Lecture 5b - TIME and wound bed prep Flashcards
What does TIME stand for?
Tissue
Infection or Inflammation
Moisture
Edges
Tissue from “TIME”
Debridement & modalities
Infection or Inflammation from “TIME”
Treat local or systemic
Moisture from “TIME”
Treat with barriers, lotions, and dressings
Edges from “TIME”
Treat with barriers, dressings debridement & modalities
What level of evidence does e-stim have?
Level A
What are some indications for e-stim for wounds?
- Pressure ulcers
- Venous insufficiency ulcers
- Arterial ulcers
- Diabetic neuropathy ulcers
- Burns
- Dehisced surgical wounds
- Chronic wounds
What are benefits of e-stim for wound care?
- Restores current of injury
- Causes galvanotaxis
- Stimulates cells
- Increases blood flow
- Increases bactericidal abilities
- Facilitates debridement
- Reduces edema
- Reduces pain
What is the charge typically found in edema?
(-) charge so when using High-Volt to push, put the (-) electrode on/near the edema
What charge does the epidermis have?
Electronegative (-) charge, SO when we have a break in the skin, there is a disruption so a wound has a (+) charge
What is the most common e-stim treatment for wounds?
HVPC
Parameters
* Frequency: 80-125 Hz
* Interpulse interval: 50-100 ms
* Intensity: 75-100 V
* Time: 45-60 minutes
Inpatient tx: 1-2x/day
Outpatient tx: 3x/wk
What are 3 e-stim methods?
- Direct technique (saline-soaked gauze; other electrode is 15-20 cm away; most common)
- Immersion technique (in water; consider risk for contamination or infection)
- Periwound technique (around wound, decrease contamination, don’t have to remove dressing)
What are some roles of the cathode (-)?
- Attracts: neutrophil, fibroblast
- Promote epithelial growth & organization
- Vasoconstrictor
- Denatures protein
- Aids in preventing post-ischemic lipid production
- Attracts macrophages
Do you start with the cathode or anode for treatment?
Begin with cathode for a few days, then switch to anode usually
What are some roles of the anode(+)?
- Attracts: neutrophil, macrophage
- Fight infection
- Decrease edema
- Lyse necrotic tissue - debridement
- Increase blood flow
- Stimulate granular tissue growth
- Angiogenesis
What are the contraindications for e-stim?
- Simple, uncomplicated wounds
- Evidence of osteomyelitis
- Cancer related wounds
- Using any metal (silver) dressing or cream
- Active bleeding
In addition to enhancing all 3 phases of healing, what does Ultrasound do?
- Reduce inflammation
- Enhance granulation tissue
- Increase wound tensile strength
- Improve scar pliability
What are indications for Ultrasound?
- Chronic wounds
- Pressure wounds
- Venous insufficiency
- Acute trauma
- Recent surgery
What are 2 ways Ultrasound may produce cellular changes?
- Cavitation
- Microstreaming
What is Cavitation?
- production & vibration of micron sized gas-filled bubbles
- as bubbles move & condense, they are condensed before moving on
- the movement and compression of bubbles can cause changes in cellular activities of the tissues
What is microstreaming?
AKA acoustic streaming
- unidirectional movement of fluids along cell membrane or bubbles bc of pressure wave associated with US
- may increase permeability in cell membrane or vascular wall
What are the 3 Ultrasound methods?
- Direct technique (fill deep wound with hydrogel/saline; cover wound with barrier then use coupling medium over barrier) nah
- Periwound technique (less effective but don’t have to move dressing; good for painful wounds)
- Immersion technique (immerse wound and sound head underwater; think about positioning)
Review Ultrasound Basics
Superficial: 3 MHz
Deep: 1 MHz
Non-thermal pulsed at 30-35% with low intensity of 0.5-1.0 W/cm^2 for healing
To remodel scar tissue, remove contractures, or improve ROM use thermal setting of 1.5 W/cm^2
Treatment time: 2-3 min for 3-7x/week
What is Non-Contact Low Frequency US (UltraMIST)?
Advertised for:
- active cell stimulation
- decreased bioburden
- increased blood flow
- cleansing & gentle debridement
Pros/Cons of Non-Contact Low Frequency US…
Pros:
- increased microstreaming/acoustic streaming
- research shows: wound size reduction & increased healing rates
Cons:
- Need specific device = expensive
- Wear PPE
What are contra-indications for Ultrasound?
- Simple, uncomplicated wounds
- Osteomyelitis
- Active profuse bleeding
- Untreated infection
- Severe AI
- Acute DVT
How does Hyperbaric Oxygen (HBO) work?
- administration of 100% medical-grade O2 at >1.5 atmospheres absolute pressure which increases the O2 dissolved within the plasma by ~14 fold
- need specialized clinic
What are 4 benefits of HBO?
- Increase concentration gradient for O2 (improve O2 ability to diffuse & HgB ability to carry O2)
- Increase ability of WBC to kill bacteria
- Stimulate angiogenesis, collagen synthesis, granulation tissue formation, epithelialization, and wound contraction
- Reduce edema
Indications for HBO?
- if periwound hypoxia is present with transcutaneous O2 monitoring testing on room air AND increases at least 10-15 mmHG breathing 100% O2
- gas gangrene, progressive necrotizing infection
What level of significant hypoxia is not appropriate for HBO?
<30 mm Hg is not appropriate for HBO
What are contraindications for HBO?
- Metallic or electric implants
- Certain types of dressings
- DVT
- COPD
- untreated CHF
- claustrophobia
- untreated pneumothorax
- severe AI requiring amputation
Thoughts on Topical HBO?
- more controversial than regular HBO
- done at the patient’s home
What is the most effective type of Ultraviolet?
UVC is most effective; can use on infected wounds or to decrease bioburden on chronic wounds
What can UVB do?
Induce inflammation & stimulate epithelialization
For ultraviolet, what is the best depth of treatment?
< 100-200 um (micrometers)
What protective measures do you need to take for ultraviolet?
- wear protective eyewear
- Protect the periwound with petroleum jelly/lotion SPF 30 +
- Hold the light perpendicular during treatment at a distance of 1 inch
How often do you use ultraviolet treatment?
daily for 30 seconds for 5 days
Exposure time to kill 99.9% of S. Aureus & MRSA: 5 seconds
How does laser therapy work?
- Operates at intensities too low to damage living tissues
- not well supported in research
Laser Cellular Effects
a lot of things
to name a few…
- Increased cellular proliferation
- Increased mitochondrial production of ATP
- Increased fibroblast proliferation
- Enhanced epithelialization rates & improved tissue tensile strength
- Increase GF release
Do I exercise?
Yes! Exercise can improve wound healing
How do we dose exercise?
- Moderate failure
- Cardio
- more blood flow = faster healing
