Necrotic wound debridement…the sight of those three words was enough to fill me with dread when I saw them on my operating list. Unpleasant, often disgusting and always extremely foul smelling, these were the cases you really did not want right before going home for your evening meal. Always done at the end of the list so as to avoid the possibility of contaminating a ‘clean’ case, you have to believe me when I say some of these wounds were the stuff of nightmares.
Imagine for a moment, dealing with a foul smelling wound, full of dead and dying tissue, without the backup of an operating theatre and the equipment and staff that goes with it. Not good eh?
Necrotic tissue is dead tissue, and when tissue dies it starts to rot, to decompose, and that smells, it smells awful, it is a smell you will never forget. It does not always occur through neglecting a wound, a simple scratch, something that you would not have considered going to the doctor or hospital about, can turn necrotic over night if the right bugs get into it. Necrotising fasciitis is an extreme but prime example of this. Necrotic tissue is soft and spongy to the touch, there is no form to it. It may be black in colour, but any shade of green and/or yellow is quite common. The wound will probably be oozing pus and fluid, and it will stink to high heaven. This decaying tissue has to be removed from the wound as soon as possible to avoid overwhelming infection.
It goes without saying that if you have antibiotics they should be given immediately, providing the patient has no allergy to the drug.
Those who live a long distance from medical assistance, or who find themselves embroiled in a situation where medical assistance is no longer a viable option would do well to know how to deal with such wounds.
This is simply allowing the body to resolve the situation itself, such as allowing a frost bitten finger or toe to drop off on its own without intervention. The digit is wrapped in a damp dressing, and kept damp until the situation resolves.
Mechanical debridement is the simplest way to try and get the dead and dying tissue out of the wound. Water under pressure is the simplest way of doing this. Sterile or boiled and cooled water if forced into the wound, flushing the dead tissue out. This can be done via a large syringe if available. An acceptable substitute is a squeezey ketchup or mayo bottle that has been cleaned and treated with bleach prior to being filled with clean water to be used on the wound. The water should be forced into one end of the wound, working systematically towards the other end of the wound. This may need to be done many times in order to remove as much decayed tissue as possible. If chlorhexidine or iodine scrub solutions are available they can be used, well diluted to assist in cleaning the wound.
Opinion varies on what should be done next. Years ago the wound was packed with a large, sterile, wet to dry pack, which was left to soak up any exudate and then allowed to dry. This was then pulled out of the wound, bringing necrotic, and healthy tissue with it. This is very painful. I do not favour this but it was/is a recognised practice depending on where you live and the availability of ongoing care.
My choice would be to remove the bulk of the decaying tissue with pressurised water as described, and then do it again with salt water. The wound should be checked every few hours and the treatment repeated, with salt water as often as is needed. This may need to be done for several days, several times a day until the wound no longer smells and is no longer purulent (producing pus). These wounds should not be sutured as the smallest amount of decaying tissue left behind will fester inside the closed wound. The wound should be covered with a clean non-adhesive, damp, lint free dressing and checked twice daily for signs of regression. If you are fortunate enough to have a supply of alignate or hydrogel type dressings or packs these should be used in preference to other types of dressings.
Certain chemicals contain enzymes that can target necrotic tissue whilst leaving healthy tissue undamaged. These chemicals are not available other than in a hospital setting, they are target specific components of decaying tissue depending on the type of wound. Some articles state that chlohexidine and iodine are suitable for chemical debridement, they are not as they contain no enzymes. They are useful for wound cleaning if available but that is all.
The only ‘over the counter’ available chemical is hydrogen peroxide. It is available in a variety of percentage solutions. 3% is the strongest that should be used to clean wounds. It’s advisable to start at 1% and if the liquid fizzes out debris stick with that rather than increase the concentration.
This simply means removal of necrotic tissue with a sharp instrument, preferably with a scalpel being held by a qualified surgeon.
This may also be called larval therapy. Maggots are used to clean the wound. In hospitals the maggots are bred in the lab, they as as close to sterile as possible and are fed tasty tidbits until their services are required. In reality a maggot is a maggot and as long as they come from Blow flies such as bluebottles and greenbottles they are fine to cultivate. If left to do what they do best they will clean out a necrotic wound very effectively. As much dead and decaying tissue as possible should be removed with washouts and then several maggots should be put into the wound. A damp dressing should be used to cover the wound and the maggots left to do their job. Obviously the maggots will need to be removed before they turn into flies, so having a steady supply would be advisable. A small amount of meat product in a damp jam jar will allow flies to lay eggs and ensure your maggot supply.
Many people will have a psychological aversion to larval therapy, and this is understandable. The patient should be warned that they will feel the maggots moving around, but the maggots prefer decaying tissue and will choose it over healthy tissue if given the choice. It is not in any way painful and really does give the wound an excellent chance of healing as they are very effective cleaning machines.
Once the wound is clean, regardless of how you got it clean, it will start to granulate, new cells will form and eventually the wound will close. This can, depending on the size of the wound take a considerable time. The use of alginate dressings or hydrogel will speed the process considerably. If not using these dressings keep the dressings you are using slightly damp with either pre-packed or home made saline solution, this will aid the healing process. Antibiotics should be continued for at least five days if you have them.
It goes without saying that the correct decision always has to be to seek qualified medical help if it is available. Dealing with these wounds is difficult and the outcome can never be predicted. Treating wounds yourself should only ever be the first choice if there is NO other choice.