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