MODULE OF SKILL LABORATORIUM PRACTICE

BLOCK : MUSCULOSKELETAL SYSTEM

TOPIC : WOUND TOILET AND DEBRIDEMENT

I. GENERAL OBJECTIVE
After finishing skill practice, the students will be able to perform wound toilet and debridemet.

II. SPECIFIC OBJECTIVES

At the end of skill practices, the students will be able to perform wound toilet and debridemet by
remove the necrotic tissue or foreign material within and around the wound.

III. SYLLABUS DESCRIPTION

3.1 Sub Model Objective
After finishing skill practice, the students will be able to perform wound toilet and
debridemet.

3.2 Expected Competencies

a. Students will be able to demonstrate wound toilet
b. Students will be able to demonstrate debridemet

3.3 Methods
a. Presentation
b. Demonstration
c. Coaching
d. Self practices

3.4 Laboratory Facilities

a. Skills Laboratory
b. Trainers
c. Wound and open fracture models
d. Students Learning guide
e. Trainer's guide
f. References

3.5 Venue
Skills Laboratory

3.7 Evaluation
a. Point nodal evaluation
b. OSCE

V. REFERENCE
1. Surgical Care at The District Hospital. World Health Organization. 2013
VI. BASIC PRINCIPLES AND THEORIES

Damage or disruption of living tissue's cellular, anatomical, and/or functional integrity defines a
wound. Wound is also defined as damage to the integrity of biological tissue, including skin, mucous
membranes, and organ tissues. Acute and chronic wounds are technically categorized by the time
interval from the index injury and, more importantly, by the evidence of physiological impairment.
Before treatment, the exact cause, location, and type of wound must be assessed to provide
appropriate care.
There is no standard classification for wounds. However, there are a number of different ways in which
wounds can be classified which are of help in describing the wound with a view to its management
and ultimate healing. The factors of greatest importance in evaluation are: the nature of the injury
causing the wounds, the timing, whether acute or chronic, and the depth of injury to the skin and
underlying tissues. These factors will all have a significant effect on the ability of the wound to heal
with or without surgical intervention. It is critical to ensure wounds are cleaned and appropriately
dressed to limit the spread of infection and further injury.

WOUND CLASSIFICATION
The CDC has established classification definitions composed of four classes of wound statuses:
1. Class 1 wounds are considered to be clean. They are uninfected, no inflammation is present,
and are primarily closed. If draining of these wounds is necessary, a closed draining method is
necessary. Additionally, these wounds do not enter respiratory, alimentary, genital, or urinary
tracts.
2. Class 2 wounds are considered to be clean-contaminated. A wound involving normal but
colonized tissue. These wounds lack unusual contamination. Class 2 wounds enter the
respiratory, alimentary, genital, or urinary tracts. However, these wounds have entered these
tracts under controlled conditions.
3. Class 3 wounds are considered to be contaminated. A wound containing foreign or infected
material. These are fresh, open wounds that can result from insult to sterile techniques or
leakage from the gastrointestinal tract into the wound. Additionally, incisions made that result in
acute or lack of purulent inflammation are considered class 3 wounds.
4. Class 4 wounds are considered to be dirty-infected. A wound with pus present. These wounds
typically result from improperly cared for traumatic wounds. Class 4 wounds demonstrate
devitalized tissue, and they most commonly result from microorganisms present in perforated
viscera or the operative field.

Acute accidental wounds can be categorized based on the mechanisms of occurrence and
presentation. Major categories include:
1. Abraded wound (vulnus abrasum)
2. Punctured wound (vulnus punctum)
3. Incised wound (vulnus scissum)
4. Cut wound (vulnus caesum)
5. Crush wound (vulnus contusum)
6. Torn wound (vulnus lacerum)
7. Bite wound (vulnus morsum)
8. Shot wound (vulnus sclopetarium)
LOCAL CARE OF WOUNDS

Management of acute wounds begins with obtaining a careful history of the events surrounding the
injury. The history is followed by a meticulous examination of the wound. Examination should assess
the depth and configuration of the wound, the extent of nonviable tissue, and the presence of foreign
bodies and other contaminants. Examination of the wound may require irrigation and debridement of
the edges of the wound, and is facilitated by use of local anesthesia. Antibiotic administration and
tetanus prophylaxis may be needed, and planning the type and timing of wound repair should take
place.

After completion of the history, examination, and administration of tetanus prophylaxis, the wound
should be meticulously anesthetized. Lidocaine (0.5–1 percent) or bupivacaine (0.25–0.5 percent)
combined with a 1:100,000 to 1:200,000 dilution of epinephrine provides satisfactory anesthesia and
hemostasis. Epinephrine should not be used in wounds of the fingers, toes, ears, nose, or penis,
because of the risk of tissue necrosis secondary to terminal arteriole vasospasm in these structures.

Irrigation to visualize all areas of the wound and remove foreign material is best accomplished with
normal saline (without additives). High-pressure wound irrigation is more effective in achieving
complete debridement of foreign material and nonviable tissue. Iodine, povidone-iodine, hydrogen
peroxide, and organically based antibacterial preparations have all been shown to impair wound
healing because of injury to wound neutrophils and macrophages, and thus should not be used directly
on the wound bed. All hematomas present within wounds should be carefully evacuated and any
remaining bleeding sources controlled with ligature or cautery. If the injury has resulted in the
formation of a marginally viable flap of skin or tissue, these should be resected or revascularized prior
to further wound repair and closure.

Having ensured hemostasis and adequate debridement of nonviable tissues and removal of any
remaining foreign bodies, irregular, macerated, or beveled wound edges should be debrided to
provide a fresh edge for re-approximation.

Great care must be taken to realign wound edges properly—this is particularly important for wounds
that cross the vermilion border, eyebrow, or hairline. In general, the smallest suture required to hold
the various layers of the wound in approximation should be selected to minimize suture-related
inflammation. Nonabsorbable or slowly absorbing monofilament sutures are most suitable for
approximating deep fascial layers, particularly in the abdominal wall. Subcutaneous tissues should be
closed with braided absorbable sutures, with care to avoid placement of sutures in fat.

In areas of significant tissue loss, rotation of adjacent musculocutaneous flaps may be required to
provide sufficient tissue mass for closure. These flaps may be based on intrinsic blood supply, or may
be moved from distant sites as free flaps and anastomosed into the local vascular bed. In areas with
significant superficial tissue loss, STSG may be required and will speed formation of an intact epithelial
barrier to fluid loss and infection. It is essential to ensure hemostasis of the underlying tissue bed prior
to placement of STSGs, as the presence of a hematoma below the graft will prevent the graft from
taking. In acute, contaminated wounds with skin loss, use of porcine xenografts or cadaveric allografts
is prudent until the danger of infection passes.
After closing deep tissues and replacing significant tissue deficits, skin edges should be
reapproximated for cosmesis and to aid in rapid wound healing. Skin edges may be quickly
reapproximated with surgical staples or nonabsorbable monofilament sutures. Care must be taken to
remove these from the wound prior to epithelialization of the skin tracts in which sutures or staples
penetrate the dermal layer. Failure to remove the sutures or staples prior to 7–10 days (or 3–5 days
for the face) after repair will result in a cosmetically inferior wound. Where wound cosmesis is
important, the above problems may be avoided by placement of buried dermal sutures using
absorbable braided sutures. This method of wound closure allows for a precise re-approximation of
wound edges, and may be enhanced by application of wound closure tapes to the surface of the
wound. Intradermal absorbable sutures do not require removal. Use of skin tapes alone is only
recommended for closure of the smallest superficial wounds.

PREVENTION OF WOUND INFECTIONS:

– Restore breathing, blood circulation as soon as possible after injury
– Warm victim; at earliest opportunity provide high-energy nutrition, pain relief
– Perform wound toilet, debridement as soon as possible (within 8 hours if possible)
– Respect universal precautions
– Antibiotic prophylaxis for deep or penetrating wounds (dirty stick, knife) and wounds older
than 12 hours
– Tetanus prophylaxis is required for any individual not up to date with (or unsure of) their
tetanus immunisation status.
FACTORS THAT AFFECT WOUND HEALING AND THE POTENTIAL FOR INFECTION :
Patient:
– Age
– Underlying illnesses or disease: consider anaemia, diabetes or immunocompromise
– Effect of the injury on healing (e.g. devascularization)

Wound:
– Organ or tissue injured
– Extent of injury
– Nature of injury (for example, a laceration will be a less complicated wound than a crush
injury)
– Contamination or infection
– Time between injury and treatment (sooner is better)

Local factors:
– Haemostasis and debridement
– Timing of closure

 Close clean wounds immediately to allow healing by primary intention

 Do not close contaminated and infected wounds, but leave them open to heal by secondary
intention
 In treating clean contaminated wounds and clean wounds that are more than six hours old, manage
with surgical toilet, leave open and then close 48 hours later. This is delayed primary closure
To promote healing by secondary intention, perform wound toilet and surgical debridement. Surgical
wound toilet involves:
 Cleaning the skin with antiseptics
 Irrigation of wounds with saline
 Surgical debridement of all dead tissue and foreign matter. Dead tissue does not bleed when
cut.

PRINCIPLE OF DEBRIDEMENT

Debridement is a major component of wound management to prepare the wound bed for re-
epithelialization. Devitalized tissue, in general, and necrotic tissue, in particular, serve as the source
of nutrients for bacteria. Devitalized tissue also acts as a physical barrier for re-epithelialization,
preventing applied topical compounds to make direct contact with the wound bed to provide their
beneficial properties. Necrotic tissue also prevents angiogenesis, granulation tissue formation,
epidermal resurfacing, and normal extracellular matrix (ECM) formation. Finally, the presence of
necrotic tissue may prevent the clinician from accurately assessing the wound's extent and severity,
even masking possible underlying infections.

In general, the indication for debridement is the removal of devitalized tissue such as necrotic tissue,
slough, bioburden, biofilm, and apoptotic cells.
Contraindication of wound debridement, in general, may be applied to dry and intact eschars with no
clinical evidence of underlying infection, such as with an unstageable pressure ulcer with an intact
eschar at the sacrum or buttock, or heel.

During wound debridement, gentle handling of tissues minimizes bleeding. Control residual bleeding
with compression, ligation or cautery. Dead or devitalized muscle is dark in colour, soft, easily
damaged and does not contract when pinched. During debridement, excise only a very thin margin of
skin from the wound edge.
1. Systematically perform wound toilet and surgical debridement, initially to the superficial
layers of tissues and subsequently to the deeper layers. After scrubbing the skin with soap and
irrigating the wound with saline, prep the skin with antiseptic. Do not use antiseptics within
the wound.
2. Debride the wound meticulously to remove any loose foreign material such as dirt, grass,
wood, glass or clothing. With a scalpel or dissecting scissors, remove all adherent foreign
material along with a thin margin of underlying tissue and then irrigate the wound again.
Continue the cycle of surgical debridement and saline irrigation until the wound is completely
clean.
3. Leave the wound open after debridement to allow healing by secondary intention. Pack it
lightly with damp saline gauze and cover the packed wound with a dry dressing. Change the
packing and dressing daily or more often if the outer dressing becomes damp with blood or
other body fluids. Large defects will require closure with flaps or skin grafts but may be initially
managed with saline packing.
Drainage of a wound or body cavity is indicated when there is risk of blood or serous fluid collection
or when there is pus or gross wound contamination. The type of drain used depends on both indication
and availability.

Drains are classified as open or closed and active or passive:

 Closed drains do not allow the entry of atmospheric air and require either suction or
differential pressure to function
 Open drains allow atmospheric air access to the wound or body cavity
 Continuous suction drains with air vents are open but active drains

Drains are not a substitute for good haemostasis or for good surgical technique and should not be left
in place too long. They are usually left in place only until the situation which indicated insertion is
resolved, there is no longer any fluid drainage or the drain is not functioning. Leaving a non-functioning
drain in place unnecessarily exposes the patient to an increased risk of infection.
 IV. Learning Guide of Wound Toilet and Debridement

Procedure for Wound Toilet and Debridement

No. Procedure Performance Scale Comment
1 2 3 4
Wound toilet and suturing and debridement
Preparation (equipment, self & patient)
 Equipment preparation :

Minor surgical set:

 Needle holder
 Surgical blades
 Blade holder
 Tissue dissector (Metzenbaum)
 Scissor
 Tissue forceps (anatomical & surgical)
 Arterial clamps
Local anesthetic set:
 Disposable syringe
 Xylocaine injection
A & Antiseptic equipments:
 Povidone iodine
 Physiologic saline (for dilution)
 Surgical masks
 Surgical caps
 Sterile surgical gloves
 Non sterile gloves
 Sterile surgical drape
 Sterile surgical drape with aperture hole (duk bolong)
Supportive equipment:
 Lamp

 Self-preparation
 Patient preparation

Procedure
SAY BASMALLAH
1. Greeting the patient
2. Introduce yourself and clarify your role to the patient
respectfully and with kindness
3. Identify the patient, including: name, age,
and sex according to medical record
4. Informed consent: explain the goal, procedure, possible risk
and agreement. Give detail answers when she/he ask certain
questions with simple words.
5. Assess the wound type:
  Clean wounds
 Clean-contaminated wounds
 Contaminated wounds
 Dirty wounds
Note:
 Frankly dirty wound, the skin and subcutaneous
tissues should be left open (situation sutures) and
stitches later (secondary suture)
 For clean or clean-contaminated wounds, perform
primary suture
 For dirty wound, tetanus prevention is necessary
6. TECHNIQUE :
 Wearing an apron, masker and cap
 Preparation the instrument: dissecting forceps
(chirurgic and anatomical forceps), hemostat (artery
forceps), tissue dissector, surgical scissor, needle
holder, scalpel, blade, needle, surgical suture,
holding forceps (korentang), lidocaine, syringe,
gloves, sterile gauze, sterile drape, band aid, bandage
scissors, povidone iodine, NaCl
 Wash hand & use non-sterile gloves (clean principle,
not sterile)
 Prepare the patient (expose the wound area to be
cleaned)
 Clean around wound area if the wound is dirty
 Change the gloves with the sterile gloves
 Swab the skin around the wound area with povidone
iodine 10% using sterile gauze inside outwards. Then
put the used gauze to basin kidney. Repeat
procedure two times
 Put a sterile surgical drape under the wound area
with assistant help
 Apply sterile surgical drape with aperture hole above
wound area
 Perform the infiltration of local anesthetic injection
(subcutaneous injection).
 Check whether the anesthetic working
 Irrigation (jet-stream) of the wound with physiologic
saline (by assistant) 2L and remove debris (by
operator)
 Perform dissecting tissue using tissue dissector, cut
the necrotic tissue using tissue scissor (mayo) and
remove debris
 Homeostatic procedure (as indicated) with direct
pressure, using hemostat or ligation
 Put off both the sterile drape
 Change the gloves with the new sterile ones
  Change both the sterile drape with the new ones
 Skin suture with or without drain
 Put off the sterile drape above the wound area
 Close the wound with moist gauze or tule dressing
gauze then cover with dry sterile gauze and fix with
the tape.
 Check for capillary refill (specially for wound at the
fingers)
 Place needle and syringe in the disposal safety box
and place all the used equipment in the kidney basin
 Put off the sterile gloves and wash hand thoroughly
7. Patient Education:
– Wound care at home :
– avoid exposure to water, especially
unsterilized water
– avoid exposing wound to dirt
– providing good nutrition
– bandage replacement: remove dressing,
clean the wound with sterile water and re-
apply moist/tule gauze with dry sterile gauze
(For wet wounds, wound replacement is
done every day until the next follow up)
– Drugs
– Follow-up : 3-7 days after discharge from
hospital

8. Document the followings in the patient medical record:

a. Date and time of procedure
c. Patient's response to procedure
d. Name of the doctor in charge
9. SAY HAMDALLAH

V. Criteria of Personal Performance Evaluation

Scale Performance Achievement Comment
1. If students are doing the task that only fill les than 35% Low
of whole items for each step precisely
2. If students are doing the task that only fill 35% - 60% Mild
of whole items for each step precisely
3. If students are doing the task that only fill 60% - 78% Moderate
of whole items for each step precisely
4. If students are doing the task that only fill at least 80% from whole items for Excellent
each step precisely

VI. Skill Laboratory Practice Arrangement

Schedule of Practice
No. Subject Allocated Time Tutor
1. History taking 25 minutes 4 persons
2.  Physical examination 40 minutes 4 persons
 VCD demo
3. Tutorial practice for each students @ 15 mnts x 7 = 4 persons
105 minutes