Betadine

1. Betadine • Providone Iodine • Used to “dry out” dry gangrene • Goal is to keep dry gangrene contained and free of outside bacteria • Cytotoxic

2. Dakin’s Solution • Diluted bleach • Completely cytotoxic • No known resistance, but no healing occurs • Never use >48-72 hours

3. Acetic Acid • Diluted vinegar • Excellent for pseudomonas aeruginonoa • Used during pulse lavage followed by NS rinse • Lymphedema patients=because of the rich protein, pts are prone to getting cellulitis.

4. Polyhexamethylene biguanide (PHMB) • Lavasept, Serasept (used to prep skin for s(x) • Broad spectrum • Used in foam dressing • Kill bacteria in drainage • More preventative measure than treatment • Kendall AMD, Suprasorb X + PHMB

5. Cadexomer Iodine • Providone Iodine combined with cadexomer starch • Allows for a slow, sustained release • Cytotoxic to bacteria, but low levels not cytotoxic to healing cells • Iodosorb

6. Topical Ointments • Silver sulfadiazine (Silvadene, burn cream) • Collagenase (Santyl) • Metronidazol Gel (MetroGel) • Mupirocin (Bactroban) • Bacitracin, neomycin, polymixin B (Triple antibiotic ointment, Neosporin)

7. Silver Sulfadiazine • Silvadene, burn cream • Sulfonamide plus antimicrobial silver • Cant tolerate the concentration needed to kill some bacteria. • It’s all we had for a long time • It is cytotoxic • Particularly beneficial for: • Pseudomonas • Acute burns

8. Silver Sulfadiazine • It’s cytotoxic – particularly to fibroblasts • Do not use >2 weeks • 2008 Cochrane Review • Prolongs healings • Not recommended for use • Allergic reactions to sulfa • Burning and pain when applied

9. Collagenase • Enzymatic debridement (Santyl) • Digests necrotic collagen • Specific and selective for denatured collagen • Effective when used for long periods of time • Maintenance debridement=when gets down to healthy, helps prevent slough from building up.

10. Collagenase • Considerations • Cost • Slow acting • Deactivated when combined with heavy metals • Silver

11. Metronidazole gel • MetroGel • Beneficial for anaerobic contamination • Fungatingwounds (end stage breast cancer, tumor is evasive and grows out, highly vascularized. • Can be combined with Mupirocin to treat MRSA • Helps with order control from wound.

12. Mupirocin • Bactroban • Bacteriostatic (bacteria lives, but can’t replicate) or Bactericidal (kills the bacteria) • Gram positive organisms including MRSA • Resistance is developing

13. Bacitracin, Neomycin, Polymixin B • Triple antibiotic ointment, Neosporin • Available in ointment or powder • Powder can be combined with collagenase • Allergies becoming more common

14. How to Dress a Wound • Moist wound healing is best • Goal of a dressing is to maintain appropriate moisture level • If necessary, lightly fill a cavity • No “packing” • Creates too much pressure • Whatever goes in, how are you going to get it out?

15. How to Dress a Wound • Considerations • Cost/insurance • Ease of Pt or caregiver to perform • Can you see what your applying a dressing to? • Allergies

16. Gauze - Use • Any wound!

17. Gauze - Advantages • Many forms • 4x4, 2x2, strip gauze, roll • Versatile • Flat, opened, fluffed, filling/packing • Cheap • Readily available w/o Rx • Mechanical debridement • Can be used with any topical or solution

18. Gauze - Disadvantages • Traumatic/painful removal • Dries out easily • Does not keep outside bacteria out • May require a secondary dressing • Leaves debris in wound bed, particularly if cut • Frequent use, longer need affects cost

19. Foams - Use • Stage II-IV pressure ulcers • PT, FT wounds • Infected or non-infected • Donor sites • Minor burns • Moderate to heavily exudating (Ins requirement)

20. Foams - Advantages • Options • Bordered vs non-bordered • Adhesive vs non-adhesive • Silver impregnated • Sheets, ropes • Moderate to heavy drainage • Safe under compression wraps

21. Foams - Disadvantage • Can macerate skin if drainage extends to wound border • Cost • Decreasing insurance reimbursement

22. Alginate/Hydrofiber - Use • Calcium alginate or synthetic hydrofiber • Stage II-IV pressure ulcers • PT, FT wounds • Moderate to heavily exudating • Tracts, undermining • Infected wounds

23. Alginate/Hydrofiber - Advantages • Keeps wound bed moist • Can be impregnated with silver, Leptospermum honey • Hemostasis properties • Atraumatic removal when fully hydrated • Variety – sheets, ropes

24. Alginate/Hydrofiber - Disadvantages • Requires secondary dressing • Can dry out and adhere to wound • Can leave debris/lint • Can macerate unprotected skin

25. Collagen Donating - Use • Donate synthetic or porcine collagen to wound bed • Provides the scaffolding for cells to populate and migrate • Attracts cells to the wound site • Increase cellular proliferation • Any wound – but needs bountiful granulation tissue

26. Collagen Donating - Advantages • Non-adherent, comfortable • Can be left on up to 7 days, need to keep wet. • Can combine with lots of different products as long as still in contact with wound bed • Does lots of great stuff for the wound bed

27. Collagen Donating - Disadvantage • Cost $30-35 per sheet • Requires a clean, non-infected wound • Requires secondary dressing

28. Transparent Film - Use • Polyurethane with porous adhesive • Allows transmission of oxygen and moisture vapor • Can be primary or secondary dressing • Stage I or II pressure ulcers • Superficial burns • Donor sites

29. Transparent Film - Advantages • Visualize wound thru dressing • Impermeable to fluid and bacteria • Autolytic debridement (more on that later…) • Dressing can be on up to 7 days • Lots of different sizes • Silver impregnated available

30. Transparent Film - Disadvantage • Does not absorb drainage • Adheres to skin • Possible skin reaction • Can cause maceration

31. Hydrocolloid - Use • Primary or secondary dressing • Stage I, II pressure ulcers. Shallow stage III, IV • Not how deep, but rather how deep the bone is below. • PT, FT • Superficial burns • Hydrophilic colloid forms gel on contact with wound fluid • Impermeable

32. Hydrocolloid – Advantages • Maintain moist environment • Impermeable to moisture, bacteria • Autolytic debridement • Wear 3-7 days • Self adhering and conforms to any shape • Can be impregnated with silver

33. Hydrocolloid – Disadvantage • Minimal absorption • Contraindicated in presence of infection • Can be difficult to remove, skin tears • No undermining or tracking • Stinks! • Can NOT have any sign Infection.

34. Hydrogels - Use • Donate moisture to a wound • Non-crosslinked polymers plus water and/or glycerin • Can be impregnated with silver • Can be used in any type of wound • Many forms – gel, sheets • Gel can be used with any type of dressing

35. Hydrogels - Advantages • Great for donating moisture • Radiation burns: does permanent damage to skin for rest of life with be poor healing. • Autolytic debridement • Easily removed from wound without trauma • Can reduce pain

36. Hydrogels - Disadvantages • Potential for maceration • Requires daily changes • Requires secondary dressing • Unless bordered sheet • Sheets cannot be used with heavy drainage • Cannot act as a filler

37. Miscellaneous Dressings • Methylene blue and gentian violet • Absorptive, bacteriostatic • Hydrofera Blue • Leptospermum honey • Debridement, antimicrobial, many forms • Medihoney • Cutimed Sorbact • Hydrophilic dressing that traps bacteria, bacteriostatic

38. Modalities • 10-15% wound closure in one week is NORMAL wound healing • If failing to meet this on a regular basis…

39. Electrical Stimulation • One of the oldest >30 years • Strength of evidence: Level A • Medicare reimbursement only if wound is considered “chronic” • Traditional wound care >30 days without progress

40. Electrical Stimulation • How does it work in wounds? • Strong evidence it works, theory on how • “Current of Injury” • When cells are injured – they give off a negative charge • Believed that in chronic wounds – this is broken • Goal of e-stim is to mimic this current • Accelerate or “jump start” wound healing cascade

41. Electrical Stimulation • What does it do? • Stimulates fibroblasts, collagen synthesis • Increase receptor sites for growth factors • Improved tissue perfusion • Decreased edema • Increase tissue oxygen • Decrease pain • Increase tensile strength

42. Electrical Stimulation • High Volt Pulsed Current (HVPC) • Most commonly used for wound care • Monophasic waves • Studies show galvanotaxis occurs in wounds with cells required for tissue repair

43. Electrical Stimulation • Galvanotaxis by the Anode (+) • Neutrophil • Macrohages (acute inflammation) • Epidermal cells (end phase) • Endothelial cells

44. Electrical Stimulation • Galvanotaxis by Cathode (-) • Neutrophils (+ charged when wound is infected) • Fibroblasts • Need Fibroblasts for angiogenesis and proliferative phase of healing • ALWAYS START (-)!

45. Electrical Stimulation • Indications • Any type of wound • Contraindications • Basal or squamous cell carcinoma in area • Osteomyelitis • Suspected, new or if not responding to antibiotics • Pain, deep ache, infection of exposed bone, increased drainage, neuropathic and foot hurts. • Ion residue in wounds (e.g. silver) • Over electrical implants, over the heart or carotid artery, near laryngeal musculature

46. Electrical Stimulation • Duration: • 45-60 minutes • Frequency • 5-7 times/week done at home. • 100pps • Electrode placement • 12:00 and 6:00 • 3:00 and 9:00 • Dispersive pad about 30cm from wound • Saline moistened gauze in wound bed for conduction

47. Electrical Stimulation

48. Ultrasound • Contact ultrasound • Used in wound healing >50 years • Not so much recently • Non-contact ultrasound • Much more trendy • Next week

49. Ultrasound • High frequency • 3 MHz for superficial dermal wounds • 1 MHz for deeper structures and periwound 1 MHz = 3-5 cm depth 3 MHz = <2 cm

50. Ultrasound • Any stage of healing: • Pulsed mode • 20% duty cycle • Before application: • Cleanse periwound skin with mild soap and water and rinse well.