Wound

Debridement
Content Creators:
Members of the South West Regional Wound Care Program’s Clinical
Practice and Knowledge Translation Learning Collaborative

Last updated: August 28, 2015

Learning Objectives
1. Develop an understanding of the significance of necrotic
tissue

2. Review therapeutic interventions for necrotic tissue

Care Program
South West Regional Wound
including:
1. Mechanical debridement
2. Enzymatic debridement
3. Sharp debridement
4. Autolytic debridement
5. Biologic Debridement

3. Review the outcome measurements of debridement and 2

referral criteria
Photographs and Illustrations
Images/illustrations obtained via Google Images, unless
otherwise stated

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South West Regional Wound
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SIGNIFICANCE OF NECROTIC TISSUE

South West Regional Wound

4

Care Program
Necrotic Tissue1-4
• Necrotic tissue impairs wound healing as it is a physical barrier
to:
• Granulation tissue formation
• Wound contraction
• Re-epithelialization

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South West Regional Wound
• Necrotic tissue may also harbor bacteria, which could lead to
wound infection, thus impairing wound healing

• The more necrotic tissue there is in a wound, the1, 5:

• More severe the damage is
• Longer it will take the close the wound 5
Necrotic Tissue1
• As tissues die they change in:

• Color

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South West Regional Wound
• Consistency

• Adherence

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Necrotic Tissue: Color1
• As the depth/severity of the wound increases, the color of the
necrotic tissue changes:
• White/gray
• Tan/yellow
• Brown/black

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South West Regional Wound
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Yellow Black

White/Gray
Necrotic Tissue: Consistency1
• As the tissues dry out, the consistency of the necrotic tissue
changes:
• Mucinious
• Soft, stringy
•

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South West Regional Wound
Soft, soggy
• Hard

Soft, soggy Hard

Mucinious
8
Soft, stringy
Consistency Continued
• Consistency of necrotic tissue is related to its moisture
content and refers to its cohesiveness1

• Consistency also varies as tissue damage worsens/deepens1,5-6:

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South West Regional Wound
• Slough: yellow/tan, thin, mucinious or stringy  partial thickness
damage
• Eschar: brown/black, soft of hard  full-thickness damage

9
Necrotic Tissue: Adherence1
• Adhesiveness of the debris to the wound bed and the ease
with which the two are separated

• Necrotic tissue tends to be more adherent:

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South West Regional Wound
• The deeper or more severe the damage is
• The less moist the wound is

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Summary of Necrotic Tissue
Characteristics

Color Consistency Adherence

Worsening Tissue Damage

White/gray Mucinous Clumps

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South West Regional Wound
Yellow fibrinous Soft, stringy Loosely attached
Yellow/tan
Soft, soggy Attached at the base only
(slough)
Black/brown Firmly adherent to base
Hard
(eschar) and edges

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Types of Necrotic Tissue
• Predominant types of necrotic tissue include:
• Slough
• Fibrin
• Eschar

Care Program
South West Regional Wound
• Gangrene
• Hyperkeratosis

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Description of Necrosis Types
Slough Fibrin Eschar Gangrene Hyperkeratosis
• Mucinious • Mucinious • Soft, soggy Hard • Soft, soggy
• Soft, stringy • Soft, stringy • Hard • Hard
• Soft, soggy • Soft, soggy
White/yellow White/yellow Black/brown Black/brown White/gray

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South West Regional Wound
• Clumps • Clumps • Attached at Firmly Firmly attached
• Loosely • Loosely base attached
attached attached • Firmly
• Attached at • Attached at attached
base base
25-100% 25-100% 50-100% 50-100% Surrounds wound
covered covered covered covered edges

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Type of Necrosis By Wound
Etiology
• Arterial/ischemic wounds:
• Dry gangrene
• Thick, dry, desiccated black/gray appearance
• Firmly adherent
• May be surrounded by an erythematous halo

Care Program
South West Regional Wound
• Neurotropic wounds:
• Do not present with necrotic tissue in wound typically
• Have hyperkeratosis surrounding wound

• Venous leg ulcers:

• Eschar or slough
• Usually yellow fibrous material

• Pressure Sores: 14
• Relates to the depth of the injury
 Care Program
South West Regional Wound
DEBRIDEMENT: INTERVENTION FOR 15

NECROTIC TISSUE
What is Debridement?
• The process of removing dead, contaminated, or adherent
tissue and/or foreign material from a wound

• Five primary methods:

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South West Regional Wound
• Mechanical Debridement
• Enzymatic Debridement
• Sharp Debridement
• Autolytic Debridement
• Biologic Debridement

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Mechanical Debridement1
• “The use of some outside force to remove dead tissue”, i.e.:
• Wet to dry gauze dressings
• Wound irrigation
• Whirlpool

Care Program
South West Regional Wound
• Wet to dry gauze continues to be the most commonly used
debridement technique despite it’s multiple disadvantages

17
Click on the picture of the Versajet for a video of jet lavage
Mechanical Debridement
Continued1
• Advantages:
• Familiar to health care providers
• Wound irrigation can reduce bacterial burden
• Whirlpool may soften necrotic debris

Care Program
South West Regional Wound
• Disadvantages (wet-to-dry gauze):
• Non-selective
• Rarely applied correctly
• Painful
• More costly (labor and supplies)
• May cause maceration
• Releases airborne organisms and causes cross-contamination9 18
Enzymatic Debridement1
 “Applying a concentrated, commercially prepared
(proteolytic) enzyme to the surface of the necrotic tissue, in
the expectation that it will aggressively degrade necrosis by
digesting devitalized tissue”

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South West Regional Wound
 Requires a physician order and must be used according to the
manufacturers instructions

 Cannot be used on dry wounds … any eschar present must be

cross hatched

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Enzymatic Debridement
Continued1
 Advantages:
 Selective
 Effective in combination with other debridement techniques

 Disadvantages:

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South West Regional Wound
 Enzymatic use is prolonged more than necessary, increasing
costs
 Can be slow – 3-30 days to achieve a completely clean wound
bed (it is faster than autolysis however)
 Requires a specific pH range (may cause local irritation due to pH
changes)
 May be inactivated by contact with heavy metals (zinc or silver)
 Risk of maceration and infection
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 Requires frequent dressing changes (1-3 times per day)
Sharp Debridement1
• Performed either one time (surgical) or sequentially
(conservative)
• Surgical sharp debridement:
• Use of scalpel, scissors, or other sharp instruments
• Removal of viable and non-viable tissue

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South West Regional Wound
• Most rapid and effective
• May convert chronic wound into an acute wound
• Requires analgesics and availability of cautery equipment
• Indicated for removal of thick, adherent and/or large amounts of
non-viable tissue and when advancing cellulitis or signs of sepsis
are present
• Requires a certain level of expertise, education and skill
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• Risk of bleeding

Click here for a video of surgical debridement

Sharp Debridement
Continued1
• Conservative sharp wound debridement (CSWD):
• Use of scalpel, scissors, or other sharp instruments
• Rapid and effective
• Used in combination with enzymatic, mechanical, and/or
autolytic debridement to speed the removal of non-viable

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South West Regional Wound
necrotic debris/tissue
• Can be performed in any health-care setting by non-physician
clinicians (if they have the knowledge, skill, judgment and
authority to do so)
• Does not require transfer to an acute facility

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Autolytic Debridement1
 “The process of using the body’s own mechanisms (enzymes)
to remove nonviable tissue”

 The collection of fluid at the wound site, “promotes

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South West Regional Wound
rehydration of the dead tissue and allows enzymes within the
wound to digest necrotic tissue”

 May be accomplished by the use of any moisture-retentive

dressings, i.e. hydrocolloids, hydrogels, hypertonic
dressings/gels, and/or transparent films

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Autolytic Debridement
Continued1
 Advantages:
 Painless in the majority of people with wounds
 Effective, versatile, and easy to perform
 Selective

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South West Regional Wound
 Low cost
 Can be used in conjunction with other debridement techniques

 Disadvantages:
 Slow
 Caregiver education required for compliance

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Biologic Debridement1
 A.k.a. larval/maggot debridement therapy (use of medical
grade green bottle fly larvae/maggots)

 Controlled “application of disinfected maggots to the wound

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South West Regional Wound
to remove the nonviable tissue”10
 Regulated by the FDA as a prescription only medical device

 Maggots are left in the wound for 2-3 days . They secrete
“proteolytic enzymes that break down necrotic tissue and
then ingest the liquefied tissue”10

 The secretions also have antimicrobial properties, promote 25

growth of human fibroblasts and improve granulation tissue
formation11-12
Biologic Debridement
Continued1
 Widely used in parts of Europe and South America

 Advantages:
 Reduces bacterial burden

Care Program
South West Regional Wound
 Growth-stimulating effects
 Selective
Click on the maggots to see a
short video on this therapy
 Disadvantages:
 Limited number of studies
 ‘Yuck factor’
 Availability of sterile medical grade maggots
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 Lack of policies and procedures
Review of Types of
Debridement
Debridement
Definition Examples
Type

Wet-to-dry gauze, wound

Use of an outside force to remove non-viable
Mechanical irrigation, whirlpool,
tissue
pulsed lavage

Care Program
South West Regional Wound
Application of a concentrated, commercially
Enzymatic Collagenase
prepared enzyme to digest non-viable tissue

Use of sharp instruments to remove non-

Sharp Scalpel, scissor, curette use
viable tissue

Use of the body’s own enzymes in wound Use of hydrocolloids, films,

Autolytic fluid along with moisture retentive dressings hydrogels, and/or
to degrade non-viable tissue hypertonic dressings

Application of medical grade maggots to Larval debridement 27

Biologic*
remove non-viable tissue therapy
Why Debride?
• To remove the physical barrier to epidermal resurfacing,
contraction, or granulation

• To reduce bacteria burden by removing necrotic tissue

Care Program
South West Regional Wound
• To convert a chronic wound to an acute wound by stimulating
the healing cascade

• To facilitate earlier coverage of the wound with active

dressings or biologicals

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Who Can Debride?
• Under the 1991 Regulated Health Professions Act (Ontario),
debridement is within the controlled acts authorized for
nursing

• An RN or an RN(EC) who meets certain conditions, i.e. has the

Care Program
South West Regional Wound
knowledge, skill, judgment and authority, can initiate and/or
provide an order for an RN or RPN to perform care of wound
below the dermis or mucous membrane, which includes
cleansing, soaking, irrigating, probing, debriding, packing,
dressing8

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Who Can Debride: CSWD
• The Long Term Care Homes Act and the Public Hospitals Act
do not allow a nurse to initiate CSWD in the absence of a
physician order

• There is no Act that precludes nurses in the community from

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South West Regional Wound
performing CSWD in the absence of a physician order, but it is
STRONGLY suggested that the nurse communicates her intent
to perform CSWD to the primary care physician BEFORE doing
so

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Who Can Debride
Continued
• Specialized practice skills such as CSWD are not generally
included in the RN’s basic preparation; therefore additional
instruction and supervision are necessary to ensure the
individual is competent to perform the identified skills or acts

Care Program
South West Regional Wound
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Who Can Debride Wounds
• The nurse who performs CSWD is expected to have:
• A good knowledge of relevant anatomy
• The ability to identify viable tissue
• Access to adequate equipment, lighting and assistance
• The capacity to explain the procedure and obtain informed

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South West Regional Wound
consent
• The ability to manage pain and discomfort prior to, during, and
following the procedure
• The skill to deal with complications such as bleeding
• The ability to recognize their skill limitations and those of the
technique
• Knowledge of infection control practices
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• The ability to utilize secondary debridement techniques if needed
How Do We Debride?
• After a thorough holistic assessment of the person and their
wound, and determination that debridement is indicated, you
must first choose the most appropriate type(s) of
debridement. This is dependent on the:
• Knowledge, skill and authority of the health care practitioner

Care Program
South West Regional Wound
• Availability of required resources
• Overall condition of the person with the wound, and their
‘healability’
• Characteristics of the wound and wound tissue
• Presence of wound related pain
• Required speed and tissue selectivity of debridement
• Costs associated with available debridement techniques
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• Presence of wound infection
• Physical environment
Choosing How to Debride7

Care Program
South West Regional Wound
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Canadian Association of Wound Care
Red/Yellow/Black System
• The type of non-viable tissue present can help identify the
phase of wound healing and as such, the most appropriate
debridement options13:
 Wound bed is clean and wound tissue is red/pink
Red
 Goal: maintain moist wound healing environment

Care Program
South West Regional Wound
 Wound bed has slough/fibrin present and tissue may be a combo of red/pink +
ivory/canary yellow/green (depending if infection is present)
 Not all yellow is bad – granulation grows through yellow fibrin. Healthy tendon
Yellow* may appear white/yellow
 Goal: maintain moist wound healing environment whilst managing excessive
exudates and removing slough via sharp, mechanical, enzymatic, and/or
autolytic debridement
 Wound bed has non-viable tissue present. Tissue combo may be dark brown/
grey/ black +/- red/pink +/- ivory/canary yellow/green.
Black*  Goal (healable wound and eschar is not stable and on heel): remove non-viable
tissue via sharp, mechanical, enzymatic and/or autolytic debridement 35
*If more than one color of tissue is present in the wound bed, target treatment based on the tissue type that is present in the
greatest amount
 Care Program
South West Regional Wound
OUTCOME MEASUREMENTS OF DEBRIDEMENT 36
AND REFERRAL CRITERIA
Outcome Measures1
• Three appropriate characteristics for evaluating the
effectiveness of debridement are the:

• Type of necrotic tissue

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South West Regional Wound
• Amount of necrotic tissue

• Adherence of the necrotic tissue to the wound

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Amount of Necrotic Tissue1
• Amount should diminish progressively if therapy appropriately

• Can be measured:
• Using linear measurements (length x width)

Care Program
South West Regional Wound
• By determining percentage of wound bed covered
• By photography

• Estimate percentages in the following way:

• <25% wound bed covered
• 25-50% wound covered
• >50 and <75% wound covered
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• 75-100% wound covered
Type of Necrotic Tissue1
• Type of necrotic tissue should change as the wound improves,
when conservative methods of debridement are used

• As necrotic tissue rehydrates its appearance will change from

Care Program
South West Regional Wound
dry/black, to soggy/soft/yellow, to mucinous easily dislodged
tissue

• Can rate the type of necrotic tissue as:

• White/gray nonviable tissue and/or non-adherent yellow slough
• Loosely adherent yellow slough
• Adherent soft black eschar
• Firmly adherent, hard black eschar 39
Adherence of Necrotic
Tissue1
• Adherence of necrotic tissue should decrease as debridement
proceeds

• Necrotic tissue may initially be firmly attached, then starts

Care Program
South West Regional Wound
lifting (usually at edges first), and eventually disengages from
the base of the wound

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Referral Criteria1
• Dry gangrene or dry ischemic wounds
• Elevated temperature
• No wound improvement
• Evidence of cellulitis or gross infection

Care Program
South West Regional Wound
• Exposed bone or tendon
• Evidence of abscess

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 Resources
SWRWCP Debridement

South West Regional Wound

42

Care Program
Review
1. The significance of necrotic tissue

2. Therapeutic interventions for necrotic tissue including:

1. Mechanical debridement

Care Program
South West Regional Wound
2. Enzymatic debridement
3. Sharp debridement
4. Autolytic debridement
5. Biologic Debridement

3. Outcome measurements of debridement and referral

criteria
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 Care Program
South West Regional Wound
For more information visit: swrwoundcareprogram.ca 44
References
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Wound Care: A collaborative practice manual for health professionals. Third Ed. Baltimore: Lippincott
Williams & Wilkins, 1997:197-214.
2. Alterescu V, Alterescu K. Etiology and treatment of pressure ulcers. Decubitus. 1988;1:28-35.
3. Winter G. Epidermal regeneration studied in the domestic pig. In: Hung TK, Dunphy JE, eds.
Fundamentals of Wound Management. New York: Appleton-Century-Crofts; 1979:71-111.
4. Sapico FL, Ginunas VJ, Thornhill-Hoynes M, et al. Quantitative microbiology of pressure sores in
different stages of healing. Diagn Biol Infect Dis. 1986;5:31-38.
5. Shea D. Pressure sores: Classification and management. Clin Orthop. 1975:112:89-100.

Care Program
South West Regional Wound
6. Witkowski JA, Parish LC. Histopathology of the decubitus ulcer. J Am Acad Dermatol. 1982;6:1014-
1021.
7. Sibbald RG, Williamson D, Orsted HL, et al. Preparing the wound bed: Debridement, bacterial balance
and moisture balance. Ostomy/Wound Management. 2000;46(11):14-35.
8. College of Nurses of Ontario. Decisions about procedures and authority. Pub. No. 41071. Toronto.
Last retrieved October 21, 2014 from: http://www.cno.org/Global/docs/prac/41071_Decisions.pdf
9. Lawrence JC, Lilly HA, Kidson A. Wound dressings and airborne dispersal of bacteria. Lancet.
1992;339(8796):807.
10. Zacur H, Kirsner RS. Debridement: Rationale and therapeutic options. Wounds: Compendium of
Clinical Research and Practice. 2002;14(7Suppl E):2E-7E.
11. Prete PE. Growth effects of Phaenicia sericata larval extracts on fibroblasts: Mechanism for wound
healing by maggot therapy. Life Sci. 1997;60(8):505-510.
12. Mumcuoglu KY. Clinical applications for maggots in wound care. Am J Clin Dermatol. 2001;2(4):219-
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227.
13. Krasner D. Wound care: how to use the red-yellow-black system. Am J Nurs. 1995:95(5):44–47.