xerowet Splashield. However, this device must be used correctly to achieve this benefit. The inclusion of a Zerowet-I device, where the dome of the splashield is held several centimeters from the wound's surface (an incorrect technique), was based on an author's observations of occasional health care workers' practices. The 18-gauge angiocath was not developed to be an irrigation device. It is manufactured solely as a means to gain temporary vascular access. To compare it with devices specifically developed to irrigate wounds may not be technically appropriate. However, it is the personal experience of the authors, gained from exposure to many civilian and military EDs and primary-care clinics, that the 18-gauge angiocath attached to a 50-ink syringe is
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commonly used as a device for wound irrigation. While its inclusion in this study may not be technically appropriate, we believe that it was clinically appropriate. No attempt was made to control for aperture size of the various techniques. The aperture of the Zerowet Splashield is slightly smaller than an 18-gauge angiocath, and the aperture of the Irrijet System is slightly larger than an 18-gauge angiocath. This study was not intended to evaluate the relative efficacy of any of the irrigation devices; rather, the intent was to evaluate their relative safety There was no attempt made to place an in-line manometer to record nozzle pressures during irrigation. The irrigator simply applied maximal one-handed pressure on the syringe plunger. Data produced by exclusively right-hand-dominant irrigators introduced a bias. Because all techniques were affected equally, this bias should not interfere with the conclusions. An additional source of bias is that the irrigators could not be blinded to the device they were using during an irrigation run.
Address for reprints: EdwinCPigrnan,MD 2140PennsylvaniaAvenueNW Washington,DC20037
CONCLUSION
Limiting the biohazard exposure to health care workers and other patients is an imperative in the ED. Use of an inexpensive device that reduces wound fluid splatter during jet irrigation cleansing is critical. Jet irrigation wound cleansing with the Irrijet Irrigation System or the Zerowet Splashield produces less splatter than cleansing with an 18-gauge angiocath. Correct use of the Zerowet Splashield produces the least irrigator exposure to splatter and after ten irrigations, with a total of 2 L of irrigation fluid, resulted in no facial splatter. REFERENCES 1. Kelen GD, Fritz S, Qaqish B, et ah Unrecognizedhuman immunodeficiencyvirus infection in emergencydepartmentpatients. N EnglJ Meal1988;318:1645-1650. 2. Kelen GD, GreenGB, Purcell RH, et al: Hepatitis B and hepatitis C in emergencydepartment patients. N EnglJ Med 1992;326:1399-1404. 3. HendersonDK, FaheyBJ, Willy M, et al: Risk for occupationaltransmission of human immunodeficiencyvirus type 1 (HIV-1)associatedwith clinical exposures:A prospective evaluation.Ann InternMed I990;113:74g-746. 4. GrossA, Cutright DE, BhaskarSN: Effectivenessof pulsating water jet lavage in treatment of contaminated crushedwounds. Am J Surg1972;124:373-377. 5. HamerML, RobsonMC, KrizekTJ, et ah Quantitativebacterial analysis of comparativewound irrigations. Ann Surg1975;181:819-822. 6. RodeheaverGT, Pettry D, ThackerJG, et ah Wound cleansing by high pressure irrigation. Surg GynecolObstet1975;141:357-362. 7. StevensonTR, ThackerJG, RodeheaverGT, et ah Cleansingthe traumatic wound by high pressure irrigation. JACEP1976;5:17-21.
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occupational safety wound healing
platter During Jet Irrigation Cleansing of a Wound Model: A Comparison of Three Inexpensive Devices From the Department of Emergency Medicine* and the Collegeof Medicine,~ GeorgeWashington University, Washington,DC. Receivedfor publication September I0, I992. Revision received December28, I992. Acceptedfor publication February 23, 1993. Presented at the Societyfor Academic EmergencyMedicine Annual Meetingin Toronto, Ontario, Canada, May 1992.
Edwin C Pigman, MD* D Brynn Karch t James L Scott, MD*
Study objective: Pressurized jet irrigation
is commonly used to cleanse traumatic wounds but results in splatter of blood, a biohazard. Three inexpensive irrigation devices were compared to assess the degree of splatter produced: a 1.25-in. 18-gauge angiocath, an Irrijet Irrigation System with a 12.7-cm splash shield, and a Zerowet Splashield held directly against the wound (Zerowet-C) and held 4 to 10 cm from the wound, an incorrect technique (Zerowet-I). Design: A standard laceration was created in pieces of beef. This wound model was placed 1 m from the floor. Paper grid sheets were placed on the irrigator's face and chest. Six grid sheets were suspended at the 9:00, 12:00, and 3:00 positions 1 m from the wound model and 1 and 1.5 m from the floor to simulate exposure to nearby individuals. Two grid sheets were placed flat on the floor, at the 10:30 and 1:30 positions, 1 m from the base of the wound model stand. The study area was contained in a 3 x 2 x 2 m plastic sheet enclosure to prevent air drafts. Intervention: Ten irrigations were performed with the angiocath, Irrijet, Zerowet-I, and Zerowet-C. Each run used 200 mL methylene blue solution delivered with a 50-mL syringe by onehand pressure. The methylene blue splatter on each of the grids was counted by size (diameter, less than 1 mm, more than 1 mm and less than 5 mm, more than 5 mm and less than 10 mm, and more than 10 ram). Resuhs: There was significantly less splatter onto the irrigator's face and chest with Irrijet, Zerowet-I, and Zerowet-C. No facial splatter occurred with Zerowet-C. There was significantly less splatter at the 9:00 and 12:00 positions at both heights, and on the floor with Irrijet, Zerowet-I, and Zerowet-C. Less significant splatter difference was noted at the 3:00 position. Conclusion: Irrijet, Zerowet-I, and Zerowet-C were superior to the angiocath in preventing splatter during this wound model irrigation. The correct use of Zerowet (Zerowet-C) was particularly effective in preventing splatter onto the irrigator's face.
62/1563
ANNALS 0FEMERGENCYMEDIOINE 22:10 OCTOBER1993
JET IRRIGATION
Pigman, Karch& Scott
[Pigman EC, Karch DB, Scott JL: Splatter during jet irrigation cleansing of a wound model: A comparison of three inexpensive devices. Ann EmorgMed October 1993:22:1563-1567.] INTRODUCTION Traumatic wound care is a common and vital element of the spectrum of care provided by emergency departments. The devitalized tissue and bloody discharge from wounds pose a risk to health care workers and other patients. In a study of consecutive adult patients in an inner-city ED, there was a 5.2% incidence of HIV seropositivity. 1 The majority of these were unrecognized infections. In a similar study at the same inner-city ED, 24% of adult patients were seropositive for hepatitis B, hepatitis C, or HIV type 1.2 While pereutaneous contact with contaminated blood poses a clear risk to a health care worker, the risk of cutaneous or mucous membrane contact remains undefined. 3 Prudence would encourage using barrier devices that reduce contact with contaminated fluids, whether that exposure is percutaneous, cutaneous, or mucous membrane. High-pressure jet irrigation, using either a steady or pulsatile stream, is a technique used for the removal of devitalized tissue and debris and the reduction in the wound bacterial load without compromising the tissue's reparative and regenerative abilities. 4-7 Jet irrigation of wounds causes splatter of blood-contaminated liquid. This study evaluated whether two inexpensive irrigation shielding devices produced less splatter than that produced with an 18-gauge angiocath.
MATERIALS AND METHODS Four devices were evaluated. The first was an 18-gauge, 1.25-in. angiocath (Deseret Medical, Inc, Sandy, Utah) attached to a 50-mL syringe. The second was the Irrijet Irrigation System (Irrijet; Ackrad Laboratories, Cranford, New Jersey). This apparatus uses a 12.7-cm-diameter, rigid, clear plastic disk attached to a flange on the flexible plastic irrigation jet tube to reduce irrigator splashback. The spring-loaded 35-mL syringe that is provided with this system was replaced with a standard 50-mL syringe. This substitution was made to avoid bias created by the smaller barrel volume and the spring-loaded resistance on the plunger with the manufacturer's syringe. The tip of the angiocath and the tip of the Irrijet jet tube were held less than 10 cm away from the wound's surface during jet irrigation. The third device was the Zerowet Splashield ([Zerowet-C] Zerowet, Redondo Beach, California) attached also to a 50-mL syringe (Figure 2). This device is
OCTOBER1993
22:10
ANNALS OF EMERGENCY MEDICINE
a 3.8-cm-diameter, rigid, clear plastic dome with an aperture for the irrigation jet. One point of the dome's circumference remains in contact with the skin surface adjacent to the wound at all times during the irrigation. The fourth device (Zerowet-I) involved the incorrect use of the Zerowet Splashshield by holding "the dome 4 to 10 cm away from the skin's surface during jet irrigation. A standard linear wound 1 cm deep and 5 cm long was created with a surgical scalpel in pieces of fresh, nonfrozen beef rump roast. Ten irrigations were performed with each of the four devices. Each irrigation used 200 mL (four syringes) of a 0.003% aqueous solution of methylene blue (aqueous dilutions of Loeffler's formula: 0.3% methylene blue, 30% denatured alcohol, and 0.007% potassium hydroxide). The irrigation was delivered with maximal one-hand pressure against the plunger using the irrigator's dominant hand. With all devices, the irrigation jet was directed at all margins of the wound to thoroughly cleanse the interior of the wound, as well as the immediately adjacent surface. This was meant to duplicate the process of human wound cleansing. The study area was a plastic drape enclosure of 2 x 3 m. A schematic diagram is presented in Figure 1. The wound model was placed 1 m above the floor on the irrigation stand. The irrigator stood behind this irrigation stand. Grid sheets were suspended from the ceiling at the 9:00, 12:00, and 3:00 positions. These sheets measured 8 1/2 in. and were divided into eight 1-in. columns and ten 1-in. rows. Two grid sheets were suspended at each position. One grid sheet's center was 1 m above the floor, and a second grid sheet's center was 1.5 m above the floor. A grid sheet was placed flat on the floor at the 10:30 and the Figure 1.
Schematic diagram of study area Plastic drape enclosure
~, I ~/2rn
(on four sides)
12:00 Splash grids 10:30 Floor splash grid
1:30 Floor splash 9rid lm
9:00 Splash grids
y~'~27" I *
/rdgation stand
3:00 Splash grids
,m
0Irrigator
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1:30 positions, 1 m from the base of the irrigation stand. The irrigator wore two grid sheets--one centered over the irrigator's xiphoid process (chest) and the other over the irrigatoFs face, attached to an eyeglass harness (face). The splatter grid sheets were coded by position and irrigation technique. Each methylene blue solution splat was categorized by diameter and hand counted. Pour size groups were created based on the splat's diameter: less than 1, 1 to 5, more than 5 to 10, and more thanl0 mm. No magnification was used to assist counting. On any grid Figure 2.
sheet where a splat count reached 500 for a given size category, alternating rows were counted, and the result was multiplied by 2 to yield the total count for that grid sheet for that size category. A set of ten splatter grid sheets was generated for each of the ten irrigations with each study groulS. This study generated a total of 400 splatter grid sheets. Comparisons of splatter counts by position and size between groups were analyzed by one-way analysis of variance and the Newman-Keuls multiple-comparison technique. Calculations were performed with the EPISTATstatistical program. Figure 3,
In'igator splatter exposure by size
Nearby health care worker splatter exposure by size ~]
No. of Splats
[]1-5ram 10,000
~5-10mm II > 10ram
1,000
No. of Splats E]
1,000
m 1-5rnm 100
100
10
10
1
1
0.1
0.1 Angiocath Irrijet
Zerowet-I Zerowet-C
Angiocath Irrijet
Face
Zerowet-I Zerowet-C
[]5-10mm B > lOrnm
IH Angiocath Irrijet
Chest
Zerowet-I Zerowet-C
Angiocath
9:00, 1.5 m
Figure 4.
Irrijet
Zerowet-I Zerowet-C
12:00, 1.5 m
Figure 5.
Nearby patient splatter exposure by size
Floor splatter by size
No. of Splats
No. of Splats [~ < 1 rnm
I ~ < 1 mm
10,000
m 1-5turn m5-1Omm I I > lOmm
~l-5mrn 1,000
100
10
0.1 Angiocath Irrijet
Zerowet-I Zerowet-C
9:00, 1 m
64/1565
Angiocath
Zerowet-I Irrijet
12:00, 1 m
Angiocath Zerowet-C
Irrijet
Zerowet-I Angiocath Zerowet-C
10:30
ANNALS 0FEMERGENCY MEDICINE
Irrijet
Zerowet-I Zerowet-C
1:30
22:10
0CTOBER1993
JET I R R I G A T I O N
Pigman, Karch& Scott
RESULTS
DISCUSSION
The grid sheet counts of splatter were evaluated after being divided into four clinically relevant groups. The irrigator splatter exposure risk was evaluated by the face and chest grids. The health care worker exposure risk was evaluated by the grids placed 1.5 m off the floor at the 9:00, 12:00, and 3:00 positions. This arrangement was meant to represent mucous membrane exposure risk to other health care workers who may be standing nearby during wound jet irrigation. The other patient exposure risk was evaluated by the grids placed 1 m off the floor at the 9:00, 12:00, and 3:00 positions. This arrangement was meant to represent mucous membrane exposure risk to other patients who may be lying on nearby gurneys. The final grouping included the two floor grids at the 10:30 and 1:30 positions. Figure 2 indicates the splatter counts by size and by irrigating technique on a logarithmic scale for the face and chest grids. The angiocath caused sigmficantly more splatter on the face and chest (for diameters of less than 1 ram, P = .001; I to 5 ram, P = .00001; 5 to 10 ram, P = .0002; and more than 10 ram, P > .1). No facial splatter was produced during any of the ten irrigation runs with Zerowet-C. Figure 3 presents the same type of data on the same logarithmic scale for the 1.5-m grids at the 9:00 and 12:00 positions. The angiocath caused significantly more splatter on these grids (for diameters of less than 1 ram, P = .024; 1 to 5 ram, P = .00005; 5 to 10 ram, P = .001; and more than 10 ram, P > .1). There was no significant difference among Irrijet, Zerowet-I, and Zerowet-C. The splatter count for the 3:00 grid is not presented graphically While the total count was less than on the 9:00 and 12:00 grids, the relative distribution Was similar. Both irrigators were right-hand dominant and tended to direct the irrigation jet from the right. Figure ~ presents the data for the 1-m grids at the 9:00 and 12:00 positions. The angiocath caused significantly more splatter only with the smaller splatter (for diameters of less than 1 ram, P=.006; 1 to 5 ram, P=.0006). There was no significant difference among Irrijet, Zerowet-I, and Zerowe;-C. The 3:00 grid had less splatter, and the difference by technique was less marked. Figure 5 presents the data for the floor grids at the 10:30 and 1:30 positions. The angiocath resulted in significantly more splatter only on the 10:30 grid in the three smaller-diameter categories (P = .002 to .006). There was no significant difference among Irrijet, Zerowet-I, and Zerowet-C.
Jet irrigationcleansing is a messy procedure. W h e n an 18-gauge angiocath is used to produce jet stream irrigation to debride a wound, at least a 2-m-diameter area of contamination with bloody fluid splatter is produced about the irrigator. It is likely that most busy inner-city EDs do not have the space available to keep all wounded patients isolated. Cramped work spaces also require that fellow health care workers must traverse this sphere of bloody fluid splatter, either while administering to nearby patients or while simply passing through. This produces at least a mucous membrane bloody fluid exposure risk to these nearby patients and fellow health care workers. Even if an ED had sufficient space to isolate patients undergoing jet irrigation wound cleansing, there still would be risk of bloody fluid splatter to the irrigator. One technique would be to wear a face mask with additional eye protection so that mucous membrane contact with the splatter is limited. Although the risk for infectious disease transmission cutaneously probably is negligible, optimal protection would require the irrigator to wear a gown (a blood-splattered shirt would be unappealing to other patients, fellow health care workers, and spouses). This full-barrier protection would be effective if patient isolation could be achieved; however, the inconvenience of putting on this gear might discourage the potential irrigator from performing this effective wound-cleansing technique. This especially may be true if the wounded patient is known to be infected with or perceived as being at high risk for hepatitis B, hepatitis C, or HIV. Either of the two inexpensive devices tested in this s t u d y - - the Irrijet Irrigation System and the Xerowet Splashield--is effective at reducing the risk of bloody fluid splatter to nearby patients or health care workers. Both are easy to use and do not interfere with performance of the irrigation. The greatest protection for the irrigator is achieved with the Xerowet Splashield. However, this device must be used correctly to achieve this benefit. The inclusion of a Zerowet-I device, where the dome of the splashield is held several centimeters from the wound's surface (an incorrect technique), was based on an author's observations of occasional health care workers' practices. The 18-gauge angiocath was not developed to be an irrigation device. It is manufactured solely as a means to gain temporary vascular access. To compare it with devices specifically developed to irrigate wounds may not be technically appropriate. However, it is the personal experience of the authors, gained from exposure to many civilian and military EDs and primary-care clinics, that the 18-gauge angiocath attached to a 50-ink syringe is
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commonly used as a device for wound irrigation. While its inclusion in this study may not be technically appropriate, we believe that it was clinically appropriate. No attempt was made to control for aperture size of the various techniques. The aperture of the Zerowet Splashield is slightly smaller than an 18-gauge angiocath, and the aperture of the Irrijet System is slightly larger than an 18-gauge angiocath. This study was not intended to evaluate the relative efficacy of any of the irrigation devices; rather, the intent was to evaluate their relative safety There was no attempt made to place an in-line manometer to record nozzle pressures during irrigation. The irrigator simply applied maximal one-handed pressure on the syringe plunger. Data produced by exclusively right-hand-dominant irrigators introduced a bias. Because all techniques were affected equally, this bias should not interfere with the conclusions. An additional source of bias is that the irrigators could not be blinded to the device they were using during an irrigation run.
Address for reprints: EdwinCPigrnan,MD 2140PennsylvaniaAvenueNW Washington,DC20037
CONCLUSION
Limiting the biohazard exposure to health care workers and other patients is an imperative in the ED. Use of an inexpensive device that reduces wound fluid splatter during jet irrigation cleansing is critical. Jet irrigation wound cleansing with the Irrijet Irrigation System or the Zerowet Splashield produces less splatter than cleansing with an 18-gauge angiocath. Correct use of the Zerowet Splashield produces the least irrigator exposure to splatter and after ten irrigations, with a total of 2 L of irrigation fluid, resulted in no facial splatter. REFERENCES 1. Kelen GD, Fritz S, Qaqish B, et ah Unrecognizedhuman immunodeficiencyvirus infection in emergencydepartmentpatients. N EnglJ Meal1988;318:1645-1650. 2. Kelen GD, GreenGB, Purcell RH, et al: Hepatitis B and hepatitis C in emergencydepartment patients. N EnglJ Med 1992;326:1399-1404. 3. HendersonDK, FaheyBJ, Willy M, et al: Risk for occupationaltransmission of human immunodeficiencyvirus type 1 (HIV-1)associatedwith clinical exposures:A prospective evaluation.Ann InternMed I990;113:74g-746. 4. GrossA, Cutright DE, BhaskarSN: Effectivenessof pulsating water jet lavage in treatment of contaminated crushedwounds. Am J Surg1972;124:373-377. 5. HamerML, RobsonMC, KrizekTJ, et ah Quantitativebacterial analysis of comparativewound irrigations. Ann Surg1975;181:819-822. 6. RodeheaverGT, Pettry D, ThackerJG, et ah Wound cleansing by high pressure irrigation. Surg GynecolObstet1975;141:357-362. 7. StevensonTR, ThackerJG, RodeheaverGT, et ah Cleansingthe traumatic wound by high pressure irrigation. JACEP1976;5:17-21.
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