Wound Management

• The Skin is the largest organ in the body, receives 1/3rd of all blood flow, pH 5.5, 15% of body weight, 22 sqft, 1st line of Defence against external environment, Fluid & electrolyte balance, Waste excretion, Temperature regulation, Vitamin synthesis
• Skin changes are influenced by Age, Nutritional/Hydrational deficiencies, Rapid weight change or extremes of weight, Stress, Reactions to medications, Heart/Liver disease, Diabetes Mellitus, Blood vessel diseases

  
• Stages of Wound Healing

  1. Hemostasis

  2. Inflammatory Phase

  3. Proliferative Phase

  4. Maturation/Remodelling Phase
• Inflammatory Phase

  • Tissue damage & bleeding, Clot formation by platelet aggregation and clotting cascade activation, Hemostasis from clotting process, Production of wound exudate which nourishes tissues, flushes out foreign debris/necrotic tissues, and supports medium for enzymes, growth factors and antibodies, Begins at the time of injury, lasts 2 – 4 days, Platelets release platelet-derived-growth-factor (PDGF) & transforming growth factor ß (TGF-ß) from α granules to attract neutrophils & macrophages, Cardinal signs of inflammation (may not indicate infection), Eventual release of TNF-α, IL-1ß & growth factors will activate macrophages and attract influx of fibroblasts & endothelial cells, If impaired or prolonged, may prevent the onset of proliferative and maturation phases
• Factors that can slow the inflammatory phase

  • Presence of foreign material
  • Necrotic tissue
  • Clinical infection
  • Continued disruption of the wound
  • Skin dryness
  • Poor blood supply
  • Thermal shock
  • Excessive antimicrobial use
• Proliferative Phase

  Begins on/~ day 3 when a new vascular bed forms within the wound, Fibroblasts peak around day 7 of injury, Initiates angiogenesis, epithelialisation & neocollagenesis, Collagen production/breakdown continues for 6 months – 1 year after injury, Granulation, Contraction, Epithelialisation, Most efficient in a moist, clean environment
• Maturation/Remodelling Phase

  Decrease in fibroblasts and vascularity, Existing collagen will cross-link, increasing tensile strength
• Intrinsic Factors Affecting Healing

  • Health Status
  • Immune Competence
  • Diabetes Mellitus
  • Age Factors
  • Body Built
  • Nutritional Status
  • Psychological Status
• Extrinsic Factors Affecting Healing

  • Mechanical Stress
  • Debris
  • Temperature
  • Dessication
  • Maceration
  • Infection
  • Chemical Stress
  • Systemic Medications
• Lifestyle Factors Affecting Healing

  • Alcohol
  • Smoking
  • Hygiene
• Acute Wound

  Progresses linearly through the stages of wound healing
• Chronic Wound

  Non-healing wound > 6 weeks, Stuck in the inflammation phase, > 80% has biofilm formation, Lack of epithelialisation, Absence or minimal Granulation tissue, Necrotic or sloughy tissue, Recurrent wound breakdown
• Wound Appearance - The Colour Model

  • Pink: Epithelialisation
  • Green/Yellow: Slough
  • Red: Granulation tissue
  • Black: Necrotic tissue
• Principles of Wound Bed Preparation (TIME)

  T - Tissue management

  I - Infection/Inflammation control

  M - Moisture balance

  E - Edge of wound
• Triangle of Wound Assessment

  Wound Bed

  Wound Edge

  Periwound Skin
• Wound Cleansing

  Tap water VS sterile saline, Infection rates lower for tap water, Dependent on quality of tap water, Freshly boiled and cooled tap water may also be used for cleaning
• Cleansing/Disinfecting agents

  • Hydrogen Peroxide

  Chlorhexidine with or without Cetrimide

  Povidone Iodine

  KMNO4

  PMHB and undecylenamidopropyl betaine

  Octenidine and ethylhethylglycerin

  Hypochlorous acid

  Superoxidised solutions
• Moisture Balance

  Exudate Management, Dry Wound Bed, Chronic Wound Fluid, Bacteria Burden, Oedema, Compression, Application of gelling primary dressings, Application of medical grade honey, Using semi-occlusive secondary dressings, Breakdown of Necrotic Tissue, Bioburden Control, Debridement
• What if the Epidermis Fails to Advance?

  Reconsider the Wound Bed Preparation and the Acronym TIME, Has necrotic tissue been debrided (T), Is there a well-vascularised wound bed (T), Presence of infection, is it under control? (I), What is the inflammatory status (I), Has moisture balance been corrected (M), Are appropriate dressings being used (M), TIMES was proposed where S = surrounding skin
• M.O.I.S.T

  M - Moisture, O - Oxygen, I - Infection Control, S - Support, T - Tissue Management, Oxygen deficiencies has been recognised to have a negative impact on chronic wounds hence the addition of hemoglobin spray, normobaric or hyperbaric oxygenation as treatment modalities
• Purpose of a dressing

  • Protect wound from trauma and microbial contamination

  Reduce pain

  Maintain temperature and moisture of wound

  Absorb drainage and debride wound

  Control & prevent haemorrhage (pressure dressing)

  Provide psychological comfort
• Traditional wound dressings

  • Spider Web (1346 AD) aka "Arachnicillin"

  Poultices

  Leaves & herbs

  Honey
• Conventional wound dressings

  • Gauze

  Gamgee

  Melolin

  Primapore

  Opsite post op
• Problems with some dressings

  Adherence to wound

  Dehydration of the wound

  Fibre shed

  "Strikethrough"
• Ideal/Optimum dressing

  Remove excess exudate

  Maintain moist wound healing environment

  Allow gaseous exchange

  Barrier to pathogens

  Thermal insulation

  Waterproof

  Trauma protection

  Non-adherent

  Safe & easy to use
• Theory of Moist Healing (Winter, 1962)

  A moist environment created beneath a semi-permeable membrane allows optimal conditions for the re-epithelialization of wounds, Wounds healing in moist conditions heal 50% faster, Simplifies debridement
• Wound should be kept clean & dry to allow scab formation
• Wounds should be exposed to air & sunlight as much as possible
• Where tissue loss is present, the wound should be packed to prevent surface closure before the cavity is filled? Followed by coverage with a dry dressing
• Modern/Advance/Composite dressings

  • Films eg. Opsite, tegaderm, suprasorb F

  Hydrogels eg. Duoderm gel, intrasite gel, suprasorb gel, purilon gel

  Hydrocolloids eg. Duoderm CGF or extra thin, comfeel, suprasorb H, cutinova hydro

  Alginates eg. Kaltostat, aquacell, seasorb, suprasorb A, algisite

  Foams eg. Allevyn, RTD foam, Tielle, suprasorb F, mepilex, biatain

  Charcoals eg. Carboflex, actisorb plus

  Silver eg. Aquacel Ag, biatain Ag, Acticoat, polymem silver, seasorb Ag

  Polymer eg. Gold dust

  Collagen eg. Stimulen, suprasorb C

  Polymeric membrane dressings eg. Polymem

  Medical grade honey eg. Medihoney, altivon, algivon, L-melsitran

  Iodine based dressings eg. Iodosorb, inadine
• Granulox

  Purified haemoglobin spray, Requires cold chain, Expensive
• Urgostat

  Sucrose octasulfate/ TLC-NOSF, Inhibits MMP, Only dressing in the world with level 1 evidence (NICE, CHALLENGE, WHAT, CASSIOPEE, REALITY, EXPLORER, SPID)
• Nano Copper

  Used in China so far, Cleansing spray/solution
• Procellera

  Bioelectric dressing (Zinc Oxide batteries), Used in US, not marketed in Asia yet, Contains silver and zinc, Activated on applying anagel, emits microcurrents
• Microcurrent

  Increases perfusion, Increases neuropeptides, Restores normal electrodynamic properties of tissue
• Emoled 400 – 430nm

  Photobiomodulation, Stimulate sensitization of cytochrome C & cytochrome C oxidase through protoporphyrin IX & flavins, Reduces inflammation and promotes mitochondrion activity leading to tissue regeneration
• NPWT

  Promotes wound bed perfusion, draws wound edges together, promotes granulation, Removes exudate, oedema and potentially infectious material, Creates moist wound environment
• Natrox

  Topical oxygen therapy via oxygen delivery system, Wound has to be clean of infection, biofilm, 1st 2 weeks, wound becomes very exudative, after which it starts to close
• Laser

  660nm, 800nm, 905nm & 970nm, Promotes angiogenesis
• Topical growth factors

  PDGF - Only FDA Approved GF, Promotes healing by 48%, ß-Fibroblast Growth Factor (ß-FGF), Keratinocyte Growth Factor – 2, Transforming Growth Factor ß-2, Epidermal Growth Factor