PROCEDURE PERFORMED: Incision and debridement of left forearm wound with sharp debridement of devitalized skin, muscle and fascia and placement of negative pressure wound dressing.
INDICATIONS: Patient is a 48-year-old male involved in a motor vehicle crash in which he was driving an 18-wheeler and rolled the truck with his window open, causing severe road rash and avulsion to his left forearm. Patient was initially tried with a nonoperative treatment of the wound with wound care. However on serial examinations, it became obvious that some of the tissue bridges that were present centrally within the wound had become devitalized or becoming necrotic and this was a nidus for infection therefore the patient was started on antibiotics and the decision was made to take him to the operating room.
DETAILED DESCRIPTION OF PROCEDURE: After obtaining consent, patient was rought to the operating theater, placed in supine position. Patient was intubated and put under general anesthesia with no incident. Time-out was
performed in which the patient was properly identified and all agreed on the procedure. Patient got preoperative Ancef 2 g IV. The left arm was placed on a board in a supinated position to expose the wound and was prepped using Betadine and draped in sterile fashion. The wound was examined again and found to have gross contamination still within pockets underneath some of the tissue bridges that were present. We began by doing sharp debridement of devitalized tissues at the borders of these tissue bridges, removing all dead tissue, several pieces of foreign debris such as glass and grass were encountered and removed after an initial round of removing this devitalized tissue, pulse lavage was performed using normal saline with chlorhexidine. At this time, it was determined that several of the tissue bridges would likely not survive and would service a nidus for further infection. In using cautery and sharp Mayos, these tissue bridges were debrided back to healthy bleeding tissue. A curette was then used to curettage the wall questionable tissue removing further necrotic tissue until the entire wound base was pink and viable tissue. Further exploration was done in all pockets with the curettage in order to ensure that all foreign objects had been removed. A single tissue bridge measuring 1.5 cm across on the proximal end of the wound was left as it is pink and bleeding and determined to be likely to survive. However it was curettaged well underneath it. Another round of pulse lavage was performed using 3 L of normal saline after this and the wound looked very clean.
Electrocautery was used to control all points of bleeding and good hemostasis was achieved. At this time, it was determined that we would place Silvadene gel over the wound. The wound was measured to be 16.5 cm x 9 cm. At this
time, it was determined that the wound would benefit from a negative pressure wound dressing and a _____, sponge was placed to sit over the wound and cut and placed in the normal fashion. After this was completed, it was attached to the KCI VAC system and a good seal had been obtained and was left at 125 mm of Hg continuous suction. At this time, the procedure was ended. The patient was woken from anesthesia and extubated without incident and remained stable throughout the entire case. the doctor was scrubbed and present for the entire case. Patient was then returned to the PACU in stable condition. Estimated blood loss was less than 10 mL. Specimens include anaerobic and aerobic wound cultures and left forearm wound tissue. There were no complications.
PLAN: The patient will be taken this Sunday for another look and possible further debridement and wound VAC change and will return to his room in the floor.
Last edited by knperry; Today at 06:08 PM.
Incision and debridement
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