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WOUND DEBRIDEMENT
DR.S.SENTHIL SAILESH
SENIOR ASSISTANT PROFESSOR IOT
MMC RGGGH
Facts in open fractures
Contamination rate of wound in open fractures is 65 %.
Chances of infection in LL open # is 3 times more than UL open fractures
Infection rate,
Gustilo type 1 -7%
type 2 -11%
type 3-18 to 56%
What will you do next
Antibiotic
Patzakis (RCT) effectiveness of antibiotic in posttraumatic wound
No antibiotic -14% infection rate
Cephalosporins - 2.4% infection rate
When will you start antibiotic
Antibiotic
ASAP ,atleast <1hrs
Early timing of antibiotics - single important factor in reducing infection
What antibiotic to give
Cephalosporins
G&A open fracture type
type 1-cefazolin dose-2gms/8hrly
Type 2-cefazolin dose-2gms/8hrly
Type 3-cefazolin dose-2gms/8hrly +
aminoglycosides doze-5mg/kg
How long will you give
3-5 DAYS
Debridement
Removal of foreign materials, necrotic tissues from the open wound to reduce pathogen load and help in wound healing
When to debride
Debride
Urgent, emergently, ASAP
Atleast <6hrs
Study- bacterial counts reached infection threshold in open fracture at mean of 5.17hrs
Study- type2&3fractures debrided
<5hrs -7% infected
>5hrs -38% infected
Delay and poor debridement are deleterious to the patient
How to debride
Sharp debridement
Superficial to deep (skin to bone)
Skin
2mm of skin edges to e removed till bleeding is present
Incision to be extended
Contused and questionable skin to e left initially
Subcutaneous tissue
Excise all devitalized tissue.
These tissues have a sparse blood supply and on subsequent debridement, further devitalization may become apparent.
debri
Fascia
contaminated & necrosed to e removed
Muscle
removal of non viable muscle(deep group necrose first)
Cgeck for colour,consistency,cotractaility
Bone
Remove necrosed tissue from fracture ends, medullary cavity
small fragments without attachment is removed
large fragments ,retained for reduction purpose
Cartilage
must e preserved
reduction and joint reconstuction
Irrigation of Wound
WHICH FLUID?
NORMAL SALINE
How much
Type 1 — 3litres
Type2 --- 6litres
Type3 --- 9litres
How to irrigate
How to irrigate
Gravity flow(<5psi)
3 liter NS suspended 6-8 feet high with compressile tubing
Low pressure flow
50ml syringe (5to10psi) pulse lavage in low pressure mode
High pressure flow
jet lavage(>20psi)
How about role of antiseptic and antibiotic during wash
No role
(betadine,chlorhexidine,ethanol,etc)
These are toxic to host cells, affect microvascular flow ,endothelial intergrity, woud healing
How about soaps
Soaps directly disrupt the adhesion and clumping of bacteria from wound
Castile soap, green soap
Considered for heavily contaminated wound
Doesn’t reduce deep infection rate
FLOW STUDY
Fully powered fluid lavage on open wound
Study from 2009 to 2013
41 sites in US, Canada,Aus,india
2551 open fractures
Reoperation in one year (wound, infection, nonunion)
Conclusion
Reop rate in gravity lavage = high pressure lavage = low pressure lavage
Reop more in soap + saline irrigation compared to saline alone
Secondary debridement
If required 48-72hrs later
Wound closure
Wound closure
EARLY – within 24-72 hrs
Recommended in Type I, II, selected III A #s
Debridement performed within 12 h, no excess skin loss primarily or secondarily during debridement, skin approximation possible without tension, no gross soil or other similar contamination, and no vascular insufficiency
DELAYED
LATE beyond 3 days
A valuable adjunct to wound closure has been the wound vacuum-assisted closure device
Helps to reduce edema, enhancing granulation tissue formation, and increasing local blood flow
Skin Cover
Early soft tissue coverage or wound closure is ideal
Increased risk of infection beyond 7 days
Can place antibiotic bead-pouch in open dirty wounds
Ideally, coverage of the open fracture should take place after one to two formal debridement
Ideally all open fractures are left open to prevent anaerobic atmosphere and delayed closure is attempted at 2-7 days based on severity of contamination
conclusion
Antibiotic – IV urgently, no role in irrigation
Debridement - asap, follow principles for soft tissue and bone
Irrigation – only NS, method - gravity flow
Wound closure - based on wound status, primary - plastic cover
Thank You
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