Black heals, debride or dry dressing?

[JenniferSews]

We have had a run of patients admitted with black heals from hospitals all over the city lately. I have read a lot but there seems to be two schools of thought. Either non surgical debridement with santyl or similar product, or skin prep and a dry dressing to keep the wound closed and hopefully dry. Can anyone point me in the right direction for some evidence based articles?

[wound warrier]

Best practice stated that if heel eschar is black and dry, just leave the areas alone. Keep the heel off of the bed is of utmost importance. If the eschar starts to separate and/or drain, then you are almost obligated to use santyl. Good luck!!

[217shana]

I have always been taught to leave stable black eschar alone especially if it is on the heel and especially if the patient is diabetic and/or has poor circulation. Some facilities require doppler studies be done when patient's have pressure areas on the heel or foot to determine the ability of the wound to heel. Once the edges of the black eschar start to separate then you can apply santyl. I have always preferred accuzyme to santyl but they took accuzyme off the market.

[margo533]

This is why certified wound specialists are needed. You need to look at the bigger picture: what's the patient's over-all condition and prognosis? The plan depends completely on that. For example, if this is am acutely terminal patient, I'd put on a dry dressing and relieve pressure. If it's a patient with the nutritional and immune status to heal, and moderately good prognosis, only then would I proceed with debridement. Soften it up with a transparent dressing, then sharp debride the eschar off. Then a chemical debrider will have the opportunity to work.

Margo, CWOCN since 1995

[Chrissy Lou]

If the eschar is dry and intact, with no surrounding erythema, then certainly I would leave it alone, especially if the patient is diabetic or has vascular issues- such care must be taken there. Letting the body do its job, on its own time, is often best. Check their supplements, MVI, how about their pre-albumin? Are they terminal? *However, at the first sign of erythema, drainage, etc, I would look closer at debriding, ATB etc. You have to wonder though, what are the hospitals in your area doing for prevention of these areas? Prevention is the BEST medicine, floating heels, barriers, etc. Perhaps you could put a plan of prevention in place?