Transcript Wound Debridement

Integumentary System & Wound
Symposium
Wound Debridement
Significance of Necrotic Tissue




As tissues die, they change in color, consistency, and
adherence to the wound bed.
As NT increases in severity color changes from
White/Grey to Tan or Yellow and finally to Brown or
Black
Consistency changes as tissues dessicate or dry
Eventually NT becomes dry leathery and hard
Significance of Necrotic Tissue





Wound etiology influence clinical appearance
Subcutaneous fat forms stringy, yellow slough
Muscle Tissue degenerates into thick, tenacious
tissue
Hard Black Eschar = Full-Thickness destruction
Grey/Blueness or white devitalized tissue may
represent prolonged ischemia
Slough


Yellow (or) Tan
Thin, mucinous or stringy
Sussman, C., Bates Jensen, B. (2001). Wound Care 2 nd addition.
Aspen, Gaithersberg, Md.
Sussman, C., Bates Jensen, B. (2001). Wound Care 2 nd
addition. Aspen, Gaithersberg, Md.
Eschar




Brown or Black
Soft or Hard
Full-thickness destruction
** The more water content present, the
less adherent the debris is to the wound
bed.
Sussman, C., Bates Jensen, B. (2001). Wound Care 2nd addition. Aspen, Gaithersberg, Md.
Adherence




Adhesiveness of debris
Ease at which the two are separated
NT becomes more adherent to the
wound as level of damage increases
Eschar more adherent than yellow
slough
Necrotic Tissue





Retards Wound Healing
Medium for Bacterial Growth
Physical Barrier to Epidermal
Resurfacing, Contraction & Granulation
More NT = More Healing Time
NT Obscures Visualization of the Total
Wound
Arterial/Ischemic Wounds




NT may appear as dry gangrene
Thick, dry, dessicated, black/gray appearance
Firmly adhered to wound bed
May be surrounded with a red halo
Sussman, C., Bates Jensen, B. (2001).
Wound Care 2nd addition. Aspen,
Gaithersberg, Md
Neurotrophic Wounds



Usually no necrosis
Often have hyperkeratosis surrounding
the wound
Hyperkeratosis
looks like callus
formation at the
wound edges
(From: Myers, B.A. (2004).Wound Management
Principles and Practice. Prentice Hall,
Saddle River, NJ)
Venous Disease Wounds



Either Eschar or Slough
Yellow fibrinous material covers the
wound
Eschar might be
due to dessication
and or necrotic debris
Pressure Sores


NT relates to amount of tissue
destruction
Early stage of pressure ulcer, tissue
may appear hard (indurated)with purple
or black discoloration on intact skin
(indicative of tissue death)
Fitzpatrick, T.B., Johnson, R.A., Wolff, K., Polano, M.K., Suurmond D. (1997). Color Atlas and Synopsis of Clinical Dermatology:
Common and Serious Diseases. McGraw-Hill: Health Professions Division: New York.
Intervention: Debridement




Prevent bacteria from colonizing
Prevent competition with viable cells for
oxygen and nutrients
Removal of necrotic and/or infected
tissues that interfere with wound healing
Debridement & Irrigation are reported to
be the most effective method of
controlling wound colonization
Appropriate Wounds for
Debridement


Partial or Full-thickness wounds
Clinical Signs of Inflammation or
Infection:
–
–
–
–
–
–
Periwound erythema
Warmth
Induration
Edema
Foul Odor
Non-viable tissue or purulent exudate
Clinical Considerations





Viable wound and periwound tissues are adequately
perfused with blood
Precautions relative to introducing pathogens must
be observed
Debridement of dry eschar over a bone or tendon is
contraindicated
Debridement is contraindicated in the presence of dry
gangrene
Caution must be exercised when debriding a wound
of a patient on anticoagulants
Debridement




Improves wound and soft tissue status
Reduces risk of infection, complications, and
secondary impairments
Enhances Wound Healing
With Debridement Wounds get “Bigger Before They
Get Better”
Identification of Tissue Types

Skin
– Epidermis:outer avascular layer
– 0.06 -.6mm thick, sloughs Q 30 days
– Waterproof keratinocytes are located in the
epidermis
– New cells located in the basal layer
Identification of Tissue Types

Skin
– Basement Membrane
• Dermal-epidermal junction
• Separates and attaches the epidermis and the
dermis
• Atrophies with aging (skin tears)
Identification of Tissue Types

Skin
– Dermis
• Provides support and nutrition for the epidermis
• Fibroblasts produce collagen for tensile
strength
• Fibroblasts synthesize elastin for resiliency,
produce other components of ground
substance (GAGS, Proteoglycans,
glycoproteins)
• Hair follicles, sweat glands, nails, blood vessels
and nerves located in the dermis.
Identification of Tissue Types



Subcutaneous Layer
– Insulation
– Nutrition
– Cushioning
Composed of:
– adipose tissue
– Major vessels
– Lymphatics
– Nerves
Easily Damaged by Pressure & Infection
Identification of Tissue Types

Fascia
– Shiny white & surrounds skeletal muscle
– Infection (e.g., necrotizing fasciitis) is spread
easily along facial planes


Precaution:
When fascial planes are separated or
penetrated the risk of bacterial invasion
increase.
Identification of Tissue Types

Skeletal Muscle
– Purpose is to provide function
– Protects: bones, joints, nerves, and
vessels
– Pads bony prominences
– Healthy muscle is dull red, contractile, and
vascular
– Necrotic muscle is a darker dull red and
avascular
Identification of Tissue Types

Bone
– If healthy, hard & white
– Cortical bone covered with periosteum
• Periosteum is richly vascularized
– Provides surface for granulation tissue formation
– Accepts skin graft if healthy
– If exposed it will dessicate, & turn yellow and will not
allow for granulation
• If exposed, cortical bone must be kept moist or
it will become necrotic
Identification of Tissue Types

Cartilage
– Connective tissue that covers and
cushions the articular surface of bone at a
joint.
– Poor vascularity
Identification of Tissue Types

Blood Vessels
– Arteries
– Arterioles
– Capillaries
– Venules
– Veins

Understanding Anatomy is crucial to
avoid damage
Identification of Tissue Types

Tendon
– Strong, elastic, fibrous tissues
– Attach muscles to bones
– When exposed can be identified by manually moving the
adjacent joint
– Poor vascularity, become infected easily
– Must be kept moist if exposed
– Healthy tendons are shiny white and are covered with
paratenon
– Paratenon carry blood, should not be debrided if healthy as
the tendon will become necrotic without it.
– A necrotic tendon will not become viable again
– Loss of function results from loss of tendon
Sussman, C., Bates Jensen, B. (2001). Wound Care 2nd addition. Aspen, Gaithersberg, Md
Sussman, C., Bates Jensen, B. (2001). Wound Care 2nd addition. Aspen, Gaithersberg, Md
Debridement

Removal of necrotic & extraneous
(foreign material, debris) tissue from a
wound
Purpose of Debridement







Decrease bacteria within the wound bed, decreasing
risk of infection
Increase the effect of topical antimicrobials
Improve the effect of inflammatory cells
Decrease the length of the inflammatory phase
Decrease the metabolic expense for healing
Decrease the physical barrier to healing
Decrease odor of the wound
Types of Debridement


Non-Selective
Selective
Non-Selective

Mechanical Debridement
– Dry to Dry
– Wet to Dry
– Wet to Wet
– Dakin’s Solution
– Hydrogen Peroxide
– W/P
– Irrigation/ Lavage
Selective

Autolytic: Use of body’s own endogenous enzymes.
Apply a moisture retentive dressing/Saran Wrap.
Wound fluid trapped beneath the dressing softens &
liquefies necrotic tissue. Growth factors and
inflammatory cells may enhance healing as well.
– Least invasive, least painful, consist with moist wound
healing model
– Contraindicated in infected wounds

Enzymatic: Use of topical exogenous
enzymes to remove devitalized tissue
– Elase, Santyl, Accuzyme, Panafil

Sharp/Surgical: Scalpel, Forceps, Scissors
Autolytic Debridement Protocol
(From: Myers, B.A. (2004).Wound Management: Principles and Practice. Prentice Hall, Saddle River, NJ)
Enzymatic Debridement

Indicated for infected & uninfected wounds with
necrotic tissue
– In infected wounds, enzymes may be used with topical
antimicrobial therapy (ex. Polymoxin B with Collagenase)

Contraindicated
– Wounds with exposed deep tissues (ligament, tendon,
capsule, bone, nerve, muscle, blood vessels)

Discontinue after 2 weeks if NT is not effectively
reduced
Enzymatic Debridement Protocol
(From: Myers, B.A. (2004).Wound Management: Principles and Practice. Prentice Hall, Saddle River, NJ)
Talking Points

Dry Eschar
– Cross Hatch or put dressing on to
rehydrate
– Enzymes are tough to activate, do better in
moist environment
From: Myers, B.A. (2004).Wound Management: Principles and Practice. Prentice Hall, Saddle River, NJ)
Sharp Debridement






Removal of nonviable tissue with sterile instruments
Physicians, Nurses, PA & PT’s
No State Practice Act denies PT’s the right to perform Sharp
Debridement
All PT Practice Acts are written broadly enough to allow PT’s to
perform wound debridement without restriction
Arkansas, Arizonia, California, Colorado, Hawaii, Montana, New
Hamshire, New Mexico, Nortyh Carolina, South Carolina,
Tennessee, Texas and Utah specifically cite wound debridement
in their PT Practice Acts
PTA’s cannot perform sharp debridement
Indications for Sharp
Debridement



Large Amount of Necrotic Tissue
Advancing Cellulitis or Sepsis
Thick Adherent Eschar
Red Yellow Black Color Code

Red
– Pale pink to beefy red, granulation tissue
• Goals: Protect wound, Maintain warm moist environment,
Protect periwound

Yellow
– Moist Yellow Slough, may vary in adherence
• Goals: Debride necrotic tissue, Absorb drainage,
Protect Peri-wound

Black
– Thick, Black, adherent eschar
• Goals: Debride necrotic tissue
Cuzzell, J.Z. Am J. of Nursing (1988)
Indication & Contraindications

Debride
– Necrotic Tissue
• Eschar, Slough
– Foreign Material
– Debris
– Residual Topical
agents
– Blisters
– Callus

Do not debride
–
–
–
–
–
–
Granular Tissue
Viable tissue
Stable heel ulcer
Gangrene, osteo
Electrical Burns
Deeper Tissues
• Muscle, tendon,
ligament, bone, nerves,
blood vessels
– Avoid in patients with
impaired clotting
mechanisms
Sharp Debridement

Two Types
– Serial Instrumental Debridement
– Selective Sharp Debridement
Serial Instrumental Debridement

Uses
–
–
–
–
Forceps and scissors
Occurs over several visits
Creates minimal bleeding
Usually requires softening necrotic tissue, making
it more amenable to debridement, by use of W/P,
Irrigation, or Pulsatile Lavage
• Goal: Remove loosely adherent necrotic tissue
Selective Sharp Debridement

Uses Scissors and/or Scalpel
– Cut along the border of viable & non-viable
tissue
– Usually, does not require prior tissue
preparation
– Gelfoam or silver nitrate may be needed to
control minimal bleeding
– Requires use of dry dressing for 8-24 hrs
after debridement
Contraindications to Sharp
Debridement






When area of debridement cannot be adequately
visualized (tunneling or undermining)
When material to be debrided cannot be identified
When clinician is out of her or his comfort zone
When competency has not been met
Sharp debridement should not be performed on
uninfected ischemic ulcers with low ABI
Only physicians should sharp debride
hypergranulated tissue
Sharp Debridement Protocol
(From: Myers, B.A. (2004).Wound Management: Principles and Practice. Prentice Hall, Saddle River, NJ)
Use of Instruments:
Forceps are used to lift devitalized tissue.
Hold the scissors parallel(level) to the specimen
to avoid piercing the specimen with the sharp end
of the scissors
(From: Myers, B.A. (2004).Wound Management: Principles and Practice. Prentice Hall, Saddle River, NJ)
Use of Scalpel:
Hold blade level (parallel) with tissue to be debrided
Debride in layers to prevent incising healthy tissue
Use forceps to apply gentle traction to the devitalized
tissue
(From: Myers, B.A. (2004).Wound Management: Principles and Practice. Prentice Hall, Saddle River, NJ)
Termination of Sharp
Debridement






Clinician becomes fatigued
Patient reports Increased Pain
Patient is less tolerant to procedure
Bleeding beyond minimal
A new facial plane is identified
All necrotic tissue has been removed
Debridement Competency
(From: Myers, B.A. (2004).Wound Management: Principles and Practice. Prentice Hall, Saddle River, NJ)
Surgical Debridement




Performed by a physician or podiatrist
Scalpels, scissors, or lasers
Performed in a sterile environment
Indicated:
–
–
–
–
Ascending cellulitis
Osteomyelitis
Extensive necrotic wounds
Wounds with extensive undermining or where
undermining cannot be determined
– When necrotic tissue is near a vital organ
– When the patient is septic
References







Arndt, A.A., Wintroub, B.U., Robinson, J.K., LeBoit, P.E. (1997). Primary
Care Dermatology. W.B. Saunders Company: Philadelphia, Plate 5, 12,
57-81.
Du Vivier, A. (1995). Dermatology in Practice. Mosby-Wolfe: New York,
1-11, 25, 53, 94, 97, 100.
Fitzpatrick, T.B., Johnson, R.A., Wolff, K., Polano, M.K., Suurmond D.
(1997). Color Atlas and Synopsis of Clinical Dermatology: Common
and Serious Diseases. McGraw-Hill: Health Professions Division: New
York.
Myers, B.A. (2004). Wound Management: Principles and Practice.
Prentice Hall: Upper Saddle River, New Jersey, 37-45, 369-391.
Sussman, C., Bates-Jensen (1998). Wound Care: A collaborative
Practice Manual for Physical Therapists and Nurses. Aspen:
Gaithersburg, Maryland.
Sussman, C., Bates-Jensen (2001). Wound Care : A collaborative
Practice Manual for Physical Therapists and Nurses (2nd ed.). Aspen:
Gaithersburg, Maryland.
White, G.M., Cox, N.H. (2002). Diseases of the Skin: A Color Atlas and
Text. Mosby: New York, 1, 3, 5.