Wound debridement

wound bed preparation

management of a wound to accelerate endogenous healing or to facilitate the effectiveness of other therapeutic measures

TIME priniciple of wound bed prep

tissue, infection, moisture, edge

tissue nonviable or deficient

defective matrix and cell debris, do debridement and restore wound base and ECM proteins

infection or inflammation

high bacterial counts or prolonged inflammation, give antimicrobials to obtain low bacterial counts and controlled inflammation

moisture imbalance

desiccation or excess fluid, give dressings and compression to restore cell migration and avoid maceration

edge of wound non advancing or undermining

non migrating keratinocytes and nonresponsive wound cells, give biological agents, adjunct therapies and debridement to stimulate keratinocyte migration

treat the cause

determine blood supply to jeal, identify/treat cause to determine healability, review cofactors/comorbidities to create individualized POC

patient centered concerns

assess, support, provide education for individualized concerns

local wound care (DIM+E)

cleanse, assess, characteristics and monitor local wound, debride healable wounds, treat critical colonization, infection, persistent inflammation, acheive moisture balance, consider advanced therapies for healable but stalled chronic wounds

systems

link improved cost effective patient outcomes to - education, evidence informed practice, interprofessional teams and healthcare support systems

why debride

masking/mimicking signs of infection, source of nutrients for bacterial cells, physical barrier to closure or granulation development, impairing contraction of wound, stimulating consistent production of inflammatory cytokines (MMP overproduction)

effects of debridement

enhance wound assessment, decrease potential for infection, remove mask of infection, remove barrier to healing, facilitate normal process of wound healing

for arterial wounds with eschar cap

leave it alone, at risk of poor perfusion without - protect

selective debridement

removal of nonviable tissue only

non-selective wound debridement

removal of viable and/or non-viable tissue

autolytic debridement

process by which the bodys endogenous enzymes liquefy necrotic tissue in the wound bed, most selective form and slowest form of debridement - typically used with all other types of debridement

contraindication to exclusively debride via autolytic

infected wounds

mechanical debridement

use of external forces or energy directly to the wound surface to dislodhe and remove bacteria and necrotic tissue

soft abrasion debridement

use of dry gauze or cotton tip to gently lift and remove nonadherent debris

whirlpool

moving water removes loose necrosis, can damage healthy granulation tissue

PLWS

irrigation combined with suction (nonselective)

mechanical wet to dry

dry out a wound then rip it out, very painful - dont perform (need frequent dressing changes)

low frequency ultrasound

aerosolization considerations, reduce bacterial loads, heals with nonthermal effects, stimulates cellular mediators to promote healing (selective or nonselective)

enzymatic debridement

needs daily application, activated by adding moisture or by drainage, selective (expensive, stinging)

enzymatic application tends to work

from the bottom up, may need to cross hatch thick necrotic tissue to allow better penetration, nickel thick application

contraindications to enzymatic debridement

clean wound, allergy to enzyme, concurrent use of heavy metal ions (inactivates enzyme), caution with certain wound cleansers

biological wound healing

maggot larvae to consume necrotic tissue and bacteria

indications for biological debridement

unable to perform other debridement, extensive necrotic tissue

contraindications to biological debridement

bleeding abnormalities, deep/tunneled wounds, psychological factors, limb threatening wounds, large vessels in wounds, allergies

biological debridement process

leave in wound bed 1-3 days, feed on necrotic tissue, cellular debris and exudate, breakdown necrotic tissue

instrumental surgical debridement

removal of viable and nonviable tissue with sterile, sharp instruments, rapid and nonselective (Doctor job)

instrumental sharp debridement

removal of nonviable tissue with sterile instruments, rapid and selective (injection for pain recommended but not controlled by PT) (PT job)

need for surgical debridement

emergent procedures, need higher degree of asepsis, exposure of bone, tendon or joint, need adequate anesthesia, excessive undermining/sinus tracts/tunneling/bleeding

preparation for instrumental devridement

pain control, hemostat/silver nitrate to control bleeding, supplies, positioning and help, lighting, aseptic field,

pain medication options

systemic - water 25 min for oral, IV is immediate; topical - lidocaine 10-15min prior, EMLA cream 60 min prior

contraindications to instrumental debridement

malignant wounds, clotting/bleeding abnormalities, ischemic tissue, medically unstable, underlying dialysis fistula, stable eschar, immuno-compromised patients, loss of visual contact, unidentifiable structures, excessive bleeding

bleeding during sharp/excisional debridement by a PT should be

minimal because only nonviable tissue is being removed (fear bleeding if you cant see the source or if you can hear it)

when is a physician required for instrumental debridement

patient medically delcining, no wound improvement after 2 weeks, new onset cellulitis, unexpected gross purulence, impending exposure of bone/tendon/nerve, abscess within tissues