When do you stop packing a wound

Introduction

In this article, THEMIS’s Lead Clinical Partner, TMLEP, discusses the significance of leaving wound packing inside a patient.

A Case Example

A patient underwent an operation, following which the wound was packed. When the time came for the wound to be cleaned and re-packed, the original packing was not removed but instead, retained along with the new packing. The patient then developed fever, wound tenderness and infection.

Independent Recommendations to Improve Healthcare Standards and Patient Safety

Wound Packing Complications

In cases such as the one above, when a patient requires specific wound cleaning and aftercare, clinicians must remember to review the patient’s case file, to determine exactly what they require, to make sure that the appropriate level of care is given.

Packing wounds is integral to the patient’s healing and should be thoroughly monitored throughout the aftercare period, adhering to the guidelines. The failure to remove packing on a regular basis, as and when needed, can be detrimental to the patient, because the packing obstructs the pus from leaving the cavity.

This in turn, can lead to the patient suffering prolonged pain and delayed healing, and can cause wound tenderness, fever and infection. Additionally, in some cases, the infection can become severe if the packing is not removed and replaced, requiring further washouts of the wound and an extended care pathway.

Preventative Measures

There are some preventative measures and checks which can overall reduce the risk of a patient inadvertently retaining packing when new packing is being administered, which include actions such as note-keeping and exploration. The measures can lessen the chance of infection and can limit wound complications:

• Using the Operation Note

In the first instance, reviewing the operation note can inform the reader exactly what was carried out and used. This can allow an assessment to be made of what packing was used, if dressing needs to be changed and how many pieces of packing are in situ.

• Exploration

When changing packing and dressings in a patient, the wound should be fully explored (with analgesia if necessary) as the wound opening can be smaller than the cavity underneath. This can prevent any foreign bodies from being left inside the patient, when the new packing is put in place.

• Note-keeping

Packing can become rather difficult to remove - if it is dark/covered in blood, this can make it difficult to identify, making removal challenging.

Moreover, if the packing is covered in blood which has thickened around the wound, this can create an ‘adhesive’ environment, making it troublesome to remove. Precautionary measures should therefore be borne in mind, consisting of note-keeping being up-to- date, for the next time the packing needs to be removed and replaced. By keeping a log of the amount of packing used, this limits the risk of any being retained.

• Packing Alternative

Packing can be biodegradable, which makes the wound check easier, however in those circumstances where the packing used is non-biodegradable, a careful record should be used. To minimise risk of inadvertent retention of the packing by the body of a foreign object, long ribbon packing can be used, rather than individual pieces, to further limit the risk of the patient retaining the packing.

Conclusions

TMLEP’S independent clinical recommendation is that when treating patients with wound packing in situ, clinicians should bear in mind some of the above preventative measures to make sure that the risk of packing-retainment is limited, which therefore aids in reducing the chance of infection.

By raising awareness of the above issues, THEMIS aims to assist in developing awareness of difficulties in dealing with wound packing and the advice to limit inadvertent retainment, thereby improving clinical care and reducing litigation risk.

Published 08 Jun 2021

Co-authored by the THEMIS Clinical Defence Publishing Team and Ms Kayley Newman, TMLEP Analyst.

References

• Co-authored by the THEMIS Clinical Defence Publishing Team and Ms Kayley Newman, TMLEP Analyst.. (2021). A Reminder of The Significance of Removing Wound Packing. The THEMIS Clinical Defence Case Studies. 1 (5), 1.

I. Gunshot wound

While at home:

• Keep the wound clean and dry. If a bandage was applied and it becomes wet or dirty, replace it. Otherwise, leave it in place for the first 24 hours.
• Clean the wound daily:

After removing the bandage, wash the area with soap and water.

You may shower as usual after the first 24 hours, but do not soak the area in water (no tub baths or swimming) until after you follow up with your doctor.

• If bleeding occurs from the wound, cover with a gauze or towel and apply firm direct pressure without letting go for 5 full minutes by the clock. This gives time for a clot to form. If this does not stop bleeding, return to the hospital promptly.

Follow Up:

Most skin wounds heal within ten days. However, even with proper treatment, a wound infection may occur. Check the wound daily for signs of infection listed below. 

Return for a wound check when instructed.

Call your doctor right away if you notice:

• Increased drainage or bleeding from the wound that won’t stop with direct pressure
• Redness in or around the wound
• Foul odor or pus coming from the wound
• Increased swelling around the wound
• Fever above 101.0°F or shaking chills

A note about retained bullets:

Bullets do their damage at the time of injury.  Once a bullet or fragment comes to rest, it rarely causes any further problem.  Unlike what you may have seen on television, it is usually not necessary to remove the bullet.  In fact, removing a bullet or its fragments may cause more damage to the surrounding tissues.

II. Stab Wound

A stab wound usually causes a small opening at the skin, but may go very deep. As a result, nerves, tendons, blood vessels and organs can be injured. Your exam today did not show injury to any deep organs or tissues. Sometimes a deep injury may not be found during the first exam, so watch for the signs below.

Because this is a type of puncture wound, the skin opening is not sutured closed. This is to reduce problems in the event of an infection. As a result, blood may ooze from the wound opening during the first 24 hours. 

While at home:

• Keep the wound clean and dry. If a bandage was applied and it becomes wet or dirty, replace it. Otherwise, leave it in place for the first 24 hours.
• Clean the wound daily:

After removing the bandage, wash the area with soap and water. Use a wet cotton swab (Q tip) to loosen and remove any blood or crust that forms.

You may remove the bandage and shower as usual after the first 24 hours, but do not soak the area in water (no swimming or tub baths) until after you follow up with your doctor.

• If bleeding occurs from the wound, cover with a gauze or towel and apply firm direct pressure without letting go for 5 full minutes by the clock. This gives time for a clot to form. If this does not stop bleeding, return to the hospital promptly

Follow Up:

Most skin wounds heal within ten days. However, even with proper treatment, a wound infection may occur. Check the wound daily for signs of infection listed below.

Return for a wound check when instructed.

Call your doctor right away if you notice:

• Increased drainage or bleeding from the wound that won’t stop with direct pressure
• Redness in or around the wound
• Foul odor or pus coming from the wound
• Increased swelling around the wound
• Fever above 101.0°F or shaking chills

III. Sutures, Staples, Steri-Strips

While at home:

• Keep the wound clean and dry.
• If you were given a bandage, you may change it daily as follows:
  • After removing the bandage, wash the area with soap and water.
  • After cleaning, reapply a fresh bandage.
  • You may remove the bandage to shower as usual after the first 24 hours, but do not soak the area in water (no tub baths or swimming) until the sutures are removed. 

Follow Up:

If sutures or staples are in place, it is important to keep your appointment for removal. If they are left in place too long permanent marks may remain.

If Steri-Strips were applied, they will usually fall off by themselves after 10-12 days. 

Call your doctor right away if you notice:

• Increased drainage or bleeding from the wound
• Redness in or around the wound
• Foul odor or pus coming from the wound
• Fever above 101.0°F or shaking chills

IV. Wound packing

Your doctor wants you to apply a special dressing, or packing, to your wound. When a wound is deep, or when it tunnels under the skin, packing the wound can help it heal. The packing material absorbs any drainage from the wound, which helps the tissues heal from the inside out. Without the packing, the wound might close at the top, without healing at the deeper areas of the wound. You were shown how to pack your wound before you left the hospital. The following guidelines will help you remember how to take care of your wound.

Your supplies: 

Keep your supplies all in one place. Put them in a basket or large bag. You will need the following:

• Packing material
• Sterile wetting solution
• Sterile gloves
• A clean bowl
• Scissors
• A clean towel
• Outer dressing material (a bandage to put on the top of the wound after you have packed it)
• Tape
• Cotton swabs or Q-tips
• A small plastic bag

Procedure:

• Clean the area where you will set out your dressing supplies.
• Wash your hands thoroughly with soap and water.
• Put a clean towel over the area and set a clean bowl on it. Don’t touch the inside of the bowl.
• Pour enough wetting solution into the clean bowl to wet the packing material.
• Cut off a length of packing material and drop it carefully into the bowl of wetting solution. (You will need less packing material as your wound heals)
• Cut pieces of tape to desired lengths. You will use these strips to secure your outer dressing. For now, hang the pieces of tape on the edge of your work surface.
• Gently remove your existing bandage (old tape, outer dressing, and packing). Put these items in a small plastic bag for disposal.
• Wash your hands thoroughly again. Use soap and water.
• Put on the gloves. Gently squeeze the packing material to get rid of excess wetting solution. The packing material should be wet, but not dripping.
• Gently put the packing material into the wound. Packing should fill the wound space completely, but not tightly. Use a cotton swab or Q-tip to gently guide the packing into small or tunneled areas.
• Open your outer dressing material and place it on the towel. Keep it away from the bowl, and don’t get it wet.
• Put the outer dressing over the packing and wound site.
• Tape the outer dressing in place.
• Remove your gloves.
• Wash your hands one more time with soap and water.

Be sure to follow-up when instructed. 

Call your doctor right away if you notice: 

• Increased drainage from the wound
• Redness in or around the wound
• Wound tissue that changes from pink to white, yellow, or black in color
• Odor coming from the wound
• Increased size or depth of the wound
• Fever above 101.0°F or shaking chills

Kimberly Nagy, MD August 2013

How long do you keep packing in a wound?

How long does it take an open wound to heal with packing?

What happens if you stop packing a wound?

How often does wound packing need to be changed?