Primary Wound Management

1. Primary Wound Management Current Concepts in Topical Therapy

2. Priority # 1: Correct Causative Factors • Pressure/Shear: Support surface + repositioning guidelines • Friction/Shear: Gentle skin care; minimal tape use; measures to prevent “scrubbing” • Venous: Leg elevation + compression • Arterial: Revascularization? Measures to optimize perfusion/protect limbs • Neuropathy: offloading

3. Priority # 2: Systemic Support • Measures to optimize perfusion • Pain control; warmth; edema control; oxygen if needed • Must have sufficient blood flow to heal—if wound poorly perfused & revascularization not an option, consider HBOT

4. Systemic Support • Nutritional Support • 30 – 35 cal/Kg/day • 1.2 – 1.5 gm protein/Kg/day (glutamine & l-arginine) • MVI • Zinc only if needed and only short-term • Consider oxandrolone for pt with significant wt loss who does not respond to standard therapy

5. Systemic Support • Tight Glucose Control • Goal: Normoglycemia • Impact of glucose >180 • Implications: check glucose records each visit; constantly reinforce link between glucose levels and ability to heal

6. Systemic Support • Measures to minimize effects of high-dose steroids: topical Vit A to wound bed (25,000 – 100,000 IU daily, depending on size of wound) • Note limited research on this topic

7. Priority # 3: Principle-based Topical Therapy • Goal: Promote wound healing by creating local environment that favors repair • Inflammatory phase: wound cleanup (debridement and bacterial control) • Proliferative phase: rebuilding (formation of granulation tissue to fill defect + new epithelium to resurface)

12. History of Wound Care • Dominant Principles and Concepts • Limited knowledge re: wound healing • Primary focus: infection control • Common Approaches • Gauze dressings with antiseptic solutions • Aggressive cleansing • Mgmt refractory wounds: “more of the same” vs. experimental agents

13. Shift to Moist Wd Healing • Winter’s Research: 40% reduction in time to epithelialization with moist surface • Subsequent studies: improved rates of healing full-thickness wounds; no increase in infection rates • Gradual shift in focus: from preventing infection to creating favorable environment for repair

14. Principle-Based Topical Therapy • Eliminate impediments: necrotic tissue, excess bioburden, wound exudate, closed wound edges • Keep wound moist, insulated, and protected

15. Topical Therapy Acronym • D = Debride necrotic tissue • I = Identify and treat infection • P = Pack dead space, lightly • A = Absorb excess exudate • M = Maintain moist wound surface • O = Open wound edges • P = Protect healing wound • I = Insulate healing wound

16. Topical Therapy: Decision-Making Guidelines • Wound Assessment: • Location • Dimensions and depth • Undermined/tunneled areas • Status of wound base: granulating? clean but not granulating? necrotic? • Exudate • Status of wound edges/surrounding tissue

24. Necrotic Wounds When to debride: --Anytime the goal is repair --Anytime the wound is infected

27. OASIS Assessment Challenges • Open Wounds: • Granulating vs. clean but not granulating • Closed versus open wound edges • Closed Incisions • Presence/absence of healing ridge • Epithelialization

28. Necrotic Wounds • Debridement Options: • Surgical • Conservative sharp wound debridement • Enzymatic • Chemical • Autolytic

29. Infected Wounds • Guiding Principle: must intervene when • there is invasive infection of soft tissue or bone or • the bacterial loads on the surface of the wound are sufficient to interfere with repair

33. Infected Wounds • Wounds involving infection of soft tissue: • Clinical S/S: redness, heat, edema, pain, exudate • Treatment: systemic antibiotics (culture based if possible) • Wounds involving osteomyelitis: • Clinical S/S: exposed bone; nonhealing tunnel • Treatment: systemic antibiotics

36. Infected Wounds: • Culture guidelines: • Purpose: to determine infecting organism and antibiotics to which it is sensitive • Procedure: Wound biopsy (punch culture) OR Modified swab: flush with N/S swab 1 sq cm of viable tissue till exudate produced

37. Infected Wounds • Wounds with sufficient bacterial load at wound surface to interfere with repair: • Clinical S/S: deterioration in quantity or quality of granulation tissue; persistent high volumes of exudate; pain • Treatment: topical agents to reduce bacterial loads (cleansers, sustained release iodine or silver dressings)

39. Infected Wounds • Topical Agents for Bacterial Control • Necrotic wounds: consider Dakin’s • Technicare cleanser for wd with daily dsg changes (kills 99% of bacteria within 2 min): Caretech Labs • Sustained release iodine (Healthpoint) • Sustained release silver agents (Acticoat, Silvasorb, Aquacell Ag, Contreet, Actisorb)

40. Create/maintain open wound edges • Cauterize with silver nitrate • Refer for excision of wound edges

42. Dressing Selection • Goals: • Wick and absorb exudate • Maintain moist wound surface • Provide bacterial barrier/protection against trauma • Insulate

43. Dressing Selection • Assessment parameters: • Wound depth > 0.5 cm? • Tunnels or undermined areas present? • Volume of exudate?

44. Dressing Selection • Classify wound: • Deep and wet: > 0.5 cm deep (or tunnels or undermining) + mod – lg amt exudate • Deep and dry: > 0.5 cm deep (or tunnels or undermining) + minimal or no exudate • Shallow and wet: < 0.5 cm deep (no tunnels or undermined areas) + mod – lg amt exudate • Shallow and dry: < 0.5 cm deep (no tunnels or undermined areas) + minimal or no exudate

45. Dressing Options • Deep and wet: • Filler dressing: alginate rope or hydrofiber rope or damp gauze (least effective option); note Nugauze or Mesalt rope best for narrow tunnels • Cover dressing: adhesive foam; gauze + tape or transparent adhesive dressing (consider need for bacterial barrier—e.g., pt who is incontinent and has trunk wound)

47. Dressing Options • Deep and dry: • Filler dressing: layer of wound gel + damp fluffed gauze; gel-soaked gauze • Cover dressing: gauze + transparent adhesive dressing (maintains hydration and provides bacterial barrier)

49. Dressing Options • Shallow and wet • Alginate + foam or gauze • Hydrofiber + foam or gauze • Nonadherent contact layer + gauze • Adhesive foam alone