CLINICAL SCIENCE

SESSION
Wound Debridement
Presentan :
Rahmat Arif
Felina Elindra
Fika Fadlila Rosalina
Guntur Cokro Nugroho

12100115146
12100115
12100115
12100115

Pembimbing :

SMF ILMU BEDAH

Fakultas kedokteran unisba
Rumah sakit AL-ISLAM bandung

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

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

Neurotrophic Wounds
Usually no necrosis
Often have hyperkeratosis surrounding
the wound

Hyperkeratosis
looks like callus
formation at the
wound edges

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)

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

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
Dakins Solution
Hydrogen Peroxide
W/P
Irrigation/ Lavage

Selective
Autolytic: Use of bodys 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

Sharp Debridement
Removal of nonviable tissue with sterile instruments
Physicians, Nurses, PA & PTs
No State Practice Act denies PTs the right to perform
Sharp Debridement

All PT Practice Acts are written broadly enough to allow

PTs 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

PTAs 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

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

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

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 (2 nd 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.