Wound Care

Question 1

types of wounds

Answer 1

• Venous
• Arterial
• Surgical
• Pressure ulcers
• Diabetic foot ulcers

Question 2

Gauze

Answer 2

• •2x2’s, 4x4 pads
• •Kerlix-roll, no stretch
• •Conform-roll, has some stretch
• •Ace wraps really have no place in wound care
  
  • Ankle sprains only. Do NOT use them for extremity compression!
• •Indications:
  
  • –Exudating wounds
  • –Can be primary or secondary
  • –Sinus tracts, tunnels and cavities
  • –Cover dressing
  • –Debridement
  • –All wound types
  • –Infected wounds (with an antimicrobial-Kerlix AMD)
• •Characteristics:
  
  • –Absorbent
  • –Readily available
  • –Conformable, packing (incl. Nugauze)
  • –May be combined with topicals
  • –Mechanical debridement
  • –Porous, non-occlusive
  • –Antimicrobial types are available
• •Disadvantages:
  
  • –Can dry out wounds/evaporative
  • –Wicks in all directions
  • –Fibers shed
  • –Requires secondary
  • –Requires frequent changes
  • –Traumatic removal when adhered
  • –Poor temperature retention

Question 3

alginates

Answer 3

• •Indications:
  
  • –Exudating wounds (mod to heavy)
  • –Primary dressing
  • –Sinus tracts, tunnels (rope)
  • –Prevent periwound maceration
  • –Infected wounds (w/silver)
  • –Granular wounds
• •Characteristics:
  
  • –Highly absorbent
  • –Non-occlusive
  • –Wicks vertically/not horizontally
  • –Trauma free removal
  • –Generally, can leave in place up to a week
  • –Conformable (sheet, rope)
  • –Antimicrobial type available
• •Disadvantages:
  
  • –Requires a secondary dressing
  • –Dessicates minimally exudating wounds

Question 4

why use silver containing products

Answer 4

• •Affects: cell wall, membrane transport, RNA function, DNA synthesis, protein function, enzyme activity
• •Silver ions continuously delivered at a level that can kill bacteria
• •Non-cytotoxic to wound and host
• •Activated by moisture

Question 5

silver containing dressings (the most common ones)

Answer 5

• Acticoat, actisorb
• Aquacel Ag
• Gentell hydrogel Ag
• Maxsorb Extra Ag (sheets/ropes)
• Optiform Ag
• Silvercel
• SilvaSorb gel, sheet or cavity
• Tegaderm Ag Mesh

Question 6

Foam

Answer 6

• •Indications:
  
  • –Exudating wounds (min to mod)
  • –Primary or secondary
  • –Sinus tracts, tunnels, cavities
  • –Infected wounds (w/antimicrobial)
  • –Granular wounds
• •Characteristics
  
  • –Highly absorbent (thick ones)
  • –Non-occlusive (w/o film)
  • –Conformable
  • –Primary or secondary
  • –Antimicrobial type available
• •Disadvantages:
  
  • –Wicks in all directions
  • –Requires secondary
  • –Maceration over intact skin
  • –Less absorptive when compressed
  • –May adhere

Question 7

hydrofera blue

Answer 7

• •Gentian violet/methlyene blue foam
  
  • –Rehydrate w/NS
  • –Bacteriostatic (even MRSA and VRE)
  • –Highly absorptive
  • –Does not affect growth factor and enzymatic dressings

Question 8

Hydrocolloid

Answer 8

• •Indications:
  
  • –Exudating wounds (min)
  • –Primary dressing
  • –Sinus tracts, tunnels
  • –Supports autolytic debridement
  • –Granular or necrotic
  • –Pressure ulcers
  • –Protection from incontinence
• •Characteristics:
  
  • –Absorbent (thick)
  • –Occlusive; autolytic environment
  • –Promote moist environment
  • –Protect from external contamination
  • –Infrequent dressing changes
  • –Various thickness and shapes
• •Disadvantages:
  
  • –Periwound maceration
  • –Growth of anerobes
  • –Odor of solublized necrotic tissue
  • –Broth often mistaken for purulence

Question 9

hydrogel (amorphous and sheets)

Answer 9

• •Indications:
  
  • –Dry and exudating wounds (min)
  • –Primary dressing
  • –Sinus tracts, tunnels
  • –Supports autolytic debridement
  • –Most wound types (including radiation)
  • –Infected wounds (w/antimicrobial)
• •Indications:
  
  • –Soften eschar/necrotic tissue
  • –Hydrate wound bed
  • –Non-adherent
  • –Conformable (gel and sheets)
  • –Supports autolytic debridement
  • –Trauma/pain-free removal, sheets cool
• •Disadvantages:
  
  • –Periwound maceration
  • –Requires secondary
  • –Not for heavily draining wounds
  • –May need frequent changes

Question 10

Non-adherent dressings

Answer 10

• •Indications:
  
  • –Painful dressing changes
  • –Protect healthy tissue
• •Characteristics:
  
  • –Painless dressing changes
  • –Does not adhere
  • –Porous type reduces maceration
• •Disadvantages:
  
  • –Non-porous type may macerate
  • –Petrolatum type may macerate

Question 11

transparent film

Answer 11

• •Indications:
  
  • –Anchor IV sites
  • –Stage I pressure ulcers
  • –Reduce friction
  • –Donor site dressing for STSG (split thickness skin grafts)
• •Characteristics:
  
  • –Visualize tissue beneath dressing
  • –Very thin, comfortable
  • –Adhesive usually well tolerated
  • –Used to secure other dressings
• •Disadvantages:
  
  • –Non-absorbent
  • –Adhesive may tear fragile skin

Question 12

composite

Answer 12

• •Indications:
  
  • –Post-op wound coverage
  • –Non-to-slightly exudating wounds
  • –primary
• •Characteristics
  
  • –Convenience combining products
  • –Save time combining products
• •Disadvantages:
  
  • –Adhesive may tear skin
  • –May macerate tissue if Telfa present

Question 13

debridement

Answer 13

• Mechanical
• Sharp
• Enzymatic
• Ultrasonic
• Biologic (yes, maggots)
• Leave these alone: intact/stable heel eschar, poorly perfused tissue, dry gangrene

Question 14

a word about irrigating wounds

Answer 14

• •Optimal pressure is 8 psi
  
  • –Equivalent to a 35ml syringe with 19G needle or an angiocath*
• •Whirlpool is contraindicated in lower extremity wounds*
  
  • –Increases venous congestion in venous insufficiency
  • –May contribute to contamination
  • –Prolonged use can dry out wound bed

Question 15

enzymatic debridement

Answer 15

• •Santyl collagenase
  
  • –Looks like vaseline. Use nickel thickness, cover w/NS moistened gauze
    
    • •Use on necrotic tissue
    • •Daily dressing changes, cover with secondary dressing
      
      • –You can lightly score eschar with 11 blade and use Santyl to help debride. DO NOT use on intact/stable heel eschar
      • –DO NOT use with heavy metal ions: mercury, silver, or povidone iodine

Question 16

topical products

Answer 16

• •Iodosorb
• •Iodoform
• •Acetic acid
• •Dakins solution
• •Betadine
  
  • –Use if heavy bioburden, many abx sensitivities, local infection.
  • –Some are cytotoxic to healthy tissue

Question 17

advanced products

Answer 17

• • Bioengineered tissue constructs derived from human or animals, applied to partial or full thickness wounds that have failed standard good wound healing interventions for at least 4 weeks without a 50% reduction in size.
• •Extracellular matrix
  
  • –Ie Endoform, Oasis, Integra
  • –Made from submucosal small intestine-collagen network, or bovine tendon-collagen and glycosaminoglycan and silicone layer
  • –Good for wounds with viable tissue base but with delayed healing. Acts as a scaffold for host tissue remodeling
• •Extracellular matrix
  
  • –Don’t use if sensitivity to porcine or bovine products
  • –Must be undisturbed for several days (7 ideal)
  • –Needs moist environment–hydrogel
• •Dermal substitute
  
  • –Dermagraft
    
    • •?still in production?
    • •Supplied frozen, penile foreskin, contains fibroblasts, growth factors present in dermal cells
    • •Indications: same as dermal matrix
    • •Shelf life 6m in -75C freezer
    • •Only dermal layer
    • •Very expensive
• •Full thickness substitute
  
  • –Apligraf
    
    • •Same indications
    • •Contains fibroblasts and growth factors present in dermal layer (same as dermagraft)
    • •Chilled, shelf life 10 days
    • •Apply up to 2 treatments
    • •Leave in place for 1 week
    • •Very expensive
• •Human amniotic membrane
  
  • –Epifix
    
    • •Same indications
    • •Room temp on the shelf, long shelf life, cover with saline and hydrogel to keep moist, wound veil (steri in place) gauze.
    • •Leave in place for 7 days. May reapply 4 times
    • •Pricey, covered by medicare with decent reimbursement
• •Growth factor
  
  • –Regranex
    
    • •Same indications
    • •Ointment with platelet-derived growth factor
    • •Must be refrigerated
    • •Expensive
      
      • –Good for burns, if you can get it!

Question 18

skin substitutes

Answer 18

• •Autologous kerantinocyte sheets
• •Biobrane
• •Oasis
• •Alloderm
• •Integra (sites prone to contracture, coverage of tendons, bone, and surgical hardware)
• •Dermagraft

Question 19

epibole

Answer 19

–This is tissue which has rolled under at the edges and causes wound to think it’s healed, but it’s not

–Solution: sharp debridement of the edges, may need a scalpel, or may be able to just use a currette, or silver nitrate sticks

Question 20

hypergranulation tissue

Answer 20

• •Wounds are lazy. They want to close over a flat surface
• •Usually due to too much moisture
• •Treatment options-silver nitrate sticks, high density foam, antimicrobial dressings and or/surgical intervention

Question 21

exposed tendon

Answer 21

• Only sharply debride black necrotic tissue tangentially
• MUST keep it MOIST! Use plenty of hydrogel here!

Question 22

slough

Answer 22

• •Matrix of cells, fibrin, bacteria, cell debris, leukocytes and exudate
• •May be yellow, white, gray, beige tan and or green (pseudomonas?)
• •May be crusty, slimy, dry, rubbery, hard or soft
• •Fibrin slough-aka a thin layer of slough
• •Non-viable and needs to be debrided

Question 23

moist wound healing

Answer 23

• •Facilitates all 3 phases of wound healing2
• •Traps endogenous enzymes to facilitate autolytic debridement
• •Preserves endogenous growth factors
• •Reduces patient pain complaints
• •Results in more cosmetically appealing scar

Question 24

objectives of comprehensive wound management

Answer 24

• Granular wound bed
• Moist wound bed
• Warm wound environment
• Manage infection
• Eliminate dead space
• Healthy periwound and intact skin
• Manage tissue loads
• Control contributing factors
• Enhance patient’s ability to heal

Question 25

functions of wound dressings

Answer 25

• Create moist environment2
• Provide thermal insulation
• Hemostasis
• Control edema
• Eliminate dead space within wound bed

Question 26

wound care dressings

Answer 26

• The type of dressing chosen for a particular wound will often not be appropriate for the life of the wound.
• Match the dressing to the wound, not the wound to the dressing!
• The appropriate dressing supports the healing process. 2,23-26
• Wounds heal 3-5x faster and less painfully in a moist environment versus a dry one.2

Question 27

primary/secondary dressings

Answer 27

• Primary Dressing
  
  • •Direct contact with wound
  • •Band-Aid™
• Secondary Dressing
  
  • •Over primary dressing
  • •Can provide
    
    • –Protection
    • –Cushioning
    • –Absorption
    • –Occlusion

Question 28

wound healing decision tree

Answer 28

Question 29

moisture-retentive dressings

Answer 29

• •Maintain moist wound environment
  
  • –Occlusion: the ability of a dressing to transmit water, vapor, and bacteria
  • –Trap wound fluid
  • –Have low moisture vapor transmission rate
    
    • •Facilitate autolytic debridement
    • •Decrease pain
    • •Faster healing

Question 30

wound care dressings

Answer 30

• Dressings may be simply divided into those that absorb moisture, and those that retain or provide moisture to the wound environment.
  
  • •Absorb: gauze, calcium alginate, foam, hydrocolloid
  • •Retain: hydrocolloid, hydrogel, transparent films
  • •Other categories: enzymes, antimicrobials, non-adherents, extracellular matrices, biologic skin equivalents
• Although there are thousands of wound care dressings on the market, there are a few categories that we can group them into for our purposes. Generally, most dressings are meant to either absorb wound exudate, or retain it. There are other types of dressings with specific purposes that we will discuss also.

Question 31

gauze

Answer 31

• •Indications: Exudate absorption, primary or secondary cover dressing, sinus tracts/cavities
• •Advantages: Absorption, combine w/topicals, mechanical debridement, conformable, may be used as a primary or secondary dressing, inexpensive for short-time use
• •Disadvantages: wicks in all directions, evaporative, dries/adheres, sheds fibers, requires frequent changes, traumatic removal when dry, highly permeable/non-occlusive
• •Examples: gauze sponges/rolls/packing
• Gauze based dressings are the oldest form of wound dressing, and they primarily are intended to either absorb wound exudate, or act as a secondary dressing, or cover, over a primary dressing, such as an ointment.

Question 32

calcium alginate and hydrofiber

Answer 32

• •Indications: mod-heavy exudate absorption, primary dressing, sinus tracts/cavities (rope), prevent periwound maceration, infected wounds (w/silver), granular wounds
• •Advantages: highly absorbent (20x), wicks only vertically, trauma-free removal, infrequent dressing changes, conformable
• •Contraindications: requires secondary/cover dressing, desiccates minimally exuding wounds
• •Examples: Restore Calcium alginate sheets
• Calcium alginate dressings, whose ingredients are derived from sea weed, are designed to aggressively absorb exudate. Additionally, they do not allow wound exudate to weep beyond the wound margins, something gauze cannot do.

Question 33

foam

Answer 33

• Indications: moderate exudate absorption, primary or secondary dressing, sinus tracts/cavities, infected wounds (w/silver), granular wounds
• Advantages: moderately absorbent, non-occlusive, conformable, various thicknesses
• Contraindications: requires secondary/cover dressing, desiccates minimally exuding wounds, wicks in all directions, may adhere to tissue, less absorptive under compression
• Examples: COPA, Flexzan, Mepilex

Question 34

hydrocolloid

Answer 34

• •Indications: Autolytic debridement, exuding wounds (min), primary dressing, granular or necrotic tissue, pressure ulcers (incontinence), when occlusive dressing in needed
• •Advantages: Absorptive, occlusive, maintain moist environment, various thicknesses and shapes, infrequent dressing changes; also retains moisture
• •Contraindications: Periwound maceration, growth of anaerobes, odor w/solublized necrotic tissue, broth mistaken for purulence
• •Examples: Restore square, Restore Sacral
• Hydrocolloids are unique, in that they are 100% occlusive, meaning that there is no exchange of gases or any other transmission across the dressing. Initially the dressing absorb exudate, but then they allow a sort of “blister” to develop, insofar as the wound exudate cannot escape, and the wound is bathed in the exudate. If the patient has healthy wound fluid, full of endogenous enzymes, the enzymes will act to autolytically debride the wound tissue.

Question 35

hydrogel (amorphous and sheets)

Answer 35

• •Indications: Eschar/necrotic wounds, radiation burns, painful wounds, granulation tissue, lightly exuding - dry wounds
• •Advantages: retains moisture, soften eschar/necrotic tissue, soothing, non-adherent, hydrate wound bed, conformable, assists autolytic debridement, trauma-free removal
• •Disadvantages: periwound maceration, requires secondary dressing, not for heavily exuding wounds, minimal absorption, may need qd changes, not Third degree burns
• •Examples: Curafil gel, Sheets
• Hydrogels, whether in a sheet or amorphous form, will retain moisture within the wound environment. Hydrogel is simply a water-based polymer that keeps the tissues moist.

Question 36

hydrogel (honey-impregnated dressings)

Answer 36

• •Indications/Contraindications/Advantages similar to standard hydrogels
• •Leptospermum, also known as Manuka honey, is commercially available
• •Consider to control wound bioburden & odor

Question 37

transparent film

Answer 37

• •Indications: superficial wounds, Stage I PU’s, reduce friction, cover donor/IV sites, may be combined with Telfa
• •Advantages: visualize wound through dressing, very thin/conformable, adhesive, secure other dressings, retains moisture (minimally)
• •Disadvantages: non-absorbent w/o Telfa, adhesive may tear fragile skin
• •Examples: 3M Tegaderm, IV 2000
• Transparent films can retain a minimal amount of moisture. Used most often to protect skin from friction damage, or to hold IV needles in place.

Question 38

non-adherent

Answer 38

• •Indications: painful dressing changes, protect healthy/fragile tissue, allows exudate to pass through to secondary (porous type)
• •Advantages: painless dressing change, non-adherent to fragile tissue, porous types reduce maceration
• •Contraindications: non-porous/petrolatum types may contribute to maceration
• •Examples: Telfa, Adaptic, Xeroform, Wound Contact Layer (Profore kit), Nterface
• Non-adherent dressings act to prevent tissue trauma when dressings are removed. We commonly use non-adherents when we apply adhesive bandages (otherwise known as Band-Aids) to our small cuts and scrapes.

Question 39

composite

Answer 39

• •Indications: 2 or more wound dressing types are needed
• •Advantages: convenience of prepackaged products combined, some water resistant
• •Disadvantages: Adhesive border may tear fragile skin, may retain exudate
• •Examples: Tegaderm composite, Stratasorb, Band-Aid
• Composite dressings are simply dressings composed of more that one material. For example, a Band-Aid is a composite dressing, with it’s adhesive border and non-adherent pad.

Question 40

enzyme

Answer 40

• •Indications: necrotic/denatured collagen
• •Advantages: specific chemical debridement
• •Disadvantages: requires Rx, daily dressing change
• •Example: Santyl Collagenase ointment
• The enzyme category has but one product on the market in the US. The active ingredient is collagenase, an enzyme that naturally occurs in wound fluid in people that are fairly healthy. It can be applied exogenously as well. It is active only on denatured collagen, and does not interact with viable collagen.

Question 41

antimicrobials

Answer 41

• •Indications: Bioburden
• •Advantages: topical delivery of antimicrobial agent, broad spectrum activity, some cytotoxic only to pathogens
• •Disadvantages: sensitivity to active ingredient, may require Rx, non-specificity, relatively expensive, some cytotoxic to fibroblasts
• •Examples: Iodosorb, Iodoform, Kerlix AMD, Acetic Acid, Dakins solution, Betadine, Silver
• Antimicrobials are used to reduce bioburden at a wound site. There is a broad range of products, some of which are very cytotoxic, others that are gentle to healthy cells, but active against pathogens.

Question 42

skin sealants and moisture barriers

Answer 42

• •Protect skin (maceration or adhesives)
• •Skin sealants
  
  • –Wipe or spray
  • –For use on intact skin
  • –Make the skin tacky to provide a better edge seal
• •Moisture barriers
  
  • –Ointments or creams
  • –Prevents perineal rashes/skin breakdown
  • –Can apply to macerated skin

Question 43

mositurizers

Answer 43

• •Key component of basic skin care
• •Help restore barrier function of epidermis
• •Maintain/restore skin hydration
• •Avoid those with perfume or alcohol (possible skin reaction)
• •Apply to intact skin
• •Petrolatum may penetrate best
• •Ointments are more occlusive than creams or lotions

Question 44

tissue adhesives

Answer 44

• •Skin glues
• •Primary wound closure without staples or sutures
• •Use on acute linear wounds without tissue loss
• •Must protect wound from tension early on

Question 45

extracellular matrices

Answer 45

• Extracellular Matrix – acellular scaffolding composed of Collagen
• •Sheets, ropes, and pad dressings
• •Gel, paste, powder, or particles
• •Consider for nonhealing category/stage III or IV pressure ulcers
• •Partial - or full-thickness wounds
• •Contraindicated if sensitive to collagen
• MMP’s: Matrix metalloproteinases—enzymes which can break down proteins such as collagen. They need zinc or calcium atoms to work properly
• TIMP’s: tissue inhibitor of MMP

Question 46

the future of wound managment: living cells

Answer 46

• •Cytokines, interleukins, colony-stimulating factors
• •Growth-promoting substances that enhance cell size, proliferation, or activity
• •In humans, wounds treated with certain growth factors improved significantly more than wounds treated with a placebo
• •Limited to chronic wounds that are recalcitrant to traditional interventions
• •Extremely costly

Question 47

the future of wound management: biologic skin equivalents

Answer 47

• •No immune response
• •Indications:
  
  • –Nonhealing, uninfected partial- and full-thickness ulcers
  • –Burns
  • –Traumatic wounds
• •Used in highly specialized areas of wound care, such as wound and burn clinics
• •Cultured fibroblasts from human foreskin
• •Dermal and epidermal substitutes to produce collagen
• • Placental tissue grafts; amnion and chorion layers
  
  • –Cryopreserved or dehydrated placental tissue
  • –Cryopreserved umbilical cord