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. Autolytic debridement works on dry wounds but rarely on wet ones. Wet wounds will just fester and get worse so they need to be dealt with by another method.
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. Clean 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 squirted over 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.
Dilute hydrogen peroxide is excellent for wound cleaning. If used after the wound has been washed with water a chemical reaction causes the hydrogen peroxide to fizz on contact with organic material removing many microscopic bits of dead tissue previously missed. Rinse with water afterwards to avoid tissue damage. 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 or hydrogen peroxide (diluted). 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.
This simply means removal of necrotic tissue with a sharp instrument, preferably with a scalpel being held by a qualified surgeon. Removing a large chunk of necrotic tissue such as an arm or a leg would in most cases result in the death of the patient if medical back up was not available. Traumatic shock, haemorrhage and/or gross infection would be the most likely causes. Attempting such a procedure unless you are medically qualified is in my opinion not an option. This is a job for 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, but a maggot is a maggot and 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.
These will obviously not be lab grade ‘sterile’ maggots but they will do the job.
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 you will need to keep it that way to allow it to heal. If clean and well looked after 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 alignate 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.
Pouring regular granulated sugar onto the clean wound will aid healing. Honey was used for thousands of years with good results but it can get messy and be difficult to carry around. In addition it’s difficult to know if the honey is pure with the amount of cross pollination that goes on in the wild. Regular sugar is easy to acquire and transport and using it requires no skill and there’s also little mess. Just spoon it onto the clean wound and apply a clean dressing which should be changed every 12-24 hours depending on the size and nature of the injury.
In a situation where hospitals are out of action and drugs and medical assistance are not available millions will die from necrotic wounds, many of which started as a simple cut or scratch. The key to not becoming a victim is prevention.
Acute awareness of your surroundings and the situation you are in is a must at all times. Keep cuts and grazes clean and covered to prevent further contamination. Keep your skin in good condition and check for chafes,blisters and scratches on a regular basis. Dry skin will crack far more readily than supple moist skin and I would advise regular use of moisturiser, any cheap cream will do, to keep your skin particularly your hands and feet, in good condition.
Insect bites should be dealt with accordingly to prevent scratching which will introduce infection. Vinegar,bicarbonate of soda or over the counter anti-histamine treatments all reduce itching and should be used as soon as the bite is noticed, don’t wait for the itch to start, the temptation to scratch at that point is too great.
Blisters should be left alone and not ‘popped’. The fluid in the blister is sterile and bursting it is inviting infection. If you HAVE to burst it, for example you can’t get your shoes on and simply HAVE to be on the move sterilise a sharp item, a regular sewing needle or pin will do and very carefully pop the bottom of the blister which will drain it quickly. Leave the loose skin intact and cover with a plaster over the needle hole. This minimises the chance of invading microbes getting into the sac left by the drainage.
It goes without saying that the 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.
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Contributed by Lizzie Bennett of Underground Medic.
Lizzie Bennett retired from her job as a senior operating department practitioner in the UK earlier this year. Her field was trauma and accident and emergency and she has served on major catastrophe teams around the UK. Lizzie publishes Underground Medic on the topic of preparedness.