The Wrong Solution

Contributed by readers • Edited by Sheldon Jacobson, MD

A 32-year-old woman with no significant medical history presented to the emergency department with chief complaints of pain in and swelling of her forearm. She had received treatment in the emergency department the previous day.

The patient had been in a restaurant when a car hit the plate glass window, sending shards of glass into the room. Her most significant injury was a deep, 4.5-cm linear laceration of the ventral aspect of the left mid-forearm. She also had numerous superficial lacerations that did not require suturing. Flexion and supination of the left hand were limited due to pain. Distal neurovascular function was intact.

The patient was seen by the surgical resident on the plastic surgery service because it was felt that there was significant potential for a deep muscle or vascular injury. The record of the previous day's treatment indicated that neither exploration of the wound nor X-rays of the forearm had found foreign material in the wound site. After irrigation, the laceration had been closed with 5-0 nylon. The patient had received a tetanus booster and had been sent home on cephalexin.

Over the next 12 hours, the patient noted swelling and a "peculiar crunching sound" when she touched or moved the extremity; there was also increasing pain in the area. She denied fever or purulent drainage from the wound.

On physical examination, the patient was in mild distress. All vital signs were normal. Examination of the wound showed that the suture line was closed and clean with minimal erythema and only slight tenderness. However, there was marked crepitation and tenderness over the wound as well as in the proximal and distal forearm. Other than the crepitus, the forearm skin appeared to be normal. On x-ray, numerous pockets of gas were visible in the subcutaneous layers of the forearm.

The attending on duty considered the leading diagnosis to be anaerobic infection causing necrotizing fasciitis. After removing the sutures, he opened and explored the wound. It was clean, with no evidence of suppuration, and the tissue bled freely when probed.

At this point, the initial treating physician arrived and also evaluated the patient. She admitted that she had pressure-irrigated the wound with hydrogen peroxide as well as saline. She could not explain why she had chosen hydrogen peroxide except to say that it was "close at hand." The wound was closed with butterfly strips; three days later, it was sutured once again for a delayed primary closure, and it healed without further complications.
 

DISCUSSION

The major error here, of course, was committed by the surgical resident who, for some unfathomable reason, decided to use hydrogen peroxide as an irrigating solution. Hydrogen peroxide solutions are corrosive and can cause tissue necrosis. In addition, they release oxygen into the tissues when they come in contact with peroxidases and hemoglobin.

The only irrigating solution that has been shown to be effective and relatively innocuous is normal saline. Almost any other foreign substance that is placed in a wound can delay healing and damage granulating wounds. This includes undiluted iodophor solutions. As a general rule, if the substance cannot be used in the eye, it should not be introduced into wounds.

Iodophors are appropriate for skin preparation, not wound cleansing. The body's capacity for wound healing is generally so great that the negative effects of an irrigating fluid are trivial compared with this natural ability. However, when a wound contains a large inoculum of bacteria or a significant amount of devitalized tissue, or when there is impaired circulation to the wound site, use of an unphysiologic irrigating fluid can tip the scale, leading to infections and dehiscences.

The second physician made a diagnosis of anaerobic wound infection without other corroborating findings. He had been on the right track in ruling out the worst possible diagnosis, but he should have called the original treating resident prior to removing the sutures and reexploring the wound. Patients with anaerobic skin infections such as necrotizing fasciitis have some evidence of necrotizing cellulitis or gangrene of the skin, as well as marked systemic toxicity. On the other hand, if he had missed such an infection early on, he would have made a major mistake.

In reviewing the utility of hydrogen peroxide in emergency practice, we find that there are actually no situations in which this agent can be recommended as the primary approach to wound management. Perhaps the final answer to this case is simply to keep hydrogen peroxide out of the emergency department.