Download - Dpc and debridement full final
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Any tissue (Skin, Muscle, Bone, etc. ) that has been
damaged torn or cut by either intentional (surgical)
or accidental (traumatic) means
DEPTH of the wound is more important than
AREA.
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The skin remains intact, but underlying tissues
suffer damage
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The integrity of the skin is destroyed.
Mechanism of Injury:
INCISED WOUND
LACERATED WOUND
PUNCTURED WOUND
GRAZE OR ABRASION
AVULSION AMPUTATION
GUN SHOT WOUND
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– The integrity of the skin is destroyed, there is no
loss or destruction of tissue and there is no foreign body in the
wound.
– Tissue is lost or destroyed, or a foreign
body remains in the wound.
– Wound edges can be approximated and secured.
A clean wound is expected to heal by first intention.
– Contamination occurs when a dirty
object damages the integrity of the skin. Debridement of
necrosed tissue may be necessary.
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INCISED
LACERATED
PUNCTURED
CONTUSED
BURNS
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Primary closure.
Delayed primary closure.
Secondary closure.
Closure of partial thickness skin wound.
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much under used method of wound care .
recommended technique for contaminated wounds.
reduced the infection rate by 50% in 104 extremity wounds.
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1. War Wounds.
2. Agricultural Wound.
3. Infectious Wound.
4. Late Non Treated tell 6-12 Hour.
5. Best for all combat injuries, human bites.
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Size and Shape
Location(s) - Entrance & Exit
Devitalized tissue
Associated injuries FracturesCompartment
syndromeBurnsNeurovascular
injuryBLEEDING!
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Morgan et al
◦ Arm and hand: 4 hours
Baker and Lanuti
◦ Arm and hand: 6 hours
◦ Jamaica
◦ Face: no time limit
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Never close an infected wound
If wound merely contaminated, clean it up and
then make a decision for primary, secondary or
tertiary (delayed primary closure)
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contaminated wounds
*Pack wound with fine mesh saline soaked
gauze and cover with a sterile dressing
*Change every 12 hours for 4 days
*On the fourth day, remove dressing,
inspect wound, and if no infection, approximate wound
edges using primary closure technique.
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Debride all dead or marginal tissue (if unsure
cut a little, does it bleed?)
Remove all foreign debris
When irrigation needed use either a
hydrostatic irrigator or a 10 cc syringe with an
18 ga angicath or Zerowet
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DEFINITION:
Removal of any devitalized skin tags and
necrotic tissue along with foreign bodies
and debris
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Removes foreign matter & devitalized tissue.
Creates sharp wound edge.
Excision with elliptical shape.
Respect skin lines.
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Before debridement After debridement
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Debridement of nonviable tissue a must!
Devitalized tissue doesn’t bleed when it is scrubbed and appears blue/black
Devitalized tissue acts as anaerobic medium and inhibits leukocyte phagocytosis (decreases wound’s resistance to infx)
Goal is to reestablish a margin of normal tissue and wound edges (elliptical area around wound)
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4 C’s: used most commonly for soft
tissue
Color dusky vs. pink
Consistency “mushy” vs. firm
Contractility non-reactive vs.
fasciculation
(forceps pinch or Bovie)
Circulation no bleeding vs. punctate
bleeding.
Freshen skin edge Incise through fascia
Remove non-
viable tissue
Irrigate
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Most do.
Exception: small fragment wounds.
Punctate
< 1 cm
No fascial defect
Irrigate, leave open, and dress
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you should not use primary repair for a
wound that is more than 6 hours old.
Wounds with too much swelling or skin loss
Wounds with dead space under the skin closure.
Highly contaminated wounds.
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High velocity gunshots may cause massive amounts
tissue damage requiring debridement.
Close range shotgun wounds also cause massive
tissue destruction.
Both may have large amounts of contamination
◦ Secondary to negative pressure of cavitation
◦ Thorough surgical debridement is
imperative
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Low velocity gunshot wounds rarely need
debridement.
High velocity and close range shotgun wounds
always need debridement.
Most civilian gunshot wounds are low velocity
and low energy
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In the limb the incision made in long axis In flexoin along the creases
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Subcutaneous fat:
Has poor blood supply .
It is liable to be heavily contaminated .
It should excised generously.
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Retraction and fasciotomy :
Deep fascia should incised parallel to long axis
of wound.
If necessary incise the fascia transversely .
The purpose is to make a good exposure of
depth of wound .
Deep to the fascia the gloved finger is the best
probe for estimation of extend of damage
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Dead and damaged muscle:
It is absolutely vital that all dead muscle excised .
dead muscle is the ideal medium for clostridial
infection lead to gas gangrene.
All muscle which is not healthy and red , not contract
when pinched or bleed when cut must be excised until
healthy contractile bleeding muscle is found .
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Technique :
Take the muscle (less the 2cm) pinch it if no contract cut it by scissor
No more than 2 cm of muscle piece should not take in forceps because it will cause inadvertent removal of healthy tissue and vital structure
Muscle will not contract when patient received paralyzing anesthetic agent
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Bleeding control:
First by packing .
Suture ligate by fine absorbable suture.
Do not use electro cautery because it make other dead tissue .
If main artery damaged repair it.
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All penetrating (high or low velocity missile)
abdominal wound should be explored
Stab wound should first excised if it’s penetrated to
abdomen and if necessary laparotomy is don.
Morbidity and mortality from
Negative laparotomy is
Very low
Un operated bullet abdominal
Wound always fatal
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Fined entry and exit wound if present and position is noted.
Estimate which abdominal organ will damaged .
In low thoracic and perineal injury aware of intra abdominal damage.
Maybe blunt abdominal trauma without any external sign.
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Sign of infection:
1. Offensive moist dressing .
2. Pyrexia .
Sever contaminated wound.
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Thanks