Wound Debridement

Aka: Wound Debridement, Skin Wound Debridement, Decubitus Ulcer Debridement, Sharp Debridement, Mechanical Debridement, Autolytic Debridement, Enzymatic Debridement, Chemical Debridement, Debridement

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II. Contraindications

  1. Do not debride wounds that are poorly vascularized
    1. Evaluate first with Ankle-Brachial Index if suspect significant Peripheral Arterial Disease

III. Mechanism

  1. Wound Debridement is a cornerstone of Chronic Wound management
  2. Debridement removes tissue that delays healing
    1. Necrotic tissue or exudate
    2. Biofilm (Bacterial colonization)

IV. Indications

  1. Preserve granulation tissue (pink)
  2. Debride Fibrin tissue (white, yellow, or green tissue)
  3. Debride Hematomas
  4. Debride necrotic tissue (black wound)
    1. Full thickness burn (Third Degree Burn)
    2. Pressure Sore (Stages 3 or 4)
    3. Gangrenous ulcer
  5. Exceptions: Stable healing ulcer with dry eschar
    1. Dry eschar does not require Debridement
    2. Debridement indications
      1. Edema or erythema
      2. Fluctuance
      3. Discharge

V. Techniques: Sharp Debridement

  1. Scalpel or scissors to remove devitalized tissue
  2. Indications
    1. Removing adherent eschar
    2. Devitalized, necrotic tissue in extensive ulcer
    3. Urgent Debridement in advanced Cellulitis or Sepsis
  3. Anesthetic
    1. Topical Anesthetic (4% topical Lidocaine applied 5-10 min before Debridement)
    2. Deeper involvement will require Local Anesthetic (e.g. Lidocaine 1% injection)
  4. Wound preparation
    1. Debridement is a clean, but not sterile procedure (wounds are already colonized)
    2. Irrigate wound with sterile saline or water to remove old product or drainage
    3. Hibiclens (or other antimicrobial soap) as a periwound wash for more contaminated wounds
    4. Dab wound bed and necrotic material after irrigation (eases Debridement)
  5. Sharp Debridement techniques
    1. Lift necrotic tissue and snip with scissors
      1. Indicated when clear plane between dead tissue and viable tissue
    2. Lift necrotic tissue and shave with scalpel (#15 blade)
      1. Lift tissue edge and apply shallow strokes horizontal to skin surface to tease away necrotic tissue
    3. Incise
      1. Entry into a hard eschar that has no obvious edge top approach for Debridement
    4. Cross Hatch
      1. Indicated to start debriding tightly adherent fibrous tissue
      2. Apply shallow strokes (<1 mm) perpendicular to surface in criss-cross pattern into the adherent material
      3. Allows for non-Sharp Debridement dressings (e.g. enzymatic agents) to penetrate for better activity
  6. Follow-up Sharp Debridement
    1. Apply clean, dry dressings for 8-24 hours
    2. Restart wet-to-moist (or wet-to-dry) dressings
  7. Debridement under Anesthesia Indications
    1. Indicated for extensive stage 4 Decubitus Ulcers
    2. Consider bone biopsy to assess for Osteomyelitis

VI. Techniques: Other Debridement techniques (via dressings)

  1. Mechanical Debridement
    1. Wet-to-Dry Dressing
    2. Hydrotherapy (Occlusive Wound Dressing)
      1. Transparent Film Dressing
    3. Wound Irrigation
    4. Dextranomers
  2. Enzymatic Debridement (Chemical Debridement)
    1. Indicated where surgical Debridement is not possible and wound infected or dead tissue
    2. Papain-urea (e.g. Accuzyme, Panafil)
    3. Trypsin-balsam peru-Castor oil (e.g. Xenaderm)
    4. Collagenase (Santyl)
  3. Autolytic Debridement
    1. In vivo enzymes self-digest devitalized tissue
    2. Contraindicated for infected wounds
    3. Synthetic dressing applied to cover wound
      1. Mildly draining wounds: Hydrogel Dressing, Hydrocolloid Dressing
      2. Moderately to strongly draining wounds: Alginate Dressing

VII. References

  1. Cole (2017) Wound Care Update, Park Nicollet Conference, St Louis Park, MN (attended 9/15/2017)

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