Emergency War Surgery NATO Handbook: Part III: General Considerations of Wound Management: Chapter XVI: Wounds and Injuries of the Soft Tissues
United States Department of Defense
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Where one draws the line in excising muscle surrounding a missile path has been the subject of intense debate in wound ballistics. The 5th CINCPAC War Surgery Conference (Tokyo 1971) stated "..the surgeon must choose between leaving tissue of questionable viability or causing morbidity by removing viable and functional tissue." Most other opinions of the past two decades have held that "complete excision of all devitalized tissue is mandatory," "bold removal of all devitalized muscle is imperative' (NATO Handbook, 1975), and that deformity or dysfunction resulting from such "bold" operations is justified.
Development of life-threatening gas gangrene is the complication most often cited to justify recommendations of "radical debridement" or wide excision of muscle. Of 224,080 wounded in France in WW I, those with soft tissue injury and no bone fracture developed gas gangrene in only 1.0% of cases and less than half of these were fatal. A streptococcal bacteremia was by far the most common cause of death. Many of the less than 0.5% of the deaths attributed to clostridia were suspected to have been due, in reality, to undetected streptococcus. Streptolysin, excreted by the virulent Streptococcus species, breaks down the fibrin that has been deposited by the body in its attempt to wall off collections of pathological bacteria. This made generalized streptococcal spread impossible to control in the pre-antibiotic era. Since the discovery of antibiotics, streptococcal bacteremia has all but disappeared from the battlefield because of antibiotics, a fact overlooked by those who suggest that antibiotic therapy is only an ancillary measure in the management of combat wounds.
Debridement should be rational rather than radical. The recommendation is not to excise the wound to the extent that viable muscle is intentionally excised circumferentially, but rather to open the wound such that drainage is assured, while at the same time excising that muscle which is severely damaged or disrupted and therefore devitalized. The surgeon must aggressively incise the wound, but should not empirically excise tissue more widely than clinical judgment would normally dictate It should be borne in mind that debridement of the wound is intended to relieve excessive tension within the wound, to rid the wound of dead tissue and massive hematoma, and to provide excellent drainage. Some would say that the relief of tension is the single most important element of wound debridement.
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