Introduction

The modern approach towards a wound – not tending to a spontaneous healing – begins with an operative procedure called ‘debridement’. The term ‘debridement’ is immediately readable and understandable in both English and French languages. Furthermore, as  written in the same way, Italian and Spanish speaking wound care specialists know its meaning and decide to keep the term in the original language. The mere translation is quite reductive in comparison with the wide “philosophic” and practice term meaning.

The latest and most complete term definition is the following: “the act of removing necrotic material, eschar, devitalized tissue, infected tissue, hyperkeratosis, slough, pus, haematomas, foreign bodies, debris, bone fragments, or any type of bioburden from a wound with the objective to promote the healing”1. Although the ‘debridement’ key position in wound care, there still no – in the related literature – a wide scientific consensus with regards to its indications and therapeutic effectiveness. The issue is even much more complex in pediatric environment because of a shortage in researches proving scientific evidences, experts opinions and clinical reports.

The eternal and hamlet dilemma related to the difference between detersion and debridement seems to be over in the sphere of the adult wound healing. The situation in the pediatric wound care seems to be less clear as the cleaning and cleansing procedures could have a debridement role in some age groups. Debridement’s aim – even in pediatric ages – is to selectively remove the following elements from the lesion edges and bottom:

a. Residual of previous dressings

b. Slough/Biofilm

c. Microbial Load

d. Cellular Debris

e. Foreign Bodies.

As the debridement can have different and sometimes too aggressive features, the pediatric debridement has the need to maintain a perfect balance between aims to be achieved and tissue budget to safeguard. A reasoned debridement has to respect the golden rules (see tab.1) and, above all, has to constantly take in consideration the dimensional ratio between the wound and the total body surface area. Such an operative approach is also successfully used in burns treatment which are basically thermal wounds even if associated with a metabolic derangement – present also in complex trauma of only mechanical origin.

In the light of above mentioned etiologic and dimensional considerations, the ideal pediatric “debrider” should be safe and painless, with a high tissue selectivity, easy-to-use for the nurses and bearable for the healthcare system . The last twenty years humanitarian experiences made in field hospitals by the Army Military Healthcare all around the world, allowed us to define the therapeutic positioning steps that should be followed in the pediatric wound care. Far from the presumption of representing a guideline for the choice of the right debridement technique to implement in various pathologic situations, the present article is just a collection of practical field experience hence sometimes hard to identify with.

History

Italian Military Health (IMH) have always been involved in peacekeeping missions with the deployment of Armed Forces all around the world. Thanks to the “in field” expertise IMH achieved a remarkable technical knowledge related to “field wound care”, highly qualified care of complex tissue wounds developed. In peace-support operations there are evidences indicating high figures in blast and firearm injuries variable on quality and quantity level and often extensive.

Such a complex clinical presentations of polytrauma are a significant part of the demand on which different countries Army Forces – involved in peacekeeping operations –proof its technical and sanitary skills in terms of competencies, means and supplies. In consideration of specific needs and of the operational environment, the field sanitary activity’s aim is to guarantee the most efficient and prompt first aid to issue in the field wounded. Care can be also addressed to civilians – when allowed by the rules of engagement – in that case patients in pediatric ages are predominant. The field hospital organizational complexity as well as its operating capabilities naturally influence the care standard that could be provided to child affected by complex tissue – acute and chronic – wounds.

Preventive triage, outpatient care and surgery are the engine of humanitarian action which gives the possibility of a proper child and collateral conflict victims treatment/care. The field hospital surgical team, used to face complex adult tissue traumas, have to shape technical skills on the children patient in order to achieve the best result with the lowest child’s pain. Such kind of care pliability – supported by the Italian Red Cross voluntary nurses personnel (see fig. in header) allowed to treat with the same qualitative national standard indigenous pediatric population. Local child were affected by complex soft tissue traumas of both thermal and mechanical nature. The wounds debridement – the first step towards the wound bed preparation – had always have a key role in the tissue trauma management.

Clinical Benefits

In our twenty-year of experience in health intervention during humanitarian operations, the most frequent injuries in patients on pediatric ages are small tissue lesions, selective debridement is done on outpatients with topical anesthesia through the usage of small curette or wet gauzes and fingertips. Personnel in charge of such task could be a doctor or a nurse, male or female depending on various cause. Generally in serious wounds, techniques of surgical/sharp debridement, ultrasonic assisted debridement and, if available, hydrosurgery are issued.

They are carried out under general and topical anesthesia – with premedication – and in operating rooms (o.r.) for field hospital patients. The implementation of selective debridement techniques allow us to rationally and safely manage both external and hospitalized patients. A dressing well planned program carried out by trained personnel does not influence child psychical state and allow a continuous therapeutic shaping based on the lesion development. [vc_separator type=’full_width’ color=’#757575′ thickness=’2′ up=’5′ down=’5′]

Discussion

The welfare response of a field hospital is affected by several causes among which can be listed the “health intelligence”, the activity of preliminary collecting of information related to the typology and the incidence of injuries most frequently observed in the territory on which the field hospital will be deployed. The awareness about such details allow to proper equip health structure with supplies adequate to tackle the local most frequent traumatic lesions.

The availability of technologic supplies and hi-tech dressing is a key element necessary to perform an adequate field wound bed preparation. If the suitable resources are available we could execute different debridement techniques shaped on the etiopathogenesis. More attention should be paid on the deep and  extensive burns located on the neck, face and hands. In this case the debridement has to take into account the possibility of an infection which undoubtedly will influence the choice of the most suitable treatment as well as a further type of reconstruction; generally in case of suspect of a local infection a surgical debridement is the most suitable. It has to be carried out in o.r. under general anesthesia and it should be followed by an antimicrobial secondary dressing. The percentage of burns  as well as the level/grade of infection will indicate the further reconstructive treatment.

Conclusion

The consultation of a wound care adult addressed handbook, could be useful in removing some doubts related to most complex cases. Regrettably the same thing cannot be done for what concerning the neonatal/pediatric wound care as no evidence-based guidelines are available. At present, the therapeutic answers for such a need are entirely dictated by case-studies reports or by the experts opinion.

The last twenty years clinical experience achieved in the humanitarian operations has enabled us to collect some data on the pediatric wound care performable “on the field”. Such a process should be useful to outline a methodological approach to the neonatal and pediatric wound bed preparation. Such a capability to treat complex wounds even in pediatric patients – grown up in ages of field hospital activities – is supported by therapeutic analogies with both “combat zone” and “wound area” among which the most relevant and present is the “Clear and Hold” one.

References

  1. EWMA document 2013

Journal of Wound Care vol.22 n. 1

  1. Baharestani  MM (2007) An overview of neonatal and pediatric wound care knowledge and considerations. Ostomy Wound Management 53(6):34-55.
  2. Garvin G (1990) Wound healing in pediatrics. Nurs Clin North Am. 25:181-192.
  3. Knapp JF (1999) Updates in wound management for the pediatrician. Pediatr Clin North Am 46(6): 1201-1213.
  4. Durante CM (2007) Operative guidelines in burns emergencies in a battle environment. Ann.  Burns and Fire Disasters 20(3): 155-158.