Special Operations Forces Medical Handbook

8-25

Do not suture a dirty or contaminated wound. If it is still dirty after irrigation, or if irrigation is not possible,
allow the wound to heal by granulation. If there is danger that the skin may close prior to the deeper tissues
granulating, then pack the wound with iodoform gauze (or Betadine soaked gauze) daily until the wound
heals up to the skin.

Procedure: Wound Debridement

1LT Harold Becker, SP, PA, USAR & LTC Lee Cancio, MC, USA

What: Remove dead or devitalized tissue to decrease infection and improve healing.

When: It is essential to debride a traumatic wound to prepare it for closure. Devitalized tissue inhibits
leukocyte phagocytosis, acts as a culture medium for bacteria growth, and provides an anaerobic environ-
ment that limits leukocyte function. Debridement relieves excess tension, provides drainage, and removes
bacteria and devitalized tissue that impair the wound’s ability to ward off infection. Whether the wound is
secondary to an abrasion, laceration, burn, frostbite or gunshot, debridement should be rational, not radical.

What You Need: Recommended: Skin hooks, Iris scissors, Metzenbaum or Mayo scissors, scalpel with
#10, #11, # 15 blades, tissue forceps, 35cc syringe, 16 or 18 gauge needle or plastic cannula, toothbrush or a
surgical scrub brush, NaCl for irrigation, retractors: Sims or Army-Navy
Improvised: Any type of scissors, scalpel with any type of blade or pocketknife, any type of tissue forceps or
hemostats, IV with catheter (any type of clean fluid), any type of brush, tap water (boiled if possible), any type
of retractor or pliable object (i.e., SAMS splint)
NOTE: Items should be sterilized with cold sterilization or boiling water if possible.

What To Do:

1. Determine the margin between devitalized and viable tissue. Use clinical judgment. Within 24 hours there
   is usually a sharp demarcation between devitalized skin and viable skin. Longer time is usually
   recommended in frostbite and gangrene. It is more difficult to differentiate nonviable muscle from muscle
   that is injured but will heal. Use color, contraction, consistency, and circulation (the 4Cs) as guidelines
   when excising muscle. Identify devitalized muscle by its dark color, mushy consistency, inability to
   contract when grasped with forceps and a lack of brisk bleeding when cut.


2. Prep and drape the wound.


3. Irrigate the wound. Use a 35cc syringe with a 16 or 18-gauge cannula and NaCl for irrigation. (This will
   provide approximately 8 psi, which will dislodge most particles). Irrigate the wound copiously.

Minor wounds not involving muscle

1. Stabilize the skin edges with the skin hooks by retracting the wound at both ends. Use your ngers
   pull the skin being debrided perpendicular to the laceration (this will prevent the skin from rolling in,
   providing an even, clean edge).


2. Using the scalpel with a #11 or #15 blade, hold it angled away from the wound edge and excise the
   devitalized skin. Holding it at an angle will ensure that eversion is achieved when the edges are
   approximated.


3. After excising the skin edges, inspect subcutaneous tissue. Excise any devitalized tissue with iris
   scissors.


4. Irrigate the wound once again with copious amounts of NaCl.


5. Close the wound either primarily or secondarily depending on the location, initial debridement, and
   the level of contamination.
   Pearl: A technique that helps distinguish devitalized tissue: apply fluorescein dye to a gauze pack and pack
   the wound. The fluorescien will stain devitalized tissue, which can then easily be debrided. If unsure, excise
   the skin until active bleeding starts.