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.

 

Debridement Notes

Exposure

 

Anatomic Considerations

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

 

Assessment of Tissue Viability

 

Debridement Techniques

 

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.

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.