Goal: Removal of devitalized tissue and debris reduces both infection and morbidity. Devitalized tissue acts as a medium for bacterial growth and inhibits leukocyte function. The goal is to remove this tissue while preserving as much perfused tissue as possible. A basic knowledge of debriding skills—cutting, clamping, grasping, ligation, and tying—allows the provider to effectively manage the balance between salvageable and unsalvageable tissue.

Identification of viable tissue may be challenging. Tissue that is clearly dead should be removed, whereas tissue of uncertain viability should be preserved and re-examined in 24–48 hours. Use the four Cs, along with clinical judgment, when excising muscle tissue: color, contraction, consistency, and circulation.

Caution: Debridement of large wounds or wounds associated with other injuries will result in significant blood loss. Be prepared to give blood transfusion.

- Best: Use an assistant; remove nonviable tissue using sharp dissection (sterile scalpel or scissors) and control bleeding using tourniquet, topical hemostatic dressings, direct pressure, clamping, suture ligation, and/or electrocautery. Questionably viable tissue may be retained with repeat debridement once every 24–48 hours until arrival at surgical facility.10
- Better: Remove nonviable tissue using sharp dissection (sterile scalpel or scissors) and control bleeding using tourniquet, topical hemostatic dressings, direct pressure, clamping, and/or suture ligation. Repeat debridement or delayed primary closure in 3–5 days.
- Minimum: When unable to evacuate and resources for serial debridements are not available, remove all nonviable and questionably viable tissue, using sharp dissection (clean blade or scissors) and control bleeding with tourniquet and/or direct pressure. Leave clean dressing in place, then perform delayed primary closure in 4–7 days if no sign of infection.11,12 See Appendix A for further details on the International Committee of the Red Cross (ICRC) method of wound care.

Debridement Notes

Exposure

- Deeper wounds should be exposed through generous skin incisions in the long axis of the extremity.
- Avoid exposing major blood vessels, tendons, and nerves, unless they are injured.

Anatomic Considerations

- Review the anatomy of the injured body part before debridement. Extremity wounds are by far the most common and the need for reference anatomic diagrams should be anticipated.
- If a major blood vessel is injured, it will require ligation, repair, or shunting. In the extremity, ligation may result in amputation; however, vascular repair or shunting are advanced surgical skills.
- Damaged parts of tendons do not need much debridement and should be preserved when possible. Tendons may be repaired later as a delayed procedure.
- Damaged nerves should not be debrided. Some nerves may be repaired as a delayed procedure.
- Loose, unattached fragments of bone should be removed; however, any bone fragments still attached to muscle should be left in the wound. After debridement and dressing placement, a fractured extremity should be immobilized with a splint.
- After debridement, attempt to ensure that vital structures (i.e. blood vessels, nerves, tendons, bone) are covered with soft tissue. This may require partial wound closure or mobilization of soft tissue to cover the structure.
- Mangled extremities may require amputation. Amputation is best left to a surgical facility and the wound kept as clean as possible while awaiting evacuation. If evacuation is not possible, amputation may be necessary.
- An injured extremity may require fasciotomy. Be vigilant for signs of compartment syndrome.
- Wounds penetrating the chest cavity should not be probed and should be minimally debrided to avoid creating a pneumothorax. If a pneumothorax is present, a chest tube should be placed through a separate, clean skin incision.
- Wounds penetrating the abdominal cavity require abdominal exploration (i.e. laparotomy) if associated with hemodynamic instability or peritonitis. Otherwise, these wounds may be debrided and dressed as any other wound.
- Small wounds or puncture wounds can be managed using local anesthesia, washing (scrubbing) the wound with soap and water or disinfectant soap, irrigating, dressing, and then allowing the wound to close by secondary intent. Some minor excision of the wound edges may be indicated.
- Large wounds require careful attention to hemostasis, wound care, and consideration for repeat debridements or delayed closure.

Complex wounds are best managed with a telemedicine consultation. Photos or video of the wound should be transmitted.

Assessment of Tissue Viability

- Color is the least reliable trait for measuring tissue viability. Evaluate the tissue’s color relative to similar tissue deemed viable. Nonviable tissue appears pale, bluish, gray, or black. Bruised tissue that is viable may also have a dark coloration.
- Contractility refers to the retraction of muscle tissue when tension is placed on it by grasping. Nonviable muscle tissue does not contract.
- Consistency evaluation involves comparing potentially dead tissue with live tissue in terms of texture, density, and rigidity. Viable tissue has elasticity and firmness, whereas nonviable tissue is friable and/or is in a state of liquefaction.
- Circulation may be the best indicator of salvageable tissue because any tissue that bleeds when very minor trauma is applied can almost always be judged as perfused and, therefore, viable.

Debridement Techniques

- Cutting: Meticulous sharp surgical technique using scalpel and scissors should be the starting point for almost all war wounds that involve penetrating foreign bodies. Typically, #10 or #15 scalpel blades (or #11, as an alternative) are used for the removal of skin tissue, and sharp scissors (e.g., Metzenbaum, Mayo) are used for the removal of deeper tissues below the dermis.
- Grasping: Forceps, such as the Adson, Rat Tooth, and DeBakey, are used for grasping and tissue manipulation to fully explore a wound.
- Ideally, equipment used for debridement should be sterile. However, if this is not available, disinfected or clean instruments will suffice (see Appendix B for nonstandard tool sterilization/disinfection).

Hemorrhage Control Techniques

Consideration for hemorrhage control should be given before starting debridement. For larger areas of debridement to an extremity, place a tourniquet before debridement. Elevate the extremity before tourniquet placement to facilitate venous return and reduce bleeding. Monitor the tourniquet times closely and attempt to keep the total tourniquet time <90 minutes.

- Direct pressure to a wound, preferably in combination with a hemostatic dressing, will stop most minor bleeding encountered during wound care.
- Hemostatic dressings should be applied along with direct pressure for a minimum of 3 minutes. At times, up to 10 minutes of direct pressure may be required.
  - Basic hemostatic dressings include Combat Gauze (Z-Medica; www.z-medica.com/healthcare), Celox gauze (Med-trade Products; http://www.celoxmedical.com), ChitoGauze (HemCon Medical Technologies, http://www.hemcon.com), and Surgicel (Johnson & Johnson, https://www.jnj.com).
  - Advanced hemostatic agents include FloSeal (Baxter Healthcare, http://www.floseal.com) and Evarrest (Johnson & Johnson, http://www.ethicon.com), among many others.
- Clamping bleeding vessels provides a temporary hemostatic maneuver. When applying a clamp, try to avoid crushing the surrounding tissues. The bleeding vessel can then be ligated and tied off. Clamps can be left on for an extended time, if necessary.
- Ligatures/sutures provide a definitive treatment. Use of a silk suture is generally sufficient, although other materials can be used as well (Appendix C). For smaller structures, either 3-0 or 4-0 suture is sufficient, whereas larger structures may require 0 or 2-0 suture.
- Electrocautery stops bleeding by burning the tissue. It is available as either a battery-powered, hand-held device or a larger portable device. This can be used to cauterize bleeding vessels up to 3mm in diameter. The bleeding site should be identified, the ends coapted between a pair of forceps or clamps, and electricity then applied. If the cautery device is used to “paint” the surface, this results in damage to surrounding tissues.

Caution: Aggressive debridement may cause uncontrollable bleeding. Do not debride an area larger than can be controlled with direct pressure or a tourniquet. Observe closely for bleeding for at least 1 hour after debridement.

Debridement is not a singular event.10 War wounds often require multiple debridement procedures as the body physiologically responds and the wound evolves. When adequate resources are available, a patient’s wound should be evaluated every 24 hours, or as often as the clinician deems necessary. When resources are very limited, the ICRC approach has been successfully used to limit interventions to an initial D&I with application of a bulky absorbent dressing.