Why is the top layer of my nails peeling off
WCW: Serial Debridement of Heel Eschar
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hello I'm dr. Jeffrey nice Gotha welcome
to another edition of the wound care
window I'm your humble host and won't
care correspondent reporting from azh
wood centers in Milwaukee I wanted to
continue our explanation of the
debridement of s scars we've showed you
several types of eschar debridement the
indications for those I wanted to
illustrate a follow up and a sequential
debridement that was started earlier
when I show you some photos this is how
this patient presented a few weeks ago
and as you'll notice the heal s car was
intact no evidence of erythema purulence
fluctuates and we maintain this as a dry
S car for quite a while when the S car
demonstrated that it was starting to
separate I began serial debridement
lifting the margins and slowly removing
the S car from the margins allowing
healing to take place from the margins
towards the center and she returns today
again doing very very well after having
arterial revascularisation which was
really the key to the success here she
did have some hyperbaric therapy what's
also helped however what you see is that
we are progressing in our separation of
the s car if you loose the margins here
you can see that I have previously de
breeded the margins and lifted and what
you're noticing along all those margins
is she has granulate and actually shows
signs of epithelial is a ssin moving
towards the center of the wound the s
car is loose now as you can see and we
need to continue our debridement and
what I'm going to see today is can we
get this hole s car off so I'm gonna go
ahead and pick up a margin and you see
it's very loose we're gonna start our
debridement and our dissection
and we'll see if we can get this thing
off for us here you'll see that the
tissue is a very soft and easily is
debris 'td she was very tender at one
point and we had to go slow with our
debridement now there's very little pain
associated with this once again I am in
that plaintiff tissues between the
viable and the non viable I am NOT going
into the viable tissue here I want to
just get a separation of the necrotic
tissue by the breeding and lifting then
you see here we get some bleeding you
can see the tissue underneath is very
viable don't want to get into a lot of
lean so I'm going to stay above that
plane of tissue when you're do breeding
like this it's really important to
position the patient so the patient is
comfortable but it's also important to
be in a position of comfort for the
person doing the debridement you want to
be in control so you need to be
comfortable be able to visualize the
area of debris even well you're taking
the tissue you want to take and not more
we'll continue our dissection and
debridement see this s cars but almost
completely immobilized here and again
the plain tissue I'm in is that margin
of tissue between the non-viable and the
underlying viable tissue and you'll see
that this is now been completely
mobilized once again we have that
leathery external appearance the
underlying tissue is necrotic you see
some liquification necrosis there and we
recognize this is a medium for bacterial
growth placing a patient like this at
risk for infection and that's why when
they start to separate we want to get
rid of this tissue so let's get rid of
it as I mentioned in Prior videos this
will require serial debridement I do not
feel bone which is good it's all covered
this tissue here is reasonably viable
we're gonna select this tissue declare
itself over time but what we now have is
an ulcer that is clean from an external
appearance standpoint the base obviously
does need some additional work down the
road but what we're gonna do is place a
topical over this the topical will be
able to interface with the entire wound
base to allow for granulation to occur
with hopeful eventual complete closure
with epithelium obviously we're gonna
watch very closely the calcaneus is
right underneath this tissue here if
that were to become exposed that would
obviously play service for osteomyelitis
i see no evidence that that at this
point recent x-rays were negative
however we'll be very careful to watch
that so I hope you've enjoyed this
follow on in our instruction on
debridement of s scars in this
illustration of a complete removal of an
S car with serial debridement thank you
for joining us on this edition of the
wound care window
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you
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