Emergency War Surgery NATO Handbook: Part II: Response of the Body to Wounding: Chapter XI: Infection
United States Department of Defense
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Prompt, adequate surgical debridement is the cornerstone of therapy of war wounds, particularly with respect to prevention of infection. In addition to adequate debridement and excision of crushed and lacerated tissue, the removal of foreign bodies and reduction of microbial density are important considerations. The current recommendation is that war wounds be debrided within six hours of injury.
Although such classic signs as impaired contractility, altered consistency, and lack of capillary bleeding have been shown to correlate poorly with tissue viability, they have a useful function. If there is any question about the adequacy of debridement, the wound is dressed and re-explored three to five days later. If there is no residual nonviable tissue and no evidence of infection, the delayed primary closure is performed. Delayed primary closure effects timely closure of an initially heavily-contaminated wound while minimizing the risk of infection. An even longer delay in wound closure may be indicated in some wounds, as was supported by the recent - albeit limited - experience with septic complications in limb wounds during the Falkland's campaign. This study showed that no septic complications developed in those patients undergoing delayed closure eight days or later from time of injury (none of five patients). Fifteen percent developed septic complications when closed at 5-7 days (six of 40), and 75% (three of four) when closed within four days. If at the time of inspection. 3-5 days post injury, nonviable tissue remains or infection is present, further debridement is performed and the infection is treated before closure is attempted.
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