ABC of Wounds management

Dr. Mahen Kothalawala MBBS, Dip in Micro, MD, MPH(NZ),

Consultant Clinical MicrobiologistTeaching Hospital Kandy

SriLanka

Management of Wounds

Part one

Objective

• Types of wounds• Mechanisms of wound Causation• Wound healing –Phases• Chronic Wounds• Identification and classification of chronic

wounds• Description of chronic wounds for the purpose

of documentation

Wounds

Acute Wounds

Cuts, Abrasions, LacerationsContusionsPuntureSkin flaps and BitesBenbow ( 2005) Any wound >

3/12 considered a chronic wound

They passes through the normal healing process readily

Fail to pass through normal healing process

Chronic Wounds

acute wounds

• heal very easily• It passes phases of wound healing– Inflammatory phase– Collagen building phase– Remodelling Phase

Aim of management of acute wounds

• Healing without complications such as infection and disfiguring

• Wound care – Remove FB– Dry or wet to dry dressing to cover the wounds– Suturing if acute– Bites - Prophylaxis

Antibiotics in acute wounds

• Only indicated if contaminated or evidence of infection is demonstrated

• Evidence of infection (local)– Redness– Warmth– Swelling– Tenderness– Local Lymphadenopathy

Acute wounds with abscess formation

• If abscesses are large need to be drained• Smaller once – can manage with antibiotics

• Betadine*, Hydrogen Peroxide*, Saline, Spirit can be used to cleanse the wound

• For chronic wounds * ********* may interfere with granulation and epethelilised tissues

Healing of acute wounds

• Wounds with minimal gaping – heals readily with scarring

• Wounds with gaping or skin loss – heals with Scar tissue formation and retraction

How do wounds heal

• Haemostasis• Inflammation• Proliferation or Granulation• Remodelling or Maturation

11Normal Healing Process…

Acute Wounds

Proliferative Phase

Proliferation, Granulation and

Contraction

Haemostasis & Inflammatory

Phase

Remodelling Phase

Healed Wound

Natural wound healing process

When Does a Wound Become Chronic?

• healthy individuals with no underlying factors an acute wound→ heal within three weeks

remodelling → over the next year or so

• When wound does not follow the normal trajectory it may become stuck in one of the stages and the wound becomes chronic.

Chronic Wounds

• Working Definition – wound lasting >3 months• Chronic wound – Fail to heal due to various

local and systemic causes– Healing process arrests at different levels of

healing– Wound may appear at different colours

Time

Hemostasis

Platelet Aggregation Neutrophil

ImmigrationMonocyte ImmigrationGranulation

Re-epithelialization

Wound Closure

Scar FormationRemodeling

Minutes Hours Days Weeks Months Years

The wound healing cascade impairs and arrests at different stages

Chronic wounds

CHRONIC WOUND

Chronic wounds

• Normal healing process impaired– Arrest at different levels –– Remains at same stage without progressing to

wound healing

• Often an underlying cause remains and undetected

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Local and systemic factors that impede wound healing

• Local factors • Inadequate blood supply **

• Increased skin tension

• Poor surgical apposition

• Wound dehiscence

• Poor venous drainage **

• Presence of foreign body and foreign body reactions

• Continued presence of micro-organisms & Infection **

• Excess local mobility, such as over a joint

• Systemic factors• Advancing age and general immobility **

• Obesity ***

• Smoking

• Malnutrition ***

• Deficiency of vitamins and trace elements ***

• Systemic malignancy and terminal illness Shock of any cause

• Chemotherapy and radiotherapy

• Immunosuppressant drugs, corticosteroids, anticoagulants

• Inherited neutrophil disorders, such as leucocyte adhesion deficiency

• Diabetes and CRF***

Characteristics of a chronic wound

• May appear different colours at any given time

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Appearance of a chronic wound

Chronic Wounds Appearance

approach has been criticised for being too simplistic as wound healing is a continuum and wounds often contain a mixture of tissue types.

Wound healing continuum

Wound Healing Continuum (Gray et al. 2005) havebeen developed. This tool incorporates intermediate colour combinationsbetween the four key colours

Management of wounds

Part two

Objectives

• Identification of different types of wounds

• Characteristics of the wounds

Types of wounds

• Necrotic Wounds• Sloughy Wound• Granulating Wounds• Epethililized Wounds• Mixed type• Infected wounds

Necrotic wounds

Necrotic tissue

• Necrotic tissue= Dead tissue = when it is dry and hard known as eschar

• It prevents wound healing – Removal is necessary – May lead to infection

• Once removed healing starts • Removal needs to asses wound staging and it

mask the true size of the wound

Necrotic wounds

• Fails to heal

• Masks the true size and staging

• Prevents antibiotics from reaching the site

• Provide foothold for microbes to grow and evade antibacterial or neutrophils – Bio film

Necrotic wound

• often appears black, • may also appear brown or grey when

hydrated. • Necrotic → initially be soft, • dead tissue → lose moisture and become

dehydrated with the surface becoming hard and dry

Sloughy wounds• Slough – yellowish/Yellow brown fibrous tissues which tightly

adherent to the wound base (dead cells and wound debris)• cannot be removed by washing• slough is not necessarily indicative of clinical infection. • Slough can be found as patches across the wound bed.• Exposed tendons may mistaken for slough.

• Effect of slough in wound healing– Presence of slough delays wound healing– Predispose to infection –provide Foot hold to organisms to attach– Prevents antibiotics/Antimicrobial agents from reaching the site

Slough in wounds

• should be removed to enable healing to take place.

• referred to as ‘de-sloughing’.

Granulating Wounds

• Granulation tissue fills the wound as it is healing.

• The tops of the capillary loops make the wound appear red and granular.

• It is firm to the touch, painless and does not bleed easily.

Granulating Wounds

Unhealthy Granulating Tissues

• Bright red granulation tissue, which bleeds easily, may indicate infection (Bale and Jones 1997).

Epethilialized wounds

• Epithelial tissue is formed in the final stages of healing.

• This tissue forms the new epidermis.• Epithelial tissue is superficial pink/white tissue

that migrates across the wound from the wound margin, hair follicles or sweat glands.

• It will cover the granulating tissue.• In shallow wounds with a large surface area,

islets of epithelialisation may be seen.

Epethililized wounds

Infected wounds

• Wound infection is the most troubling wound complication (Cutting 1998).

• Avoiding infection is vital in good wound management.

• Therefore it is good practice to recognise the contributing factors that precede a diagnosis of infection.

Wound Infection Continuum

• The Wound Infection Continuum (Gray et al. 2005) recognises the various levels of bio-burden in the wound– Wound Contamination– Wound Colonization– Critical Colonization– Wound Infection– Spreading wound infection– Wound Sepsis

Wound Surface

2.Organisms from GIT and GUTGram Negatives such as E.coli,

Klebsiella, Enterobacter, Anerobes

1.Organims from sorrounding skin- Regional flora-CONS,

Deptheroids, Anerobes

3.Organisms from External environment- HCW through direct or

indirectly –MRSA, Pseudomonas, Multiresistant organisims etc

Wound Contamination

Wound Colonization

Critical Colonization

Wound Infection

Advance Wound Infection

Fecal and urinary management systems

Hand hygeine

Wound Infection• The presence of multiplying organisms within

a wound that overwhelm the host immune response with associated clinical signs and symptoms. (Kingsley 2001)

Organism Density

Factors which influence wound infection

• 1. The quantity of micro-organisms• 2.quality –Virulence and antibiotic resistance• 3. The patients resistance to the level of

bacteria in the wound( immune response)

• Microbial bio-burden within wounds can range from contamination, colonisation, critical colonisation and infection.

Clinical Signs of wound infection

• Classical Signs1. Increased pain2. Copious amounts of exudate3. Malodour4. Cellulites5. Pyrexia6. Abscess Formation

Additional Signs

– Increase in size of wound– Delayed wound healing– General unwellness– Dark discoloured granulation tissue– Increased friability– Pocketing at base of wound. (Cutting and Harding

1994).

Investigations for wound infection

• When wounds are not healing in the expected way and display signs and symptoms of infection or for the presence of multi-resistant bacteria such as MRSA (Gilchrist 2001).

• Three types of Investigations– Deep tissue biopsy –During surgery(Bowler et al 2001).– Wound Fluid Sampling

Aspiration using aseptic technique from deep– Wound Swabs

Indications for wound swabs

• Wound swabs are generally preferred when– Wound fails to heal as anticipated– When evidence of infection present– Suspecting drug resistance

Management of wounds

Part three

Objective

• Care of different types of Wounds

Care depends on

• Type of wound

• Amount and type of of Exudate

• Presence of critical colonization or evidence of infection

Care of necrotic wound

• Necrotic wound• As areas of necrosis interfere with healing process,

need to remove it through any of the following means– Mechanical Debridement –Wet to dry dressings– Autolytic Debridement- Occlusive dressing and wound

exudate will debride by its enzymatic relations– Enzymatic Debridement –By sofetneing slough by using

enzymes –Iruxol and Papaya– Bio logical Debridement –Maggots therapy– Surgical Debridement –Surgeons blades

Care of Exudative wound

• Dry wound• Mildly exudative wound• Moderately exudative wound• High exudative wound• Care of periwound area

Care of Sloughy wound

• De-sloughing

• Prevention of slough formation

• Enhance granulation

Care of granulating wounds

• Care of granulation tissue – avoid dry or wet to dry dressings

• Prevent over granulation

• Prevent infection

• Exudate management and care of peri-wound area

• Skin grafting or skin substitutes

Care of Epethelialized wounds

• Same as in granulating wounds

Care of infected wounds

• Reduce bio burden –Cleansing, reduction of necrotic and sloughy tissue

• Local antiseptics – rotational• Local antiseptics- cedoxomer iodine,

crystalline silver, PHMB• Exudate management• Care of periwound area

Antibiotics

• For spreading infection and or evidence of systemic infection

• Take blood cultures• Treated with Broad Spectrum antibiotics

intravenously. • Topical antimicrobials - used to reduce wound

bio burden (EWMA 2006).

Antimicrobials

• Topical antiseptics/Antibacterials• The range of topical antimicrobial agents currently used

includes– chlorhexidine, – products containing iodine (cadexomer iodine and povidone– iodine) and – products containing silver (silver sulfadiazine and

silverimpregnated– dressings) (EWMA 2006).– The antiseptic/antimicrobial polyhexamethylene biguanide (also

known as polyhexanide or PHMB)

• .

Management of wounds

Part four

Care Planning.

Overall strategy and scope of the treatment plan depends on patient’s

condition, prognosis, and reversibility of the wound.

Appropriate Goals

• Prevent complications or the deterioration of an existing wound

• Prevent additional skin breakdown and protection of the surrounding skin

• Minimize harmful effects of the wound on the patient’s overall condition

• Promote wound healing and achieve cure• Prevention of wound from recurring and life style

modification

Wound Care Plan (WCP)

Patient Cantered – dealing with person with a

chronic wound

Holistic –Total care -Not only wound itself- need to address pts other needs, diseases, and psychosocial wellbeing

Inter-diciplinaryNeeds Participation of

multitude of disciplines

Basic elements in wound care plan

• Cleanse Debris from the Wound• Possible Debridement• Manage Exudate• Promote Granulation and Epithelialization

When Appropriate• Possibly Treat Infections• Minimize Discomfort

A. Cleanse Debris from the Wound

Cleansing agents

– Flowing Water –Requesting pt to bath before dressing change– Normal Saline***– Commercial Cleansers– Hydrogen Peroxide– Povidone iodine– Hypochlorite solution– Sterile vinegar solution– Mechanical Cleansers –Whirl pools– Salt dips

Aims• Reduce bio burden• Reduce dead and dying debris• Clean the wound

2. Possible Debridement

• Mechanical • Autolytic• Enzymatic• Biological• Surgical

C. Manage Exudates• Identify the level of moisture• Manage exudates by dressingsNature of Exudate Type of wound Aim of exudate

managementMethod /Agent

No exudate Dry Keep the base moist

Hydrocoloid agentIntrasiteNeed occlusive and non occlusive dressing

Mild exudate Moist Keep the wound moist

Absorb moisture

Moderate Wet Keep the wound in moist state by reducing exudate

Absorb moisture Form dressing

Heavy Wet +++ Keep the wound moist

Absorb

D. Promote Granulation and Epithelialization

• Granulation enhancers

• Minimal Dressing changes to reduce disturbances to the granulation

• Avoid usage of substances which impede granulation tissues

E. Treat infections

• Systemic antibiotics

• Local Antiseptics to the wound

• Rotational antiseptics etc

F. Minimize discomfort

• Pain relief

• Psychological support

• Family education and create conducive environment

• Social support

WCP include

• Initial Assessment and Documentation• Identifying the risk factors• Optimize Local wound care

– Selection of Dressing• Systemic therapy and nutritional supplementation

– Diabetes control– Antibiotics if indicated

• Follow up and progress assessment periodically• Change the plan if not improving• Re-asses• Empower the pt and family members

WCP Step one

Assessment and documentation

Initial Assessment and documentation

Assessment and documentation

• It is ongoing process• Initial assessment – at the time of first

presentation• At every dressing changes – need to asses and

document the state of wound to monitor progress

WCP-Step two

• General Assessment of pt characteristics• Ht, Weight, QI, BP, Skin color• Past medical history• Investigation done previously• Drug and allergic history

•Chronic Wound Care: 10 Pearls for Success

Chronic Wound Care: 10 Pearls for Success!! Dr. Gary Sibbald, BSc, MD, MEd, FRCPC (Med), FRCPC (Derm), MACP, FAAD, MAPCA

1. For those with Diabetes for wound healing and further prevention: A - Check A1c - greater than 9% will affect wound healing.

Recommended is less than 7%. B – Blood Pressure C - Cholesterol D - Diet E - Exercise F - Foot care - Check both feet at each appointment, shoes

should be professionally fitted, consider chiropody. S- Smoking

• 2. For those with Venous Ulcer Disease - Compression bandaging is for treatment, stockings are for prevention.

– (Exudate/creams will damage the integrity of the stockings).

– COMPRESSION IS FOR LIFE! The right compression is the one the patient will wear

3. For those with any distal neuropathy - Shoes should be professionally fitted.

4. Smoking Cessation -IMPORTANT FOR ALL! - each cigarette decreases leg circulation for 30% for an hour or increase sympathetic tone for 8 hours

5. If wounds not decreased by 30% in size by week 4, unlikely to heal by week 12. Consider biopsy or a comprehensive re-assessment

6.Query Infection? Culture using the Levine technique (Compress wound with normal saline for 10 minutes, press swab into a clean granulated area to express fluid and rotate 360 degrees

7. Treat the cause! Consider all the possible contributors to non-healing: Drugs, Occult, Diabetes, Systemic Disease (e.g. diabetes anemia, vascular disease), smoking, non-adherence

• 9. Treat the wound! Debridement, Infection, Moisture Balance, and then Edge

• 10. Interdisciplinary collaboration - Physicians, Nursing, Chiropody, OT, PT, Dietician, and Caregivers.

Wound Care

• Complex• Yet Acheivable

Case one -Documentation

Patients Name – RMW67 yrDiabetic ptFrom MaharagamaA retired Clerk

Date of Clerking -21/5/2012

Wound –Medial side of the rt legExtending from Medial Maleolus region

Maximum Length – 13 cmMaximum Width -8 cmMaximum Depth 2mmSurface area - 39 cm2

Stage 11Per-iwound Area –black Discoloration +

No underminingNo tunnelling

Exudate – Mucoid MildNo evidence of infectionSmell – Not offensiveColour of the wound bed –Mixed

Necrosis 5%Granulation 30%Slough 15%Epethelialized 5%

No evidence of Redness surrounding skinNo regional LymphadenopathyVenous Insufficiency

General – Mobile pt AfebrileNot anemic- 9.8g/dl

Step Two

• General 168cm• 84kg• 160/100 kg

• Past medical history – DM for 20 yrs on regular therapy• Past history of similar illness

• Drugs- On tolbutamide• HT- No drugs

• FBS- 130 mg/dl

Team

• Surgeon• Wound Care Practioner• Nursing officer• Physician• Physio-therapist• Nutritionists• Attendant

Empower the patient and responsible family member

• Teach the correct way to dressing

• Irrigation

• Compression

Progress Assessment (two weekly)

Week 1 Week 3 Week 5 Week 7 Week 90

10

20

30

40

50

60

70

80

90

100

Necrosis Linear (Necrosis) Slough Linear (Slough) Granulation Linear (Granulation)

Epethililization

Dressings

• Objectives

– Type of Dressings– Selection of dressings– Dressing recommendation

Dressings

• When a wound is infected → expensive dressings useless

• Management of exudate, pain is very necessary.

• Additionally debridement of necrotic or sloughy tissue can alter the wound environment significantly and help to reduce the overall bioburden and reduce odour (EWMA 2006).

Dressing Selection

• Primary Dressing – A dressing that touches the wound

• Secondary Dressing – Keeps the primary dressing in site – Fasten it to the wound

• Some dressings function as primary dressings only

• Some could function as primary and secondary dressings as well - adhesive

Dressing Selection

• Depend on – Type of wound– Patient preference/Dr preference – Stage of healing of the wound• Proliferation or Granulation phases• Remodelling or Maturation phases• Presence or absence of Infection or Colonization –Bio

film

Dressing Selection

• Depending on wound healing passes through its different stages different types of dressings may be required

• Normally moist environment will enhance wound healing

• Exudate provide moist healing• Too much of exudate, – interfere with wound healing-leads to autolysis by the

action of enzymes in the exudate– Inhibits-granulation and epethilization

Ideal wound dressing for moist wound healing need to ensure....

• Wound remain moist– not macerated• Wound need to remain free from active infection• Free from toxic materials of the dressing

Papaya and Komarika• To maintain the wound at optimum temperature

for healing• Undisturbed by the frequent need for dressing

changes • Maintain optimum PH conducive to wound healing

Advanced wound dressing

• Are designed to control the environment around wound -↑ healing

• Mainatainance of moisture balance– Some donate fluid to keep wound moist (ex Hydrogels)-

used for dry wounds– Some maintain moisture or retain moisture without

donating or loosing (Hydro colloids)– Some designed to absorb excessive moisture (Alginate and

foams)• Fight Infection/Critical Colanization/ – Silver impregnated dressings– Iodine containing dressings/powder/cream etc

Practice which need be discouraged

• Irritant solutions• Irritant cleansers• Frequent de-sloughing or using de-sloghing

agent

Desloughing

• Hydrogels, hydrocolloids and medical grade honey can be used to autolytic debridement for difficult to heal ulcers

• Sterile larvae- can be used to bio surgical debridement

Dressings

• Two types

• Inactive Dressings• Active dressings

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Inactive dressings

• Dry dressings• wet to dry dressings• Polyurethane film dressing –Breathable and

non breathable film dressings• Vasline tules• Antibiotic impregnated tules

Dry dressing and wet to dry dressing

• Gauze dressing• Can be medicated or non medicated• Good for acute wounds

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Dry dressings……

1. Tend to absorb wound moisture 2. Tightly Adherent to granulation Tissue –

will break upon removal

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Vaseline Gauze

PU Film Dressings

Film dressings and tules

• Not shown to be better than dry dressings

• Only advantage – no breaking of granulation tissues

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Active dressings

• Plays a role in wound healing– Provide a covering, – enhance granulation tissue formation, – Reduce slough formation– Inhibits bacteria– Keep wound moist– Some provide growth factors

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Examples

• Hydrogels –fibre and Foams• Hydrocellular dressings• Foams• Alginates• Crystaline Silver and Slow Iodine releasing

materials

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Hydrogel

• Cross linked gel dressing– Flexigel – Intrasite

• Keep the wound moist• Suitable to mildly exudating wounds and to

dry and necrotic wounds

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Foam dressing

• Suitable for mild to moderate exudating wounds

• Adsorbs exudate rapidly and enhance thickness

112

Forms

• Used for cavities and fill the dead space (cavitating lesions)

• Promote healing from the edge

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Alginate Dressing

Adsorbs excessive moisture

• Summary