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How to Perform Debridement of a Black Eschar & Yellow Necrosis?

Part 1 – Black Eschar

This is a demonstration of a wound care physician performing sharp debridement of a sample wound with black eschar. The demonstration shows the proper instruments and techniques used in the procedure. The demonstrator explains why black eschar develops and why sharp debridement is often necessary for the removal of necrotic tissue for wound healing. This demonstration is performed by a trained wound care physician with relevant wound care certification for educational purposes only and should not be tried at home.

Understand Wound Care:
Sharp Debridement Demonstration
Part 1- Wound with Black Eschar
Commentary: Dr. Japa Volchok

This demonstration will show the correct procedure for performing debridement of a black eschar such as commonly found on a sacral pressure ulcer or a chronic pressure ulcer of a lower extremity site. Eschar is generally composed of necrotic granulation tissue, tendon, muscle, or skin. Sometimes, a rare condition called pyoderma gangrenosum can also cause large, painful ulcers to develop on the skin, most often on legs. Initially in this demonstration, you will see a pig’s foot and a demonstration of the correct method of anesthetizing with an injectable anesthetic such as lidocaine. Additionally, a topical anesthetic may be used.

 

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 granulation tissue and the healthy remaining skin.

 

To ensure adequate anesthesia for the debridement area, a small wheel on the edge of the healthy skin can be created with an 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 of a wound 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 cell tissue is incised with the scalpel.

 

Using the edge of the scalpel, and the body of the blade, an adequate incision can be performed. It is important to identify the interface between the necrotic tissue and healthy tissue and maintain the incision within this plane. As one performs the debridement, the necrotic eschar or dry eschar will begin to peel off. Similar to how an orange peel removes from the orange fruit itself. As you can see in this demonstration, this plane is being developed. And, the demonstrator is working around three edges of the dry 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, as I stated previously, 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. And, maintaining the interface just on the side of the necrotic tissue can minimize blood flow 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 so as to control any hemorrhage that could occur. After the removal of the necrotic tissue to a large extent, 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 cell surface. Immediately underneath this is the subcutaneous tissue. And, at the base of the wound here, one can see the muscle level. Just immediately above that, there’s a fascial plane. When performing debridement of a wound, 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.

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Part 2 – Yellow Necrosis

This is a demonstration of a trained wound care physician with relevant wound care certification, performing sharp debridement of a sample wound with yellow necrosis. The demonstration shows the proper instruments and multiple techniques or debridement methods. The demonstrator explains why sharp debridement is often necessary to prevent wound infection, which is crucial to wound healing. This demonstration is performed by a trained wound care physician for educational purposes only and should not be tried at home.

Understand Wound Care:
Sharp Debridement Demonstration
Part 2- Wound with Yellow Necrosis
Commentary: Dr. Japa Volchok

In this demonstration, you will see debridement being performed with a dermal curette. This is a debridement for the indication of a chronic pressure ulcer that has yellow necrosis present within the base of the wound. This is often necrotic subcutaneous tissue or necrotic muscle or fascia. It is different from the more black eschar or dry eschar, which is a leathery, more adherent type of necrosis.

 

In this demonstration, we’ve used a pig foot and chicken fat to simulate a chronic pressure ulcer with yellow necrosis. Initially, a dermal curette, 4 millimeters has been selected. The dermal curette has cutting edges on both sides of a circular blade. It is commonly held in a pen-like fashion. And, it’s applied at a 45-degree angle to the wound bed. It is important to maintain the curette parallel to the surface of the wound as turning it on edge will produce a knife-like application.

 

Using short strokes, the physician will begin to remove the necrotic granulation tissue from the underlying healthy tissue as demonstrated in this video. It’s important to use short strokes and apply uniform pressure as any erratic movements can result in a deeper incision which might lead to hemorrhage.

 

Prior to performing a debridement, it’s essential to achieve adequate anesthesia so as not to cause any discomfort to the patient. This can be achieved using topical benzocaine or injectable anesthetic such as lidocaine.

 

As the debridement progresses, you will see that the yellow necrotic tissue is removed. Blood flow from any underlying capillaries can be easily controlled with pressure and the wound can finally be cleansed with saline to remove any loose debris.

 

Alternatively, a 15 blade scalpel and forceps can be used to perform debridement of yellow necrosis. Commonly, this is achieved for a larger wound or a wound that has more adherent yellow necrosis then might be removed easily with a dermal curette. A dermal curette often times, the blade will fill with the necrotic tissue being removed and will necessitate more than one instrument.

 

In the demonstrated debridement method, the scalpel and forceps instrumentation is being used to remove yellow necrosis. Short, even strokes are being applied with minimal pressure being directed into the base of the wounds. This will prevent injury to underlying structures as well as minimize any bleeding that may occur. If there are tendons or sensitive critical structures within the base of the wound, these can be avoided and carefully debrided around so as to avoid underlying injury. Even though debridement for most wounds is considered standard clinical practice for wound management, the current standard of care guidelines require a high level of expertise for wound management and it’s best to have staff with wound care certification and experience to carry out the various debridement methods.

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Author: Dr. Japa Volchok, DO

Dr. Volchok is the Vice President of Operations at Vohra Wound Physicians. Trained as a vascular and general surgeon he joined Vohra in 2009. Dr. Volchok is currently responsible for Vohra’s telemedicine program, legal and regulatory matters, and physician recruitment. He completed an executive management program at the Harvard Business School.

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