Unit 8 - Debridement & Wound Management

What is debridement?

The removal of devitalized, nonviable tissue from a wound to promote healing.

What is the purpose of debridement?

• Prevent infection

• Promote granulation

• Optimize healing conditions

• Prevent biofilm formation

General Indications for Debridement

• Presence of necrotic tissue

• Delayed wound healing

• Signs of infection or biofilm presence

• To improve the effectiveness of topical treatments

General Indications for Debridement: Red wound

• a beefy red to pale pink granular wound bed and ready to heal

• contraindicated because there is no devitalized tissue, and any attempt to debride this wound will only delay healing

• Protect

• Maintain a warm, moist environment

General Indications for Debridement: Yellow wound

• a wound with exudate and is covered in necrotic tissue called slough, which is a mixture of white blood cells, pus, and fibrin

• The wet of the slough will promote bacterial growth, making a yellow wound more susceptible to infection and maceration of the periwound area

• Debride necrotic tissue

• Absorb exudate and protect the peri-wound area

General Indications for Debridement: Black wound

Debride necrotic tissue

• Eschar can be moist, yet is dry, thick, and tough when allowed to lose moisture adhering it to the wound bed.

• Debridement is indicated and can transition the wound bed to either a yellow bed or to a red wound bed, as when eschar is removed during sharp debridement. It can expose the wound bed area to a red granular base

General Contraindications for All Methods

• Red granular wounds

• Wounds in an ischemic extremity with hard, dry, stable eschar

  • Progression = immediate referral to a vascular surgeon

• Crucial Surgical Debridement Need

  • Limb-life saving procedures delayed with continued PT setting interventions

  • Extensive debridement necessary

    • Gangrenous / Exposure to deeper structures

    • Large stage 3 and 4 pressure injuries with undermining, tunneling, sinus tracts

Preparation Steps for Debridement

• Ensure sufficient lighting & position the patient comfortably allowing wound visualization

• Be aware of your body mechanics to decrease the chance of fatigue

• Wash hands and don gloves

• Remove current dressing and discard appropriately

• Discard soiled gloves and sterilize hands before donning clean gloves

• Irrigate the wound with saline solution to inspect for debridement indication and method

• Discard soiled gloves

• Educate the patient on the procedure chosen

• Don clean gloves and initiate the method chosen

Debridement Methods

• autolytic

• enzymatic

• mechanical

• biologic

• sharp

Debridement Methods: Autolytic

Uses occlusive and semi-occlusive moisture-retentive dressings to encourage the body’s enzymes to break down necrotic tissue, or for wounds that other methods are contraindicated

• Indicated for:

  • Wounds with necrotic tissue

  • Other methods are contraindicated

  • Larger debridement plan

Debridement Methods: Enzymatic

• Utilizes proteolytic enzymes to selectively degrade necrotic tissue

• Uses enzymes like collagenase to break down necrotic tissue

• Indicated for chronic wounds with necrotic tissue

• Can be expensive and requires a prescription

Debridement Methods: Mechanical

Includes both selective and nonselective physical methods

• Nonselective

  • affects both viable and non-viable tissue

    • may damage viable tissue

  • These include wet-to-dry dressings, pulse lavage, whirlpool, and high-pressure irrigation

• Selective

  • Low-frequency ultrasound with the brand named MIST

  • Distinctly differs from high-frequency ultrasound you are familiar with from the biophysical agent course, as it does not contact the surface

Debridement Methods: Biologic

Uses sterile maggots to consume necrotic tissue selectively

• Indications for its use is a wound bed with extensive necrotic tissue that's unresponsive to other debridement methods

• This method may not be widely accepted by patients

Debridement Methods: Sharp

Uses surgical instruments to remove necrotic tissue precisely

• fast and highly selective method performed with scalpels, scissors, and forceps

Precautions for Debridement Selection

• Ensure proper assessment before debridement

• Consider patient comorbidities

• Monitor for signs of infection or complications

Autolytic Debridement: Indications and Protocol

• Indications:

  • All etiologies with necrotic tissue

  • Patients who cannot tolerate more aggressive debridement

• Protocol:

  • Apply occlusive or semi-occlusive dressings (e.g., hydrocolloids, hydrogels, honey-based dressings)

  • Monitor for infection; assess dressing choice and discontinue if signs of infection develop

  • The dressings of choice will remain in place for 2 to 3 days

Autolytic Debridement: Contraindications

• a deep cavity wound or an infected wound

• If surgical or sharp debridement is indicated, autolytic debridement would not be a method of choice.

• The use of moisture-retentive dressings will continue after the wound bed is free of necrotic tissue or foreign material, yet recognize it is no longer called autolytic debridement at this point

• Would be terminated if it fails to decrease any necrotic tissue in the expected time frame, which could be as little as three days

Enzymatic Debridement: Indications and Protocol

• Protocol:

  • Apply collagenase enzyme directly to necrotic tissue

  • Protect periwound skin with barrier creams

  • Regularly reassess for progress

• Indications:

  • Infected or uninfected wounds

  • Wounds with moderate to heavy necrotic tissue

  • Patients unable to undergo surgical or mechanical debridement

  • Failure of another debridement method

Enzymatic Debridement: Contraindications

• an exposed structure such as bone, tendon, ligament, et cetera.

• facial burns

• not effective in the debridement of calluses.

• should not be used in a wound bed without necrotic tissue,

• should not be utilized with dressings or topical agents with acidic solutions or heavy metal ions because these inactivate the collagenase

• Termination should occur when all necrotic tissue has been removed, or if the amount of devitalized tissue seen within the wound bed is not significantly reduced within two weeks of the start of use

Mechanical Debridement: Indications and Protocol

• Non-Selective Methods:

  • Wet-to-dry dressings: Apply moist gauze, allow to dry, and remove

  • Pulsatile lavage (4-9 psi, no greater than 15 psi)

  • Whirlpool therapy

  • High-pressure irrigation

• Selective Methods:

  • Low-frequency ultrasound (MIST)

• Indications:

  • Wounds with adherent slough or thick necrotic tissue (covering 100% of the wound bed)

  • Patients who require cost-effective options

Biologic Debridement: Indications and Protocol

• Protocol:

  • Apply medical-grade maggots to wound bed

  • Cover with semi-permeable dressing

  • Remove after 48-72 hours

• Indications:

  • Wounds with significant necrosis

  • Patients' intolerant to other methods

Sharp Debridement: Indications and Protocol

• Protocol:

  • Identify non-viable tissue

  • Use appropriate sterile instruments

    • Selective vs. serial instrumental

  • Avoid excessive bleeding or damage to viable tissue

• Indications:

  • Wounds with extensive necrotic tissue

  • Urgent need for tissue removal

Sharp Debridement: Serial Instrumental

• Forceps and scissors

• Tissue preparation

• Several visits to complete

• Minimal bleeding or pain

Sharp Debridement: Selective Sharp Debridement

• PT only

• Scissors and/or scalpel

• Hemostatic agent (Gelfoam, silver nitrate) / topical pain medication

• Few sessions to complete

Sharp Debridement: Advantages

• Inexpensive

• Key component of active wound management

Sharp Debridement: Disadvantages

• Skill required

• Possibly painful

Sharp Debridement: Contraindications

• Arterial/Ischemic ulcers (ABI < 0.4)

• Dry gangrene or dry ischemic wounds

• Systemic infection or elevated temperature

• Exposed bone, tendons, prosthetics

• Stable eschar in arterial insufficiency/diabetes

Sharp Debridement: Termination

• Fatigue

• Uncontrolled pain

• Decline in patient’s status

• Decreased tolerance to the procedure

• Time limitations

• Excessive bleeding

• All tissue left is viable tissue

What is an Infection?

occurs when pathogenic microorganisms proliferate within a wound overwhelming the immune system, leading to delayed healing or systemic complications

How is an infection diagnosed?

• Clinical signs and symptoms

• Wound culture results

• Presence of biofilms

• Systemic response (e.g., fever, elevated WBC count)

Risk Factors for Infection: Host

• Diabetes mellitus

• Malnutrition

• Obesity

• Immunosuppression

• Older adults

Risk Factors for Infection: Local

• Ischemia / Peripheral arterial disease

• Contaminated wound with necrotic tissue or debris

• Chronic wounds

• Use of inappropriate or no dressing

Signs & Symptoms of Wound Infection: Local

• Increased pain, redness, and swelling

• Purulent drainage

• Malodor

• Delayed healing

Signs & Symptoms of Wound Infection: Systemic

• Fever and chills

• Increased white blood cell count

• Erythemal streaking (red streaks from wound)

Biofilms and Chronic Wound Infections

• Adheres to wound surfaces, making removal difficult

• Reduces antibiotic effectiveness for bacterial species

• Requires specialized debridement and antimicrobial treatments

Biofilm Management

• Physical removal with sharp or mechanical debridement

• Use of antimicrobial dressings (e.g., silver, honey-based)

• Adjunctive therapies (e.g., low-frequency ultrasound, negative pressure wound therapy)

Infection Management Strategies

• Wound cleansing using non-cytotoxic solutions

• Debridement to remove infected tissue and microbial biofilms

• Dressing selection to promote healing and control bioburden

• Medication guided by culture results (bacterial , yeast, fungal, viruses)

  • Staphylococcus Aureus (most frequent bacteria)

Clean Technique in Wound Care — Principles for Infection Prevention

• Hand hygiene before and after wound care for 15 sec, 3-5 mL of soap

• Use of clean gloves and sterile instruments

• Avoidance of cross-contamination

• Application of sterile dressings in a controlled environment

Dressing Selection for Infection Control

Antimicrobial Dressings:

• Silver dressings

• Honey-based dressings

• Iodine dressings

• Foam dressings

Silver dressings

broad-spectrum antimicrobial action

Honey-based dressings

antimicrobial, pH balancing, and anti-inflammatory

Iodine dressings

effective against bacteria and fungi

Foam dressings

absorptive and protective for exudative wounds