Modalities Flashcards
When should modalities be considered?
Chronic wounds
Wounds that fail to respond to standard care
Problems with Research to Support Adjunctive Interventions
Patient-related variables Wound-related variables Treatment-related variables Research-related problems Manufacturer-sponsored research
Modalities and Physical Agents
to Enhance Wound Healing
Wound irrigation Whirlpool Pulsed lavage Electrical stimulation Ultrasound Ultraviolet Diathermy Low-intensity laser Monochromatic infrared Negative pressure wound therapy Hyperbaric oxygen
Purposes of wound irrigation:
Removes loosely adhered debris, bacteria, exudate, residual topical agents
Facilitates debridement
Irrigation after whirpool:
removes 4x more bacteria than whirlpool alone
Indications for wound irrigation:
Standard component of treatment for all wound types (Our standard cleanser is Vashe)
Good for use in narrow tunneling wounds
Contraindications/Precautions for wound irrigation:
Wounds with active, profuse bleeding
Be careful with splash back
Method of wound irrigation:
35-mL syringe and a 19-gauge angiocatheter
Pressurized saline canister
Waterpik at lowest setting
Pressure of irrigation:
Irrigation pressure of 4–15 psi
Irrigant:
saline or tap water
Advantages of wound irrigation:
Simple Quick Inexpensive Effective Can use for wound in any location Can use in any setting
Disadvantages of wound irrigation:
Messy
May not use adequate amount of irrigant
Splash back
Purposes of whirpool:
Removes loosely adhered debris, bacteria, exudate, topical agents
Facilitates debridement by softening and loosening necrotic tissue
Promotes circulation
Decreases pain
Makes range of motion exercises easier
Helps remove adhered dressings
Indications of whirpool:
Infected wounds
Thick eschar or slough
Thick or heavy exudate
Pain management
Contraindications/ Precautions
of whirpool:
Clean, granulating, or epithelializing wounds (no evidence)
Active bleeding
Need to reduce temperature with arterial insufficiency ulcers due to difficulty with heat dispersion
Patients who are hydrophobic, confused, combative, with seizures
Dependent position may increase edema
May cause drying of surrounding skin
Impaired sensation
Temperature of non thermal whirpool
80-90 F
Temperature of neutral whirpool
92-96 F
Temperature of thermal whirpool:
96-104 F
Treatment time for whirpool
10-20 mins
Advantages of whirpool
Comfortable, pain control
Effectively removes debris
Warms tissue promoting perfusion of tissue
Disadvantages of whirpool:
Can’t calibrate irrigation pressure
Potential for maceration, edema, cross-contamination
Time intensive for setup and cleanup
Expensive
What are primary goals of whirpool if used on infected and necrotic wounds?
reduction of bioburden and removal of non-viable tissue are primary goals.
Evidence against whirpool:
Additives may be cytotoxic, however limited evidence shows proper concentrations are not significantly cytotoxic
Force from jets may be traumatic however limited evidence indicates less force than pulsavac
Pulsed Lavage
Removes dirt and foreign contaminants
Softens necrotic tissue
Removes toxic residuals from topical agent
Pressure of Pulsed Lavage:
4-15 PSI
What kind of debridement is pulsed lavage?
Nonspecific mechanical debridement
Concerns with pulsed lavage:
Aerosolization of contaminants, requires clean room
Protect granulation tissue
What is pulsed lavage with concurrent suction?
Delivery of irrigant under controlled pressure with handheld device
Applies negative pressure to wound bed
Benefits of pulsed lavage with concurrent suction?
Facilitates debridement
May enhance granulation tissue formation, epithelialization, and tissue perfusion
Indications of pulsed lavage:
Wounds requiring irrigation or debridement
Wounds with tunneling/ undermining
Contraindications/ Precautions
of pulsed lavage:
Exposed deep tissue, body cavities Facial wounds Recent surgical procedure Latex allergy/sensitivity Precaution: anticoagulants Precaution: deep tunnel, insensitivity
Method of pulsed lavage:
Irrigation pressure of 4–15 psi
Handheld device with tubing attached to irrigant reservoir and suction device/canister
1–3 liters of normal saline
Time: typically takes 15–30 minutes
Must do with pulsed lavage:
Wear appropriate PPE to protect from splash injury and aerosolization (all people in treatment room)
Room with four walls and a door, cover IV sites/open areas not being treated, wipe down all horizontal surfaces
Use surgical drape an PPE
Advantages of pulsed lavage:
Encourages thorough irrigation
Can use in any setting (requires clean room) and on wound in any location
Ergonomical
Disadvantages of pulsed lavage:
Messy More expensive than simple irrigation Not appropriate for large wounds Tips and some tubing designed for one-time use Aerosilization contaminates environment
Jet lavage:
Mist of saline delivered by pressurized oxygen
Gentle to wound
Rehydrates necrotic tissue and gently debrides
Electric Stimulation
Effective in treating wounds of all depths.
Effective in managing necrotic tissue, inflammation, & infection
Facilitates wound contraction and wound resurfacing.
Enhances lymphatic and venous drainage, blood flow
What does estim attract?
Attracts macrophages and neutrophils
Promotes epithelialization, wound contraction, ATP generation, and collagen synthesis
Negative pole (cathode) of estim:
Moves fluid from area, Dilates capillaries, Stimulates nerves, Retards microorganism growth (bactericidal), liquefies proteins, softens tissue, stimulates granulation, decreases edema, fibroblasts proliferate and make collagen, basic environment, promotes angiogenesis, attracts neutrophils when infection present, attracts fibroblasts
Postive pole (anode) of estim:
constricts capillaries, sedative to neurons, facilitates healing , attracts macrophages, neutrophils, and epidermal endothelial cells, acidic environment, coagulates protein, hardens tissue
Indications for estim:
Adjunct to healing for chronic or recalcitrant wounds that are clean or infected
CMMS: category III/IV that fail to respond after 30 days of standard care
Contraindications/precautions for estim:
General precautions for electrical stimulation
Untreated osteomyelitis
Not in combination with topical agents containing heavy metal ions
Precaution: sensory neuropathy
Advantages of estim:
Can use in any setting/ universally available
Does not cause pain (often reduces pain)
Extensive research supports use as adjunct to enhance wound healing
Disadvantages of estim:
Time consuming
Risk of contamination
Not appropriate for large wounds
Frequency for estim:
80-115 Hz
Intensity for estim:
75-200 V
Interpulse interval for estim:
50-100 microseconds
Active cathode:
infected, to reduce bioburden
Active anode:
promote granulation and epithelialization
Polarity change for estim:
every 3 days
Time for estim:
45-60 mins
How often to do estim?
3–7 day/wk for 30 min/day
Ultrasound during inflammatory phase:
stimulates release of growth factors from platelets, mast cells, and macrophages which are chemotactic to fibroblasts and endothelial cells. Accelerates inflammatory phase to speed proliferative phase. US is most effective when initiated in this phase
Ultrasound during proliferative phase:
stimulates fibrobast migration and proliferation. Also stimulates endothelial cells and angiogenisis. May also facilitate wound contraction
Ultrasound during epithiliazation phase:
stimulates release of growth factor necessary for regeneration of epithilial cells and promotes circulation
Ultrasound during remodeling:
improves scar extensibility if initiated in the inflammatory phase
Contraindications for ultrasound:
Infected wounds, osteomyelitis, DVT, Malignancy, Severe athersclerosis
Protocol for US for acute wounds:
initiate during the inflammatory phase to achieve benefit of increased tensile strength of scar by speeding proliferation. 1 minute/ cm2 with maximum of 15 minutes three times per week. .5 watts/ cm2 pulsed if impaired circulation.
Protocols for US chronic:
initiate as soon as possible. 1 minute/ cm2 with maximum of 15 minutes three times per week. Intensity .5-1 pulsed. Recommend initial treatment at 1.2 then decrease to lower range to stimulate inflammatory response. Can apply with hydro gel or film dressing and coupling gel or in a plastic basin of water. Limit to 14 treatments, improvement should be noticeable within 3-4 treatments
Benefits of US:
Collagen deposition Granulation tissue formation Angiogenesis Enhances wound contraction Improves scar pliability
Noncontact low-frequency ultrasound:
Debridement and decrease wound bioburden
Indications for US:
Adjunct for chronic or recalcitrant wounds
Contraindications/Precautions for US:
General precautions for ultrasound Untreated osteomyelitis Wounds with active profuse bleeding Severe arterial insufficiency Deep vein thrombosis
US Superficial
3.0 MHz
US Deep wound:
1.0 MHZ
US Pulsed:
0.5-1.0 W/cm2
Remodeling closed wound:
Continuous: ≤1.5 W/cm2
Time for US:
2–3 minutes per zone
How often for US?
2x/day or 3 day/wk
US mist
Mist created by US
Rehydrates necrotic tissue and gently debrides
May provide benefits of US for wound healing as well as debride
Low Frequency Contact US
Utilizes current with saline spray as coupling medium
Low frequency US is powerful enough to liquefy adipose tissue and disrupt biofilm
Advantages of US:
Can use in any setting Quick Less setup/cleanup time Does not hyperhydrate Does not require dependent positioning
Disadvantages of US:
Less research support
Not appropriate for large wounds
May be painful or difficult to perform
Risk of contamination
Ultraviolet C
Enhances cell proliferation
Promotes growth factor release
Stimulates granulation tissue formation
Promotes exfoliation enhancing healing through induction of erythematous response in the skin
What does Ultraviolet C facilitate healing in:
Venous or arterial insufficiency ulcers
Pressure ulcers
Neuropathic ulcers
Laser Therapy:
For seeping wounds that need drying,
Does not come in contact with the patient
Reduces pain and inflammation
Synthesis and repair of DNA and RNA
Increases collagen synthesis, organization/tensile strength, and maturation
Proliferates nerve growth and sprouting
Increases all portions of proliferative phase of healing
Releases/discharges lymphatic congestion
Diminishes scar tissue and adhesion formation
Increases ATP production
Monochromatic Infrared Energy
Delivers near-infrared energy at 890 nm wavelength to the skin by way of flexible diode pads
Purported to improve blood flow to treated area by up to 400%
Slight improvement in diabetic neuropathy
Negative Pressure Wound Therapy (NPWT)
Sub-atmospheric pressure (suction) applied to the wound via open celled foam sponge in the wound
Negative Pressure Wound Therapy (NPWT) Benefits:
Increases local blood flow, capillary filling, and lymphatic flow
May help approximate wound edges and facilitate contraction and closure
Currently, insufficient evidence that NPWT is superior to standard care
Beneficial heavily draining and cavernous wounds.
NPWT contraindications:
malignancy, untreated osteomyelitis, necrotic tissue with eschar present, and over exposed blood vessels or organs? ( special systems used for open abdomens)
NPWT precautions:
active bleeding, anticoagulants
Purpose of NPWT
Increases local blood flow Decreases wound/periwound edema Increases granulation tissue formation Increases angiogenesis Increases epithelialization Decreases wound bioburden Promotes cell proliferation Maintains moist, warm wound environment
Indications for NPWT:
Adjunct for chronic wounds
Postsurgical wounds and grafts
Wounds with exposed deep tissue or hardware
Traumatic wounds
Contraindications for NPWT:
Necrotic wounds Body cavity wounds Untreated osteomyelitis Exposed blood vessels Caution: patients on anticoagulants
Pressure for NPWT:
50-175 mmHg
Disadvantages of NPWT:
No standard for use Pain Noisy May hinder patient mobility Difficulty obtaining air-tight seal May cause skin damage Costly
Advantages of NPWT:
May cost less over time
Can use in any setting
Moist wound environment
Hyperbaric Oxygen
Primary mode of treatment for air or gas embolism, decompression sickness and CO2 sickness. Adjunctive therapy for radiation tissue damage, gas gangrene, compromised skin grafts, crush injury, compartment syndrome, acute traumatic ischemias, necrotizing soft tissue infections, refractory osteomyelitis, and problem non-healing wounds
Puposes/Effects of Hyperbaric Oxygen:
Increases oxygen concentration gradient
May reduce bacterial growth
May enhance angiogenesis, granulation tissue formation, epithelialization, and wound contraction
May reduce edema
Indications of Hyperbaric Oxygen:
Gas gangrene Peripheral ischemia Crush injury Wagner grade 3 or higher ulcer Progressive necrotizing fasciitis Osteomyelitis Osteoradionecrosis
Contraindications of Hyperbaric oxygen:
DVT CHF Claustrophobia Pregnancy Severe arterial insufficiency Noncomplicated wounds
Method of hyperbaric oxygen:
Patient in chamber breathing 100% oxygen at 1.5–2.5 ATM
Treatment time: 90–120 minutes
Treatment frequency: 2x/day–3x/wk
Treatment length: 10–60 sessions
When is wound unlikely to respond to HBO?
if 50% decrease in wound surface area not noted after 10 treatments
Advantages of HBO
TCOM test can help predict efficacy
May prevent limb loss
Disadvantages of HBO:
Extremely high cost
Extensive treatment time
Average patient requires 37–44 Rx costing $75,000
