WOUND

1. WOUND CARE Presentation by: Scott Michel, MA, ATC Head ATC, Kalamazoo College

2. Outline of Presentation We will discuss, digest, interpret, investigate how much we (as in you all) know about the tissue injury cycle and how it relates to healing. Discuss the very important role that exudate plays in wound healing Then comes the meat and potatoes: Types of wounds and how to deal with each one. Warning all soft stomachs: Very cool pictures will be used for this portion  Methods of treatment and discussion on different techniques of debridement and wound closure. Time reserved for some volunteers to show off all that they have learned at the end. Question and answer period.

3. Your Body was designed to be able to heal itself You just have to know how to utilize it!

4. Tissue Healing Cycle • Three Phases of Healing • Phase I: Acute Inflammatory Phase • Phase II: Proliferation/Fibroblastic/Repair Phase • Phase III: Remodeling/Maturation Phase

5. PHASE I: Inflammatory Phase • Vasoconstriction • Ischemia Hypoxia Necrosis • Coagulation begins • Vasodilation • Enzymes released: histamine, bradykinin, leukocytes, neutrophils, macrophages , monocytes, growth factors • Exudate forms (protein foundation for fibrin) • Margination • Phagocytosis • “Platelet Plug” (leading to formation of collagen)

7. Lets define some terms • Growth Factors - is a naturally occurring substance capable of stimulating cellular growth,proliferation and cellular differentiation. Usually it is a protein or a steroid hormone. Growth factors are important for regulating a variety of cellular processes. Growth factors typically act as signaling molecules between cells. Examples are cytokines and hormones that bind to specific receptors on the surface of their target cells. • Cytokines - A small protein released by cells that has a specific effect on the interactions between cells, on communications between cells or on the behavior of cells. The cytokines includes the interleukins, lymphokines and cell signal molecules, such as tumor necrosis factor and the interferons, which trigger inflammation and respond to infections. • Monocytes - A white blood cell that has a single nucleus and can ingest (take in) foreign material. Monocytes later emigrate from blood into the tissues of the body and there differentiate (evolve into) into cells called macrophages. • Neutrophils - A type of WBC, specifically a form of granulcyte, filled with neutrally-staining granules, tiny sacs of enzymes that help the cell to kill and digest microorganisms it has engulfed by phagocytosis. • Fibroblasts - A cell present in connective tissue that makes and secretes collagen.

8. Phase II: Proliferation Phase • Fibroblastic stage (immature CT) • 2-3 days 6-8 weeks (depend on person and severity) • Fibroblasts lay down in injured area (start to form scar tissue) • CT starts to form • Starts out vascular and elastic • Granulation Occurs • Scar tissue forms (avascular and inelastic) • Fibroblasts become fibrocytes (mature scar tissue cells) which leads to the formation of myofibroblasts. Key player in contraction of wound and reorganization of scar matrix.

9. Phase II Cont.

10. Remodeling Phase Myofibroblasts: These cells contract the microfilament bundles linked to the extracellular matrix, which induce compaction of the collagen network and contraction of the wound.

11. Wound Specific Risk factors • High level of exudate • Location of wound (pressure areas) • Depth or size • Duration: How long has wound been present • Recurrence or stagnation • Absence of proper treatment

12. Diabetic Foot Ulcer Pressure Ulcer OUCH!!!

13. The Role of Exudate • What is it? • Exudate contains a variety of substances including water, electrolytes, nutrients, inflammatory mediators, white cells, protein-digesting enzymes (eg matrix metalloproteinases – MMPs), growth factors and waste products. • The importance of it in a healing wound • Promotes healing in a number of ways, but most importantly aiding in cell proliferation • Prevent the wound bed from drying out • Aid the migration of tissue-repairing cells • Providing essential nutrients for cell metabolism • Assisting separation of dead or damaged tissue • Amount Variations • Common rule of thumb: Larger the wound the increased amount of exudate. • Wounds that have high rate of production? • Negative effects? • MMP’s which breakdown the cell-supporting extracellular matrix, are present in a mainly inactive form. In chronic wounds exudate appears to have opposite effects. This exudate contains elevated levels of inflammatory mediators and activated MMP’s.

14. What Exudate Tells Us Table from World Union of Wound Healing Societies Initiatives(WUWHS) Consensus Document

15. Exudate Cont. Table from World Union of Wound Healing Societies Initiatives(WUWHS) Consensus Document

16. Thoughts?

17. Types of Wound • ABRASIONS • Injury where a superficial layer of tissue is removed, as seen with 1st degree burns. • LACERATIONS • Injury where tissue is cut or torn.

18. Wounds Cont. • AVULSIONS • Injuries where a section of tissue is torn off, either partially or in total. In partial avulsions, the tissue is elevated but remains attached to the body. A total avulsion means that the tissue is completely torn from the body with no point of attachment.

19. Wounds • PUNCTURE • A puncture wound is caused by an object piercing the skin and creating a small hole. Some punctures are just on the surface. Others can be very deep, depending on the source

20. Acute vs Chronic • When Does A Wound Become Chronic? • In healthy individuals with no underlying factors an acute wound should heal within three weeks with remodeling occurring over the next year or so. • It becomes chronic when it gets stuck in one of the stages • Chronic wounds are thus defined as wounds, which have “failed to proceed through an orderly and timely process to produce anatomic and functional integrity, or proceeded through the repair process without establishing a sustained anatomic and functional result.”

21. 3 Examples of Chronic Diabetic Foot Ulcers (DFU Venous Ulcers Pressure Ulcers / Bed Sores

22. HOW DO WE AVOID IT GETTING TO THIS? The wound looks much better. The maggots have removed the necrotic tissue. First application of maggots Third application of maggots After the fourth application the wound is shallower.

23. Maggot Debridement Therapy • Advantages and disadvantages of maggot debridement therapy (“MDT") • Efficacy, as demonstrated in several small but significant controlled clinical studies. • Takes about 15-30 minutes to apply a secure dressing to keep the maggots in place. • Excellent safety record. • Maggots are highly perishable and should be used within 24 hours of arrival. • Simple enough that non-surgeons can use it to provide thorough debridement when surgery is not available or is not the optimal choice. This means that it is also possible to provide surgical quality debridement as an outpatient or in the home. • Low cost of treatment. • http://www.youtube.com/watch?v=l_V1kt10RrU&feature=player_embedded

24. Correct Management Is The KEY • The goal is to clean the wound without damaging cells that survived the original trauma especially those that are vital to the healing process. • Goldenberg (1996) surveyed ATC’s about the then current perceptions of wound management. • His research illustrated that both povidone-iodine and hydrogen peroxide have shown to delay the wound-healing process. • Lineaweaver et al compared four different types of antiseptics and found that at full strength, povidone-iodine, hydrogen peroxide, acetic acid, and sodium hypochlorite were 100% toxic to fibroblasts. • Also found that after irrigating wounds in adult rats with povidone-iodine wound epithelialization was significantly retarded 4 to 8 days later.

25. Management cont. • Foresman et al tested 16 different cleansing agents in vitro and found that the Betadine surgical scrub solution had to be diluted 1:10,000 before leukocytes were able to perform their phagocytic function • Becker took 35 contaminated head and neck surgical cases and, before closure, irrigated the incision with either saline or povidone-iodine. None of the wounds flushed with saline became infected; 28% of the wounds treated with povidone-iodine did.

26. But My Mom Said…. • “Put some hydrogen peroxide on it!!!!” • When applied to wounds it interacts with the enzyme catalase (found in tissue and blood) to release oxygen bubbles which helps kill bacteria. • Drawbacks: • Increased exposure of keratinocytes to hydrogen peroxide was toxic to cells. (Tatnall 1991) • Causes early toxicity to cells in wound bed and early separation of the scab.

27. Which Method of Debridement is Most Recommended? • Debridement: The act of debriding (removing dead, contaminated or adherent tissue or foreign material). • 3 Types: Mechanical, Chemical, and Autolytic • Mechanical- Includes wet-to-dry gauze method, irrigation, hydrotherapy • Chemical- Involves the use of topical agents (like the antiseptics mentioned earlier) • Autolytic- Utilizes occlusive dressings which allow the wound to debride itself • My question to you….Which method have you used, or seen used? (this is when you gain participation points) • Method most commonly used by surveyed ATC’s was the wet-to-dry gauze method…..OUCH!!! • Setbacks: UH….PAINFUL!! ; disrupts healthy tissue

28. Debridement Method • According to Rodeheaverand the US Department of Health and Human Services, the most effective way to debride and cleanse a wound is to irrigate it with water, saline, or a nontoxic agent. • This technique must be performed gently to avoid disrupting the healing tissue. • The pressure of the irrigation is more important than the solution used. Pressures recommended by the US Department of Health and Human Services are between 4 and 15 lb/in2. Pressures greater than 15 lb/in2 of force will have damaging effects to the wound tissue. • A saline squeeze bottle(250 mL) with irrigation cap will exert 4.5 lb/in2 of pressure.

30. Moist vs Dry Healing • Goldenberg found that most ATC’s believed that a moist environment had a higher infection rate than a dry one. • Research has shown that there is a 7% infection rate with the conventional method as opposed to a 2% infection rate with moist healing. • Due to more acidic environment that occurs beneath which results in the inhibition of growth of two common bacteria strains: Staphylococcus aureus and Pseudomonas aeruginosa • Might also be the result of the number of leukocytes found under the dressing • Nemeth et al found that occlusive (moisture-retentive) dressing therapy on skin biopsy sites healed wounds 3x faster than those treated with the conventional method • The area is hypoxic, which stimulate macrophages and fibroblast function, and the release of growth factors.

31. Moist vs Dry Cont. MOIST Healing Conventional Dry • Cells require a moist environment for re-epithelialization of new tissue. • Wound heals from the sides and the bottom. • Protect nerve endings. • Scab retards healing b/c epidermal cells have to penetrate deeper where skin is moist and work from bottom up. • Nerve endings may be damaged with removal of dry dressings.

32. Occlusive Dressings THREE TYPES Film Dressing -Transparent ; allows for viewing of exudate -No absorbent qualities, but adhere very well which may damage epithelium with removal HydrogelDressing -90% water that reduces pain and inflammation; will not damage wound epithelium as long as moist -Must be removed daily Hydrocolloid Dressing -Unlike film dressings have two layers that absorb the exudate that results in a soft moist mass for optimal healing. -Can be left on for up to 7 days and no damage occurs when removed.

34. TIME TO APPLYWhat would you do?

35. TIME TO APPLYWhat would you do?

36. TIME TO APPLYWhat would you do?

37. TIME TO APPLYWhat would you do?

38. Basic Points to Take With You(excerpt from MyWound.org) If you wouldn’t put it in your eye, don’t put it in a wound. Offloading, or taking the burden (pressure) off of a wound, is extremely important. What you take off a wound is often times more important than what you put on it. After a wound heals, it has less strength than normal tissue and the site is prone to re-opening – so protect it. We do not “air dry” or “soak” wounds – the dressings we use try to maintain the proper amount of moisture A wound does not need to remain “scabbed” in order for healing to occur – bacteria feast on scabs Antibiotics, by themselves, don’t heal a wound (there is no magic pill)