At the onset of this discussion, let me say that I have no experience with war wounds and I appreciate that they may require a different management than described here. Nevertheless, I think it is likely that many of the principles about to be stressed apply rather broadly to all wounds.

Satisfactory debridement of and extensively contaminated wound followed by primary closure can be intellectually challenging, labor-intensive and time-consuming. However, the rewards in terms of uneventful healing and savings in time and money justify the effort. Instead of subjecting the wound to multiple washouts and debridement, followed by delayed primary closure, the wound can be debris did and closed primarily in almost all instances, assuming a competent surgeon and absence of time constraints. Success after debridement in primary closure is far more related to the skill and perseverance of the surgeon then to the degree of contamination. The current practice of multiple irrigation’s and debridement followed by delayed primary closure is a carryover of mass casualty experience. This plan is reasonable in such situations. However, when patient numbers and time limitations are not limiting factors, initial thorough debridement in primary closure is a far better paradigm. Infection secondary to the latter routine is rare. My preference for this mode of management, I confess, is based on experience. I would add that my experiences been considerable and as noted earlier, stretches over 45 years.

Assume you are the consulting surgeon who has been called to the emergency room or trauma by. Most wounds either will of stop bleeding spontaneously or the emergency room physician left controlled the bleeding with sutures or a pressure dressing. In the latter instance, you will usually be confronted with a blood saturated dressing rather snuggly applied. Before removing the dressing put on a patient’s down for your clothing’s protection and a pair of sterile gloves. Cover a male stand with a sterile towel or two and collect all the instruments and solutions you may need. These will include 4 to 5 curved mosquito hemostats, small needle holder, scissors, a 4-0 or 5-0 chromic suture, 2% lidocaine with epinephrine, a 3-mL syringe with a ½ inch 30-gauge needle and a few sterile 4 x 4 gauzes. Have the nurse or technician wet the pressure dressing with warm saline and then instruct him or her to slowly remove the dressing. While this is going on, you should have a local anesthetic syringe and your dominant hand and a couple of moist for 4 x 4’s and the other. As the wound is exposed, spread a small amount of local on it and temporarily control any active bleeding with the wet sponges. Then inject local about the bleeding points and clamp and lie date them. Report remove any large or non-absorbable sutures that may have been placed by the previous physician this approach is a much more humane way of dealing with the situation rather than the usual “clench your teeth and bear it.”

As an aside, when removing addressing from a finger or thumb, place the digit under a cold stream of running water. This maneuver will decrease the pain and also loosen the dressing.

Wounds secondary to blunt trauma are routinely associated with some abrasion of the skin at the margins. The abraded area may not be apparent at the time of repair but will manifest itself within a day or so by slight crusting. This crusting is a way to distinguish whether a wound repaired by another physician a day or so before you see the patient, was secondary to sharp or blunt force, without having to ask the patient. This is a minor point, I admit.

Contaminated wounds, the result of blunt force, are almost always surrounded by abrasion with dirt tattoo. As a general rule, the dirt tattoo should be addressed prior to the breeding that wound. Cleansing the abraded area with the saline saturated sponge initially is a far more effective way to deal with the tattoo then using a scrub brush. Any residual tattoo can be removed by scraping the abraded area with the blade of a scalpel, as though you were smoothing off whittled would. The linear streaking is best dealt with the point of the scalpel blade. Please see the chapter on Special Situations for more detail on how to treat contaminated abrasions. Occasionally the skin tension will be so loose prior to wound closure that the looseness interferes with the scalpel scraping. In such situations, the defer the use of the scalpel until intradermal closure is been carried out. Most contaminated abrasions should be anesthetized prior to debridement.  See the chapter on anesthesia for details in this regard

My approach to dealing with contaminated wounds is initially to cleanse the surrounding skin and then the wound itself thoroughly with saline saturated sponges after removing any sand, pieces of gravel, plant debris, glass and any other foreign material with a hemostat. These steps are carried out following the initial prep. The wet gauze mopping should be done under at least 2.5 x magnification

Have a skin hook and your nondominant hand and a saline saturated sponge on a curved mosquito hemostat in the other and continue with the mopping until the wound is as clean as possible using this technique. Contaminated wounds from blunt trauma will have dirt in every nook and cranny and that is where the skin hook comes in handy. Those areas of the wound which are not meticulously clean are excised. Again, magnification is very important. Use a small neurosurgical Adson forceps and Iris scissors. Excised only contaminated and non-viable tissue. Many surgeons do breed with a scalpel or a large scissors and are far too aggressive in that they sacrifice too much non-contaminated, viable tissue.

Contaminated skeletal muscle often will present as a small speck of foreign material superficially yet when the spec is excised and underlying pocket of debris will be encountered. This phenomenon appears to be secondary to the consistency of muscle.

During debridement, some bleeding points may require more than gentle pressure to control. Pinching the bleeding areas with a small hemostat may be sufficient but other bleeders may require clamping and ligated.

This mopping approach as compared to the irrigation and suction technique has two theoretical advantages and one very practical one. Harvey Cushing showed in 1901 that refusing tissue with saline as deleterious effects. Saline is isotonic button not I so ionic. Mopping with a saline saturated sponge involves much less exposure to saline and does variation. This criticism of the irrigation approach may be more theoretical than practical but I believe it has some merit. The second disadvantage with variation is that it almost routinely gets the drapes wet and may contribute to contamination of the wound. Again, this possible drawback is a little speculative. The final disadvantage is very real, however. Irrigation and suction and sedated pediatric patients will awaken them immediately and consequently should be avoided.

Another problem with the irrigation and suction routine is that foreign material not dealt with at the first procedure is covered by granulation tissue by the time of the next routine. The retained foreign material leads to more scarring even though infection is avoided. Again, there may be more paltry than truth in this argument but in my experience wounds that art abraded and close primarily exhibit less scarring, although there may be more factors involved than the retained foreign material.

Trimming of the wound margins is best done after the rest of the wound has been the debrided. Usually this trimming is preferably carried out with a scalpel with a 15 blade and find toothed forceps.

There are six principal reasons for trimming wound margins: the margins are beveled, are irregular, are contaminated, are the result of blunt force, are necrotic or old.

Suturing beveled margins will result in a raised scar. The margins should be at right angles to the surrounding skin surface. Tidying up irregular margins will lead to a less conspicuous scar. Contaminated and necrotic margins obviously should be excised. If the wound is several hours old, it is a good practice to trim the margins. Wounds secondary to blunt force almost always have some degree of circulatory damage at the margins and consequently the margins should be trimmed.

When the breeding, place excised tissue on a sponge and one corner of the Mayo. This procedure is more convenient and a timesaver rather than tossing every bit of excised material into the wastebasket.

When significant bleeding occurs during debridement, the initial impulse is to use suction and vigorous sponging to identify the source. It is far more effective to apply pressure with a large sponge for a few minutes, a maneuver that will decrease blood loss and usually reveal the source of the problem.

Occasionally you will encounter a fresh clean wound with non-beveled margins. In these instances, follow the advice of the old cliché of “if it ain’t broke, don’t fix it.” Merely close the wound after exploration and gentle cleansing with a saline saturated sponge.

Some undermining of wound margins often is appropriate to decrease tension. This procedure can easily be done with the scalpel using a 15 blade, at a level about 2.5 mm below the dermis.

A step which is often left out of the wound repair by the inexperienced is exploration. Every wound should be carefully explored and this fact documented in either your written or dictated note. It is good practice to reference cleansing, anesthetization, exploration, debridement and repair when documenting your care of everyone.

When the wound is the result of rather severe blunt force and involves extensive fracturing of the soft tissues-- and this type of problem is often seen in the brow area-- it is usually best to close the muscle, fat and dermis in one layer. This same plan applies when bleeding from a blood thinner makes hemostasis difficult. Single layered closure of the sub epithelial tissues under slight tension often is necessary to control the bleeding secondary to Plavix. The patient or a family member should hold gentle pressure on such a wound for an hour postoperatively.

If the extent of skin loss in a wound militates against primary or flap closure, skin grafting should be done at the time of the initial repair. A stent dressing may be applied and left in place for 10 to 14 days as long as there is no drainage, odor or other sign of infection. In almost every area it is impossible to obtain the stability and gentle pressure afforded by a stent dressing with a dressing secured with gauze and tape. Consequently, as long as the wound appears to be doing well, there is no need to remove the stent until the graft has matured enough to not require addressing. This type of postoperative graft care differs markedly from that necessary when grafting is done 48 hours after the injury. In the latter instance, you must assume the wound is colonized with bacteria and a stent graft is contraindicated. Rather the graft, after being sutured into position, should be covered with a single layer of greasy gauze followed by moist 4 x 4 and dry 4 x 4’s and secured with tape. On the first postoperative day, the entire dressing except for the greasy gauze is changed. The greasy gauze is left in place. The next day the entire dressing is changed and the entire dressing should be changed for the next several days. After that time, if the graft is doing well, q.o.d. Changes are adequate. Usually by 14 days the graft may be left exposed, assuming it is doing well.

Using a stent dressing on a graft of a granulating wound is a recipe for disaster. When the stent is removed a few days later, almost always you will be confronted with a sea of exudate and no evidence of a graft.

As a general rule, it is helpful to discontinue antibiotics two days prior to grafting (or doing a delayed primary closure) on a granulating wound. One hour prior to surgery and continue them for two days. I also use antibiotics for two days following primarily grafting wounds. I am aware of the current paradigm of giving antibiotics only preoperatively in the case of a primary or delayed grafting of a wound. I still stand by the recommendations in the preceding paragraph, which have proved themselves in my experience. During my 57-year career following medical school, I have seen antibiotic dosage paradigms come and go. I base my routine on what has worked best for me.

How does one know when a contaminated wound has been adequately debridement? The answer is, as one of my mentors used to say, is when it is clean enough to have your lunch off of. As emphasized previously, magnification is essential in determining this endpoint.

Some authors have recommended doing a stat bacterial count prior to doing a primary or delayed primary closure. I have never employed this step but rather have always depended on clinical judgment. I routinely shave off the granulation tissue prior to a delayed primary closure. In my experience, a bacterial count in the circumstances referenced is unnecessary and only adds an extra expense.

There obviously is a learning curve in mastering the nuances of thorough debridement. However, it is a skill worth pursuing because of the multiple benefits expense- wise, time- wise and in regard to decreased scarring. The economic implications of management of contaminated wounds by adequate debridement and primary closure are astronomical, compared to the multiple washouts and debridement with delayed primary closure.

Debridement of the type described in this chapter is almost a lost art. The multiple irrigation and debridement approach busily is the paradigm de jour. Students and residents are rarely exposed to the techniques outlined above. They are instead taught that the risk of infection outweighs the possible advantages. It is true that adequate debridement is often a tedious, time-consuming exercise but once all the contamination has been removed and cleaned, viable tissue remains, primary closure is very safe.

I would be naïve to hope that most students or residents would rapidly become proficient in the debridement skills reference. Nevertheless, they should be exposed to this approach to the management of contaminated wounds.

I have observed staff surgeons and fifth year surgical residents close or suggest that wounds be closed which were grossly contaminated, even to the naked eye. The individuals involved were not stupid but ignorant of what thorough debridement entails. It was appalling to me that they had never been shown how to adequately clean up a dirty wound.

Several decades ago, patients were routinely “cleaned up” and inspected for soft tissue injuries by nurses and technicians when they arrived in the emergency room. Such initial cleansing and assessment is the exception today and it is not uncommon for a laceration to be noted hours or even days after admission. Most of these wounds can be closed primarily with proper care, as long as they are not invasively infected. Antibiotic coverage obviously is mandatory.

Most physicians do not appreciate the significant difference in the management implications and patient experience between wounds of the head neck and scalp compared to similar wounds of the legs or feet. A 4 to 5 centimeters defect of the scalp or face usually is a minor discomfort postoperatively to the patient. A similar wound of the leg or foot can be quite a nuisance pain and edema-wise unless elevated higher than the heart and ambulation is curtailed. Often with sizable wounds of the leg or foot, weight bearing should be avoided for three weeks and splinting may be indicated. Splints make bathing more of a challenge. Early ambulation can deleteriously impact wound healing as can lack of adequate elevation. Wounds of the hand also require elevation higher than the heart and this usually can be easily accomplished with a properly positioned sling. Elevation of wounds decreased venous pressure, improve circulation, decrease edema and decrease pain.

First and superficial 2nd degree burns the hand should be initially treated with cool compresses and elevation, and may be left open. I am not an advocate of Silvadene. Blisters should be left intact as long as they are not infected because they constitute the best possible temporary dressing. Deep 2nd° burns of the hand usually require grafting.