Technique of Sharp Wound Debridement

1. Technique of Sharp Wound Debridement

2. 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

3. 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?

4. 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.

5. 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!

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

7. 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

8. 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

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

12. Curette

13. Basic instruments

14. Adson Brown forceps with teeth

15. 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?

16. 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

17. Relax

18. 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

19. Sharp Debridement

20. 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

21. 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.