Technique of Sharp Wound Debridement

Preparation for debridement: Physician order for sharp debridement Developing a strategy: What are the goals? To heal or not to heal? Will all your work be in vain? Know the patients past and current medical history, wound assessment, vascular status, neurological status, medications Obtain patient or family consent Instruments and supplies Apprehension (yours VS. the patient’s) Location, location, location

Physician order for sharp debridement: Is the order specific to exactly what needs to be done? Has the physician seen the wound recently or is this an order called in over the phone?

Developing a Strategy: What are the goals. To heal or not to heal Developing a Strategy: What are the goals? To heal or not to heal? Will all you work be in vain? To remove necrotic tissue To reduce bacterial count To allow granulation to occur Just keeping the wound clean or do we realistically expect the wound to heal. Dictates treatment plan: expensive Vs. non expensive modalities You just spent 15 minutes upside down debriding a necrotic plantar foot wound. Your back hurts. You come back next week and look at the patient and find out they’ve participated in Tango lessons for 5 of the last seven days.

Know the patients past and current medical history, wound assessment, vascular status, neurological status, medications: Do not take a sharp instrument to a patient without knowing the above information. It is a poorly planned procedure if you do!

Obtain patient or family’s consent “Sure, go ahead and cut on my mother.” Informed consent: Explain expectations, risks and benefits

Instruments and Supplies Iris Scissors Tissue Forceps with and without teeth Curettes Hemostat Rongeur Scalpel #3 handle with blade #11, #15, #10 disposable Bandage scissors Wound measuring device Camera

Instruments and Supplies Gloves sterile or non sterile Sterile/clean field i.e. chuck, drape Syringes and needles Topical or injectable anesthetic if needed Gauze Cotton tipped applicators Saline Hemostatic product i.e. Silver nitrate, Surgicel, etc. Hazardous waste bag -red

Tissue Forceps Rongeur #10 Blade Iris Scissors #15 Blade Curette Adson Brown Forceps

Curette

Basic instruments

Adson Brown forceps with teeth

Apprehension: Yours Vs. the Patient’s Know your limitations How long is the procedure going to last? If you’re nervous, not confident, or have a gut feeling that something's not right, don’t proceed Is the patient comfortable, in pain or combative?

Location, Location, Location Patient should be in a comfortable position You should be in a comfortable position There should be adequate lighting Have an assistant if possible Aseptic field

Relax

Technique for sharp debridement with a scalpel or scissors Grasp the eschar or necrotic tissue with a tissue forceps or hemostat Using a scalpel or scissors, cut underneath staying parallel to the plane of the wound Be sure to visualize where the tip of the instrument is cutting Remove the tissue in layers if unsure of how deep to go

Sharp Debridement

How much to debride? Depends on the amount of non viable tissue How much can the patient tolerate? It is important to set limits A bedside debridement should take 5-30 minutes depending on location, amount of tissue removed, patient comfort and clinician fatigue Rate of debridement will also depend on your experience

Following removal of non viable tissue the wound is cleaned with normal saline. Check for any uncontrolled bleeding and perform hemostasis if necessary. If indicated, take cultures of the wound. Deep tissue cultures/samples are preferred to superficial swab cultures. The wound is then dressed per orders. Debridement may have to be daily, weekly or on a PRN basis. Physician orders should reflect this.