This is a demonstration of a wound care physician performing sharp debridement of a sample wound with black eschar. Along with the discussion based the usage of proper instruments and techniques used in the procedure, we’ll learn why black eschar develops and why sharp debridement is often necessary to remove necrotic tissue to heal wounds.
Disclaimer: This demonstration is performed by a trained wound care physician with the usage of a pig’s foot for the purpose of showing the correct method of anesthetizing with injectable anesthetic. This article demo is for educational purposes only and should not be tried at home.
Instruments and Technique
When performing debridement of a black eschar of a pressure ulcer etiology, commonly the only area that is sensate and may cause discomfort to the patient without adequate anesthesia, is the interface between necrotic tissue and the healthy remaining skin.
To adequately anesthetize the area for debridement, a small wheel on the edge of the healthy skin can be created with injectable anesthetic. This is then extended underneath the area to be debrided in a fan like fashion. Once adequate anesthesia has been performed, the necrotic area is addressed.
A number 15 scalpel or a dermal curette can be used. Often times a forceps is also helpful. Initially, the leading edge or interface between the normal skin and the necrotic area is identified. This is where the debridement should begin. A small incision at this interface is made to create a leading edge. This is then elevated using the forceps or the dermal curette. Tension is maintained on the black eschar and the interface between the subcutaneous and the epithelial tissue is incised with the scalpel.
Using the edge of the scalpel, and the body of the blade, adequate incision can be performed. It is important to identify the interface between the necrotic tissue and healthy tissue and maintain incision within this plane. As one performs the debridement, the necrotic eschar will begin to peel off. Similar to how an orange peel removes from the orange fruit itself.
Removal of Necrotic Tissue
This plane is now being developed. The demonstrator works around three edges of the eschar, maintaining the interface between the healthy tissue and the dead necrotic tissue while maintaining tension with the forceps.
It is common that the interface between the necrotic tissue and the healthy tissue, is an area that can be sensitive to debridement without adequate anesthesia. In addition, this is where one will find the most vascular portion of the wound. Maintaining the interface just on the side of the necrotic tissue can minimize bleeding as well as discomfort.
If the patient is on anti-coagulant medications such as coumadin, plavix or a heparin-type medication, it may be judicious to perform a staged debridement in order to control any hemorrhage that could occur. Once most of the necrotic tissue removed, one can use the edge of a scalpel or dermal curette to remove any remaining necrotic tissue that may be present between the interface of the normal tissue and the necrotic tissue that has been removed.
This will illustrate the various levels of tissue that may be encountered during a debridement. Initially, one can see the epithelial surface. Immediately underneath this is the subcutaneous tissue. At the base of the wound, one can see the muscle level.
Just immediately above that, there’s a fascial plane. When performing a debridement, commonly skin and subcutaneous tissues are removed in the necrotic area. In addition, the fascial plane may be removed and necrotic tissue may be removed from the muscle level as well.
Watch the video demo in its entirety here: https://youtu.be/z8WwniRtqEw