2. Wound Debridement

MAJ Travis Burns, M.D.
 
I. Introduction
            A. Debridement derived from French verb “débrider”
            B. Initially used to denote action of “cutting certain parts which—like a bridle—constrict or strangulate the organs which they cover”1,2
            C. Goal of surgical debridement
                        1. save lives
                        2. preserve function
                        3. remove contaminants and nonviable tissue to reduce risk of infection and associated complications
            D. Large zone of injury associated with high energy wounds
                        1. likely to evolve over time
                        2. likely to require serial surgical procedures3
            E. Viable tissue should be retained for reconstructive efforts at higher levels of care
II. Indications for Surgical Debridement
            A. Wound size greater than 2 cm
            B. Associated fracture
            C. Fascial defects
            D. Penetration of pleura, peritoneum, vascular structures, joint capsule
III. Wound evaluation and skin incision
            A. Wound debridement necessitates
                        1. extension of wound edges
                        2. exploration and inspection of the tissues within the zone of injury
                        3. removal of contamination and nonviable tissue
            B. Devitalized skin edges should be sharply excised
                        1. skin remarkably resilient
                        2. excision of large areas should be avoided except for grossly damaged or shredded skin
            C. For traumatic skin flaps, if base to length ratio exceeds more than 1:2, should be sharply excised
                        1. extension of traumatic wound usually made in long axis of limb
                        2. extensions across flexor creases should be done obliquely to prevent contractures
IV. Muscle and Subcutaneous Tissue Evaluation
            A. Damaged subcutaneous tissue and fascia are sharply excised
            B. Complete fasciotomies should be performed for compartments with elevated intracompartmental pressure
            C. Classic indicators to determine muscle viability (may be unreliable during initial evaluation)4
                        1. color
                                    a. least reliable sign for muscle viability
                                    b. surface tissue may be discolored due to contusion, blood under the myomesium, or local vasocontriction
                        2. consistency – ability to rebound to initial shape after grasping with forceps may be most reliable early sign
                        3. contractility
                                    a. assessed by observing retraction with pinch of forceps
                                    b. assessed by observing stimulus with electrocautery device
                        4. capacity to bleed – may be difficult to detect early due to vasospasm
            D. Sharp dissection utilized to remove devitalized tissue from wound incrementally
                        1. neurovascular structures in continuity left intact unless revascularization procedure necessary for arterial injury
                        2. neurovascular structures should be covered with muscle, fat, or skin, if possible
                        3. tendons should be preserved and covered with local tissue
                        4. vacuum-assisted devices should not be used near exposed arteries, nerves, or veins
                        5. repeat assessment with serial surgical debridement likely to be beneficial in complex wounds (see figure 1, figure 2)
            E. Challenging to appropriately balance wound debridement to minimize infectious complications with preservation of soft tissue for reconstruction; no objective measures or tests currently available to discern tissue to debride versus retain
            F. More aggressive debridement likely warranted if wound evaluation not possibly for greater than 24 hours
V. Osseous Evaluation 
            A. Necessary to deliver bone ends in open fractures for adequate debridement of fracture edges and intrameduallary canal
            B. Open wounds that penetrate joint capsule require arthrotomy and irrigation of intraarticular space
                        1. joint capsule should be reapproximated if tissue is available for closure
                        2. bone fragments lacking periosteum or soft tissue attachments are debrided
                        3. major articular fragments should be retained regardless of soft tissue attachments if joint is to be salvaged
VI. Irrigation
            A. After debridement, wounds irrigated with warm, low-pressure pulse irrigation or simple low pressure flow through sterile tubing
            B. Volume and type of irrigation not defined by scientific studies
                        1. volume depends on wound size and contamination
                        2. current recommendations
                                    a. grade 1 fractures – 3 L irrigation
                                    b. grade 2 fractures – 6 L irrigation
                                    c. grade 3 fractures – 9 L irrigation
            C. Antiseptics and antibiotics not recommended additives to irrigation solution
                        1. toxicity to host cells
                        2. lack of proven benefit
            D. Potable water can be utilized in austere environment if sterile solutions unavailable
VII. Postoperative Care
            A. Traumatic open wounds in austere environment should not be closed primarily to minimize risk of infectious complications
            B. Sterile dressings or negative pressure wound therapy devices should be used between procedures and during medical evacuation
            C. Splint should be applied to all severe extremity soft tissue wounds
                        1. patient comfort and soft tissue rest
                        2. should immobilize joint above and below zone of injury
            D. Open wounds reevaluated every 24-48 hours or after transfer to next level of care
            E. Need for repeat surgical debridement largely subjective
                        1. patient considerations
                                    a. evidence of persistent contamination
                                    b. devitalized tissue
                                    c. high energy mechanism
                                    d. local or systemic signs of infection
                        2. management issue considerations
                                    a. time until evacuation
                                    b. length of evacuation
                                    c. volume of other operative cases
VIII. Debridement Surgical Steps
            A. Administer appropriate IV antibiotics and tetanus prophylaxis for all penetrating wounds as early as possible
                        1. cefazolin 1 g q8 hours for gram-positive coverage
                        2. gentamicin 5 mg/kg/24 hours for gram-negative coverage
                        3. penicillin 2,000,000u IV q 4 hours for anaerobic/clostridia coverage
            B. Sterile preparation of the entire limb including prehospital applied tourniquet, as the extent of the zone of injury is not always evident
            C. Once surgical team prepared, and anesthesia has proper vascular access, field tourniquet released
            D. Control active hemorrhage
            E. Longitudinal extension of traumatic wound if necessary to evaluate soft tissue
            F. Excise nonviable tissue
                        1. necrotic skin and subcutaneous tissue
                        2. muscle that is friable, noncontractile, ischemic, severely damaged, or grossly contaminated
                        3. bone that is grossly contaminated or devoid of soft tissue
            G. Identify major nerves and leave in continuity – primary repair of transected nerves not performed in austere environment if definitive care resources available to patient
            H. Irrigate with low pressure pulsatile lavage or simple flow through cystoscopy tubing
            I. Flaps should not be fashioned for closure
            J. Leave wound open and apply sterile dressing
            K. Splint for soft tissue rest and comfort during transport
 
References
 
1. Bowyer G. Debridement of extremity war wounds. J Am Acad Orthop Surg. 2006;14:S52-S56.
 
2. Rechert F. The historical development of the procedure termed debridement. Bull Johns Hopkins Hosp. 1928;42:93-104.
 
3. Ficke JR, Pollack AN. Extremity war injuries: development of clinical treatment principles. J Am Acad Orthop Surg. 2007;15:590-595.
 
4. Scully R, Artz C, Sako Y. An evaluation of the surgeon’s criteria for determining the viability of muscle during debridement. Arch Surg. 1956;73:1031-1035.
 
The view(s) expressed herein are those of the author(s) and do not reflect the official policy or position of Brooke Army Medical Center, the U.S. Army Medical Department, the U.S. Army Office of the Surgeon General, the Department of the Army, Department of Defense or the U.S. Government.

Materials and support for The Disaster Preparedness Toolbox is provided by Lt Col. Ky Kobayashi, MD and Col. Benjamin Kam, MD.



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Tuesday, April 15, 2014 10:49 am