WCW: Serial Debridement of Heel Eschar


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