Modalities Flashcards
1
Q
Optimum environment for wound healing
A
- Conquer pain
- Warm
- Oxygenate
- Hydrate
2
Q
Modalities
A
- Whirlpool
- E-stim
- Negative pressure wound therapy
- Ultrasound
- Ultravoilet light
- Hyperbaric oxygen chamber
3
Q
Whirlpool
A
- Primary purpose is to deodorize, soak, loosen & soften adherent necrotic tissue
- Non-selective mechanical debridement
- Most effective for wounds covered loosely in adherent necrotic tissue or exudate
- Not effective at removing adherent necrotic or fibrinous tissue, but may soften necrotic tissue for another form of debridement
4
Q
Reasoning behind whirlpool exacerbation of venous HTN & slowing of venous ulcer healing
A
- Requires dependent positioning of the extremity, exacerbating edema
- Warm water encourages superficial vein dilation & increased edema
- Adds moisture to an already highly exudating wound
- Cross contamination of wounds
- Warm water facilitates bacterial growth
- Disrupts cellular migration
- Poor control of pressure from turbine
- Non-selective form of debridement gets rid of inflammatory cells
5
Q
Contraindications for whirlpool use
A
- Compromised CV or pulmonary function
- Acute phlebitis
- Renal failure
- Impaired cognitive status
- Dry gangrene
- Neuropathic feet
- Severe arterial insufficiency
- Already macerated tissue
- Incontinence (full-body tanks)
6
Q
Precautions for whirlpool use
A
- Clean, granulating wounds
- New skin grafts or flaps
- Venous insufficient wounds
- Distal extremity edema
- Sensory impairment
- Diabetic ulcers/callus (maceration)
7
Q
OSHA precautions for whirlpool
A
Fluid resistant gowns, hair covers, footwear covers, gloves & face-shield recommended
8
Q
Whirlpool forces >15 psi
A
May drive bacteria deeper into tissue
(Safe force between 4-15 psi)
9
Q
Whirlpool therapy protocol
A
- 5 to 20 min
- 1x daily
- 8-15 psi, keep wounds away from turbine
- Temp 98 degrees F (too high temp creates stress on CV & pulmonary systems, too low may result in vasoconstriction of limb)
10
Q
Electrical stimulation
A
Outside of skin: electronegative (epidermis)
Inside of skin: electropositive (dermis)
- Active ion transport: Na+ basal side Cl- apical side
11
Q
Current of injury
A
- There is a shift in polarity -> wound bed is positively charged
- Current flow occurs at edges of wound
12
Q
Don’t PANIC
A
Positive anode placed in wound bed to drive macrophages in
Negative is cathode placed over periwound area
13
Q
Inflammatory phase of healing and E-stim
A
Phagocytosis & autolysis -> macrophages move to DC (+) & neutrophils move to PC or DC (+)
14
Q
Proliferation phase of healing and E-stim
A
Fibroplasia -> fibroblast move to PC or DC (-) keratinocytes move to DC (-)
15
Q
Remodeling phase of healing and E-stim
A
Wound contraction & epithelialization -> myofibroblast move to PC (-) epidermal cells move to DC (-)
16
Q
E-stim electrode arrangement for direct or monopolar method
A
- Treatment electrode placed directly over wound
- Dispersive electrode placed on intact skin 2-15 cm from wound & is moved around like clock to get different dispersion of current flows
- Placed closer for shallow wounds, farther for deeper wounds
17
Q
E-stim electrode arrangement for indirect or bipolar method
A
- Treatment electrode placed on opposite sides of wound on intact skin 2-15 cm from wound
- Closer for shallow wounds, farther away from deeper wounds
- Dispersive electrode places on intact skin 20-30 cm away
18
Q
E-stim parameter settings
A
- HVPC
- 100-150 V to allow sensate pt to perceive a moderate tingling paresthesis (250-500 microcurrent/sec)
- Insensate pt, increase voltage until muscle contraction then decrease until fasciculation just disappears
- 100 ppm, 100 us duration
- 50-60 min duration
- 3-5 days per week
- same protocol for low voltage monophasic pulsed current (30 mA current, 128 pps)
19
Q
Negative polarity
A
Cathode on the wound as long as regular wound measurements progress 7-14 treatments
- Attracts keratinocytes, fibroblasts, myofibroblasts trying to jumpstart proliferative phase
20
Q
Positive polarity
A
When wound measurements indicate non-progressing wound 7-14 treatments
- Attracts macrophages & neutrophils to jump start inflammatory phase
21
Q
Start E-stim with…
A
Negative polarity (proliferative) -> positive polarity (inflammatory) -> negative polarity again if no healing occurs, maintain for 7-14 treatments
22
Q
Contraindications for E-stim
A
- Basil or squamous cell carcinoma
- Untreated osteomyelitis
- Placement of electrodes such that current flows through pericardial area
23
Q
Negative pressure wound therapy
A
- Open cell foam dressing in wound cavity & applying controlled sub-atmospheric pressure (125 mmHg) below ambient pressure -> pulls fluid into wound from periwound/surrounding tissue
- Negative pressure increases tension among adjacent cells -> alters cell shapes -> stimulating growth & division
24
Q
Mechanisms of action for NPWT
A
- Maintains moist wound environment (normothermic, humid wound environment & reduces passive vapor moisture loss)
- Increases vascular perfusion
- Edema reduction via reduction of cytotoxic compounds (proteases, cytokines, metalloproteases, and free-radicals)
- Tension/deformation of cells (decreased MMP levels)
- Decreases bacterial colonization (bioburden)
- Increases rate of granulation
- Enhances epithelial migration
- Increases flap survival
25
Indications for use of NPWT
- Stage III, IV pressure ulcers
- Diabetic ulcers
- Partial thickness burns (smaller)
- Dehisced incisions
- Mesh skin flaps, grafts, muscle flaps
26
NPWT protocol
- Debridement eschar & hardened slough
- Reduce bioburden through cleansing
- 2 foams: black - polyurethane (deep, burns, flaps) white (soft, superficial, tunneling)
- Cut foam to fit wound & count pads in wound for documentation (they will need to come out)
- Continuous pressure at 125 mmHg
- Ensure seal is airtight
- Dressing change 3x weekly
27
Contraindications for NPWT
1. Necrotic tissue
2. Untreated osteomyelitis
3. Malignancy in wound
4. Fistulas to organs or body cavities
5. Exposed blood vessels or nerves
6. Patients with bleeding disorders
- Precaution: active bleeding or anticoagulant use
28
Ultrasound for thermal effects
- High frequency (1-3 MHz)
- Raise temp up to depth of 5cm
3 MHz 1-2 cm deep warming
1 MHz allows deeper warming
29
US for debridement/bactericidal effect
- Lower frequency (20-40 KHz)
30
Coupling mediums for US
- Gel
- US along wound edges of wound (periwound area promoting blood flow)
- Noncontact immersion uses water 1 cm away from surface, good for small irregular body parts
31
Pain suppression & US
Pain threshold is increased, from heating or stimulation of pain fibers
32
Cavitation and US
Cavitation strength inversely proportional to Hz (greater with kHz)
- Thought to help with debridement of adherent fibrin, slough, biofilm
33
Acoustic micro streaming and US
- Ca++ influx, collagen synthesis, fibroblast proliferation
- May promote inflammatory response for movement into proliferative phase
34
US protocol for wound treatment
- Pulsed US at 20% duty cycle
- Measure wound depth to determine 1 or 3 MHz (use 3 for shallow wound 3 cm and 1 for deep wounds)
- Full thickness wound US on intact periwound skin only
- Partial thickness wound use sterile sheet hydrogel over wound and US over sheet
- 5 minute duration, 3x/week for 2 weeks
35
Indications for ultrasound use
- Chronic diabetic foot ulcers and pressure ulcers With absence of inflammatory phase
36
Contraindications and precautions for ultrasound use
- Pregnancy
- Malignancy
- Vascular abnormalities
- Thrombophlebitis
- Pacemaker
- Acute wound inflammation & fracture (already have an inflammatory phase, don’t need more)
37
Effects of UV radiation
- Induces inflammatory response
- Stimulates epithelialization
- Increases epidermal turnover
- Increases epidermal thickness stratum corneum (hyperplasia)
- Enhances granulation tissue formation
- Increases blood flow to wounds
- Latent erythema
- Bactericidal effects - highly effective at killing microorganisms
- Serum sterilization
- Surgical theater decontamination
- Some 99.99% kill rate in antibiotic resistant bacterial pathogens (MRSA)
38
Indications for UV radiation
- Slow or non-healing wounds (recalcitrant aka stalled wound)
- Necrotic wounds (penetrates through)
- Purulent, infected wounds (bactericidal)
39
Contraindications for UV radiation therapy
- Pulmonary tuberculosis
- Cardiac, liver, or renal disease, lupus
- Wound carcinoma
- Eczema, psoriasis
- Hyperthyroidism
- Severe diabetes
- Herpes simplex
40
UVC therapy protocol
- Remove dressings and clean wound bed
- Apply sunblock (SPF 30 or >) to periwound or drape
- Lamp placed 1 inch from wound surface
- Exposure time varies with infection (45-180 seconds) longer for more bacteria
- 1-2 times per day for 1 week
41
Hyperbaric oxygen therapy
- Under normal atmospheric pressure 0.3 volume percent of dissolved O2 in plasma
- Therapy can drive much higher
- Used for treatment of hypoxia wounds
- Pt breathes 100% O2 at greater than 1.4 atmospheric absolute (driving O2 into tissue)
- 90 min treatment at ATA results in increase O2 levels in muscle and subcutaneous tissue formation 3-4 hours after
42
Low level (cold) laser
- Laser interacts with chromophores (pigments) within cells
- Fibroblast, muscle satellite cell, immune cell proliferation, ATP synthesis and oxygen transfer (cell culture)
- Enhance granulation, wound closure, and fracture/tendon healing
- Positive effect for wound healing in humans
- 3x per week for 8 weeks, helium-neon laser, 60 J/cm^2 per treatment
