Wound surgical debridement

In deeper, obviously contaminated, older or complicated wounds, surgical debridement is appropriate. Each wound is laid open along its long axis. Wounds should be thoroughly debrided and washed out with excision of all non-viable tissue. Fasciotomy may be necessary on occasion. As a guide, the 4c s criteria may be used -remaining tissue must demonstrate ... 

The nonpharmacologic treatment of diabetic foot ulcers may include off-loading, chemical or surgical debridement of necrotic tissue, wound dressings, hyperbaric oxygen, vascular or orthopedic surgery, and the use of human skin equivalents.30... 

Management of bite wounds consists of aggressive irrigation and topical wound dressing, surgical debridement, and immobilization of the affected area. Primary closure for human bites is not generally recommended. Tetanus toxoid and antitoxin may be indicated. 

In necrotising soft tissue infections surgical debridement is the mainstay of therapy. There is not much evidence in support of topical application of antibiotics in irrigation fiuids topical antibiotics are reported to cause allergic contact dermatitis in up to 5-20%. Irrigations with acetic acid can reduce colonisation of wounds with Pseudomonas sp. 

The method of debridement selected will depend on the individual characteristics of the wound. Surgical and autolytic regimes are underpinned by encouraging the body s own healing... 

Hie most thorough and accurate method to debride an ulcer wound is to surgically remove any necrotic tissue. Surgical instruments (scalpel, forceps, scissors, or laser) are used to cut away the dead tissue. Surgical debridement may be associated with bleeding, which can be controlled by direct pressure, electrocautery, or by cauterising the wound with silver nitrate. ... 

Of the bum injury patients admitted to a specialized Regional Bum Center in Toronto, Ontario, Canada, over an 8-year period, the 24 chemically injured patients made up 2.6 % of the total [29], Occupationally related chemical exposures accounted for 75 % of these injuries, and the involved chanicals included hydrofluoric acid, sulfuric add, black liquor (a heated mixture of sodium carbonate, sodium hydroxide, sodium sulfide, sodium thiosulfate, and sodium sulfate), lyes (alkaline corrosives), phenol, and potassium permanganate. Complications were seen in 58 % of chemically injured patients, including chemical ocular injuries, wound infections, tendon exposures, toe amputation, and systemic toxicity. Of these 24 patients, 14 required extensive surgical debridement and skin grafting. One patient with a 98 % TBSA chemical skin injury died. Of those patients who had typical decontamination measures such as removal of contaminated clothing... 

Necrotic tissue in or peripheral to the wound bed can allow bacterial proliferation and retard tissue cell growth by blocking access to nutrients and oxygen. This dead tissue can be removed by allowing the moist environment to soften and debride it. Enzymatic solutions have also been used with success. On the other hand, surgical debridement of the necrotic tissue is favored by some clinicians for wounds such as diabetic ulcers because it exposes the wound surface to healthy tissue and vasculature. 

A botulinum antitoxin is available and can be obtained from stores held in regional centres and the HPA Centre for Infections as well as Porton Down. The decision to use antitoxin therapy will usually be made by a senior infectious diseases clinician and should rely on clinical or historical features rather than laboratory test results. Surgical debridement and antibiotic therapy may be indicated for suspected wound botulism. Respiratory failure may require endotracheal intubation and mechanical ventilation with subsequent monitoring and treatment in a critical care environment. 

Wounds must be decontaminated and dressed. Surgical debridement may be required to ensure that aU radioactive material has been removed. Clinical staff must take appropriate precautions (Box 6.4). 

Debridement can be accomplished by surgical or mechanical means (wet-to-dry dressing changes). Other effective therapies are hydrotherapy, wound irrigation, and dextranomers. Pressure sores should be cleaned with normal saline. 

After the source of infection is identified, prompt efforts to remove or eliminate the source should be initiated. With an infected intravascnlar catheter, the catheter should be removed and cnltured. Urinary tract catheters should be removed if association with sepsis is suspected. Suspicion of soft tissue (cellulitis or wound infection) or bone involvement should lead to aggressive debridement of the affected area. Evidence of an abscess or sepsis associated with any intraabdominal pathology should prompt surgical intervention. 

There are a variety of methods that can be used to debride a wound, including autolytic, chemical, mechanical, and surgical. Autolytic debridement utilises the body s own enzymes and moisture to dissolve and clean the wound of necrotic tissue. This method has the advantage of being virtually painless for the patient, but can take many weeks to achieve. A moist wound environment is the key factor to autolytic debridement, and is obtained by using occlusive or semi-occlusive wound dressings. 

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