Wound Healing and Treatment Flashcards
Role of physical therapy in wound healing and treatment
- debride and cleanse wounds
- minimize drainage to healing tissues
- promote healing of wounds
- restore function to tissue and surrounding tissues (unique to PTs)
3 factors affecting wound healing
- wound environment
- local factors
- systemic factors
4 components of wound environment
- temperature
- wound hydration
- tissue necrosis and foreign bodies
- infection
What is the ideal temperature for healing wounds?
- all wounds desire a warm, moist, environment
- ideal wound healing occurs above 30 degrees Celsius
- maintaining a normothermic wound environment of 37-38 degrees Celsius improve wound healing
what do dry wounds inhibit?
progression of the inflammatory phase
what can help add or retain moisture of the wound?
covering wounds and adding moisture via dressings or topical preparation
what do wound fluids have?
growth factors and enzymes important to healing
what can wet wounds do?
prohibit wound healing and lead to periwound maceration
Wound environment - Tissue Necrosis and Foreign Bodies
- epithelial migration can not occur over dry tissue
- necrosis provides food for bacterial microbes
- debris in the wound will also feed microbial colonies
Wound environment- Infection
- presence of microbes or colonization is normal as skill normally has the presence of some bacteria
- however, levels that raise too high will impair wound healing
- infection prolongs the inflammatory stage of healing
3 local factors of wound healing
- circulation
- sensation
- mechanical stress
Local Factors - Circulation
- Inadequate circulation increases the risk of infection
- blood needs to reach microcirculation
- issues with SNS
Local Factors - Sensation
- Impairs ability to identify signals of tissue damage
- can lead to continued trauma to the area
Local Factors- Mechanical Stress
Sheer and friction forces are linked with initiating and perpetuation skin breakdown
- Have to great pressure off a wound
- Major issue to address to assure a good healing environment
What are the 5 systemic factors of wound healing?
- Age
- Inadequate nutrition
- co-morbidities
- medications
- social behaviors
How can age affect wound healing?
- slowed immune response
- decreased cellular turnover
- epidermal and dermal atrophy (thinner skin cant handle sheer forces
- impaired pain perception
- increased probability of co-morbidities
How can inadequate nutrition affect wound healing?
- decreased cellular energy
- protein required for cellular repair and will affect all phases of healing
- changes in food intake will cause immediate changes in healing (ALL phases)
How do co-morbidities affect wound healing?
- diseases affecting tissue perfusion
- immunocompromised conditions
- Mobility issues
How do medications affect wound healing
- steroids can make the skin thinner
- NSAIDs –> thinning blood –> not great circulation
What social behaviors can negatively affect wound healing?
- alcohol use
- smoking (AT LEAST cut down)
Main purpose of debridement
- remove necrotic (non-viable) tissue
- a warm, moist environment is needed for epithelialization to occur and epithelial cells will not migrate across necrotic tissue
- debridement removes necrotic tissue, eschar, and slough
Other purposes of debridement
- decrease bioburden
- remove old cells
- decrease stimulation of inflammatory cell production
- remove callous and epiboly edges
- facilitate angiogenesis
- prepare wound bed skin equivalents/growth factors
- prepare wound bed for flap/graft
- determine depth of tissue destruction
4 Types of Debridement
- Mechanical
- Chemical/ Enzymatic
- Autolytic
- Sharps/ Surgical Debridement
Mechanical Debridement- Used for, advantages, disadvantags
- Used for: very superficial and scant slough, small, visual foreign debris (gravel, dirt, etc)
- Advantages: very easy to do and cheap
- Disadvantages: not very selective (can harm good tissue)
Mechanical Debridement Definition
- Removal of tissue with a rubbing force
- Can occur when removing dressings
- Non-selective
- Can be harmful to healthy or granulating tissue (don’t use around granulating tissue)
- Other conditions of the wound will tell you the aggressiveness to use
- Can add saline in the wound to add a little pressure
Chemical/ Enzymatic Definition
- Enzymes used to selectively remove dead tissue
- 3 types: Proteolytics, fibrinolytics, collagenases (only one used in US)
- Apply to wound only and must be kept moist
- Use scalpel to hatch open eschar and put collagenases in
- the bigger it is, the less likely we will do that
Chemical/ Enzymatic - Used for, advantages, disadvantages
- Used for: larger areas of necrosis, eschar
- Advantages: more selective than mechanical
- Disadvantages: very expensive, when it goes awry it can be very damaging, not a bunch to select from
Autolytic Definition
- Uses body’s own enzymes
- support by providing a moisture retentive dressing
- takes time (the bigger it is, the longer it takes)
Autolytic: used for, advantages, disadvantages
- Used for: most wounds at some point in healing
- Advantages: natural
- Disadvantages: slow, when we slow the process, microbiomes can get in and increase opportunity for infection
Sharps/Surgical Debridement Definition
- Removal of dead tissue via cutting away
- used when radial debridement is required
- performed by MD or therapist (surgical sharps is typically MD)
- Benefit by removing a large area at once and still be selective
- Typically used when there is a lot of necrotic tissue in there
Surgical/Sharps Debridement: Used for, advantages, disadvantages
- Used for: wounds with large amounts of necrotic tissue
- Advantages: most selective, large areas at once
- Disadvantages: surgical suite is expensive, can cause bleeding in the area (must be prepared)
Once debrided, how often are wounds cleansed?
as often as necessary
How can you promote healing?
- through coverage of the dermal defect
- prove a noise, clean environment
- apply the appropriate form of dressing
Things important for PTs to remember
- restore function to the tissue and surrounding structures
- one needs to be mindful of the normal process of tissue repair including returning the tissue to its normal function
- things such as tendon gliding and viscoelastic qualities need to be addressed
Types of Wound Management
- Whirlpool
- Pulsatile Levage
- Negative Pressure Wound Therapy
- Hyperbaric Oxygen
- MIST (non-contact ultrasound)
Physical and mechanical effects of whirlpool
- Softens eschar, loosens necrotic tissue
- Deodorizes and cleanses wound
- Soaking removes dressings
- Stimulates granulation tissue due to agitation
- Maceration of periwound area
Contraindications for Whirlpool
Venous insufficiency, DM, DVT, High fever, incontinence,
significant cardiac disease (including pts. with pacemakers and implanted defibrillators), dry gangrene, renal failure, severe phlebitis, compromised pulmonary status, unresponsiveness, lethargy, ostomies, severe contractures lending to poor positioning in whirlpools, casted extremities
Whirlpool precautions
Clean granulating wounds, epithelializing wounds, new skin grafts, venous wounds, and non-necrotic neuropathic ulcers
Whirlpool Additive: Providine-Iodine (betadine)
- Powerful antimicrobial –effective at decreasing wound
and water bacterial count - Only solutions especially prepared for whirlpools
should be used - Non-specific agent = non-selectively cytotoxic
Whirlpool Additives: Sodium Hypochlorite (bleach)
Results in the release of free chlorine which acts as an
effective antimicrobial agent
Some dilutions can be painful to patients and may
irritate non-involved tissue
Whirlpool Additives: Chloramine-T (Chlorazene)
Contains chlorine and a hydrogen nitrogen mix
Effective at decreasing colony counts in wounds
Less irritating and less cytotoxic than sodium
hypochlorite
Added to water prior to submersion
Whirlpool Additives: Dakin’s Solutions
Bactericidal agent used against streptococci and staph
Non-specific –will damage clean wound bed
– Has to be real real real bad bc its real toxic
Whirlpool Additives: Acetic Acid
- Removes Pathogens
- Does not enhance wound healing
What is Pulse Levage?
- occurs with concurrent suction (can also provide mechanical debridement)
- Continuous fluid flow with a handheld device to regulate irrigation pressure
- Suction creates a negative pressure at wound bed removing the irrigant (0.9% NS)
Objectives of Pulse Levage
Facilitates removal of debris and pathogens
Reduce bacteria and infection
Promote granulation and epithelialization
Negative pressure of suction stimulates granulation of clean wounds
Cleansing with gentle pressure for irrigation and debridement
Does pulse leverage have systemic effects?
no
local effects only
Benefits of pulse levage
Portable for PT
Periwound maceration avoided
Treatment of tunneling and undermining (at lower PSIs) (a go to but also a precaution)
May be used in some situations where systemic effects makes whirlpool contraindicated
Quick(efficient)
Less risk of cross contamination
Indications for pulse levage
- necrotic wounds
- tunneling and undermining in wounds
- more appropriate for venous insufficiency ulcers
Contraindications for pulse levage
- actively bleeding wounds
- clearly exposed arteries, nerves and deep connective tissue
Pulse Levage Precautions
Facial wounds, near major vessels, near cavity linings
(pericardium, peritoneal), tunneling and undermining, Bypass/graft sites, anastomosis, exposed tendon/nerve/bone, use with anticoagulant meds., infection control issues
Why do you have to be careful when using pulse levage on wounds with tunneling and undermining?
because you cant see what’s under there
Method for applying pulse levage
Irrigant is 1000-3000 mL of normal saline
One sterile unit is used at each session
Set up unit according to manufacturer’s instructions
Choose PSI: varies between 4-15 PSI
Apply to wound bed
How often should pulse levage be applied?
BID for severly infected wounds, typically QD and
may be QOD based on wound condition
What PSI should you use when applying pulse levage to wounds with tunneling and undermining?
4 ,5 ,6
Benefits of NPWT
Approximation of wound edges
Removes interstitial fluid and infections debris
Provides closed, moist environment for healing
Increased local tissue perfusion
Promotes granulation tissue formation
Reduce bacterial load
Decreased frequency of dressing changes
Can be used where bone and tendon etc. may be exposed
Indications for NPWT
Pressure ulcers
Chronic or acute wounds
Dehisced abdominal wounds
Neuropathic wounds
Traumatic wounds and burns
*Wounds with < 30% necrotic tissue
Contraindications for NPWT
Wounds with > 30% necrotic tissue
Malignancy in wound
Untreated osteomyelitis
Unexplored fistula
Necrotic tissue with eschar present
Directly over exposed vessels and organs
Ischemic wounds
Precautions for NPWT
Active bleeding, anticoagulants, exposed vessels and organs, bone fragments, fistulas, boney prominence, grafts
(20-30% necrotic tissue be very careful)
Method for NPWT
Cleans the wound
Apply vac dressing of choice: GranuFoam (black
polyurethane) improves granulation, or VersFoam (white
polyvinyl alcohol PVA) less aggressive and more comfortable than some black foams: ? gray (new on market)
Drape, Trac Pad, canisters to collect exudates
Attach to machine
Turn machine on and select parameters
——Pressure: 25-200 mmHG (typically 125 mm HG)
——Adjust pressure in 25 mm increments
——Mode: continuous vs. intermittent
Achieve seal
Frequency: Q48-72 hours, 24 hours if fear of irritation to new granular tissue
VAC runs continuously 24 hours, may be turned off for a
maximum of 2 hours
Wound must be off loaded to be affective
What is hyperbaric oxygen
Application of oxygen in pressurized chamber; patient breaths 100% pure O2 for 90-120 minutes BIW to TIW
Hyperbaric Oxygen Objectives
Increased Oxygen concentration gradient
May reduce bacterial load
Enhances angiogenesis, collagen synthesis, granulation tissue formation, epithelialization, wound contraction
May reduce edema
Hyperbaric Oxygen benefits
helps with treatment efficiency
Hyperbaric oxygen indications
Chronic wounds or slow healing wounds that reverse with
oxygen test, TCOM (transcutaneous oxygen monitoring)
<40psi(could also read mmHg 760-2300 mmHg depending on sea level)
hyperbaric oxygen contraindications
- DVT
- CHF
- COPD
- Pregnancy
- Severe Arterial Insufficiency
- Non-reversing hypoxia
Hyperbaric oxygen precautions
claustrophobia
What is MIST
saline mist delivered with an ultrasound applicator
MIST objectives
Soften necrotic tissue
Reduce bioburden
stimulate cell activity
MIST benefits
Painless application
Stimulates growth factor production
No cell death to viable tissue
No cross contamination of wound bed
indications of MIST
Chronic or slow healing wounds
MIST contraindications/precautions
Breast Implants
Over thoracic area if pacemaker is present
Over/near heart
Over low back during pregnancy
Over pregnant uterus
Over areas of malignancy
Epiphyseal plates
Laminectomies (if central nervous tissue exposed)
Joint cement
Some plastics in prothesis
Eyes
MIST methods
Frequency: 40kHz
Intensity: < 0.50 W/cm2
Rx frequency of visits: 3 X wk
Duration: 3-20 minutes based on wound size; > 30cm2 saline
bottle to be refilled every 5 min.
Transducer distance: 5-15 mm from wound bed
Modalities for wound healing
- electrical stimulation
- ultrasound
- UV light
- Infrared
Theory and rationale for electrical stimulation
Skin surface is negatively charged
Wound tissue is positively charged (sodium current)
Galvanotaxic Effect of E Stim
(1) Anode – attracts neutrophils and macrophages
(2) Cathode – attracts neutrophils (when infected or inflamed) and fibroblasts
What may inhibit Galvanotaxic Effect
dehydration, or non-conductive material in the wound
What does E-Sim mimic
body’s bioelectrical signal to promote healing
Does E Stimulation have an antibacterial effect?
Yes
Microamperage direct current vs. HVPC
Needs to be direct
What is the electric potential of acute, non-infected wounds
during the first 3-4 days it is positive and then becomes negative
electric potential of chronic wounds
Conflicting information – most current literature suggests initiating Rx with cathode and then switching to anode, or regularly switching polarity
Parameters for HVPC
Frequency = high
Pulse duration = 60=100 microseconds (bigger pulse = more recruitment)
Amplitude = sub-motor
Electrode placement = monopolar with active wound bed (can be on wound or surrounding)
When is ultrasound particularly effective?
during the inflammatory stage and early proliferation
stage if used at low intensities
Ultrasound during inflammatory phase
Evidence to suggest that ultrasound can increase the release of growth factors and stimulation of cells involved in early healing (mast cell, microphages…)
Accelerate the inflammatory process, not an anti-inflammatory agent
Ultrasound during proliferation phase
Proliferation phase is also accelerated lending to early
remodeling
Facilitates wound contraction by: increasing fibroblastic activity and indirectly increases macrophages through factors released
Ultrasound during remodeling phase
Mechanical properties of scar tissue are altered when exposed to US during the inflammatory and proliferation phases
Provide better environment for patterning of scar tissue
Effects of UV light
- bactericidal effect
- erythermal response
- Vitamin D production
bactericidal effect of UV light
may be due to interruption of DNA synthesis or RNA
Erythermal Response
Believed to stimulate wound healing by initiating the
inflammatory response
Vasodilatation and increase capillary permeability
Infrared
Superficial dry heating agent – effects of increased blood flow and capillary permeability major contributors to wound healing
Functions of wound dressings
- provide moist environment
- provide thermal insulation
- provide barrier to microorganisms
- protect exposed nerve endings, thus decreasing pain
Types of wound dressings
- Primary: direct contact with wound
- Secondary: provides protection, cushioning, & or absorption #1 can be used without #2, but #2 can’t be used without #1
**cannot use secondary if you do not have primary
Dressing categories
- gauze dressings
- impregnated gauze dressing
- film dressings
- foam dressings
- hydrocolloids
- alginates
- hydrogels
- composite dressing
- advanced wound managements products
- topical agents
Gauze Dressing description
Mesh cotton or synthetic fabric woven into various forms both in a sterile and non sterile format ; woven and non woven; available in sheets, packing strips
Gauze dressings function
cushions wound, maintains moist environment, most common, mechanical debridement, may leave lint
behind, may traumatize granulation, may macerate periwound, absorbs exudate
What is the go to dressing for infection and mild exudate
gauze
impregnated gauze description
mesh gauze dressings that have been impregnated with petrolatum, bismuth, zinc
impregnated gauze function
decreases trauma to wound bed, decreases pain
What patient population does dr conroy like to use impregnated gauze on?
diabetic population
Film dressing description
An acrylic hypoallergenic coated thin transparent polyurethane & polyethylene sheet that is semi-permeable to gas & impermeable to fluids & bacteria
film dressing function
conforms, maintains moist warm environment,
allows for wound inspection, protects from shearing and
friction, waterproof, semipermeable to vapor, moisture &
gas exchange, promotes autolysis, never use on heavily
exudative wounds; not recommended for infection,
tunneling or deep cavities (lets you see inside)
foam dressing description
polyurethane foam with hydrophilic wound side and hydrophobic outside; permeable to gas not bacteria
* Big bandaids
Function of foam dressings
Cushions wound, maintains moist warm
environment, moderate absorbency, high rate of vapor
exchange & moisture, good for hypergranulation tissue,
heavy exudate, never use on dry wounds, eschar, heavy
infection (a little more absorptive than gauze)
Hydrocolloids description
SINKORAMA
Combination of gel forming polymers
(hydrophilic colloidal particles) with adhesive compound
lamented onto flexible water-resistant outer layer; may be
occlusive or semi-occlusive with varying composition;
combines with the polymers to form a soft gel mass in the
wound
Function of Hydrocolloids
Maintains temperature, encourages autolysis,
No air exchange, Impermeable to urine, stool, bacteria,
moisture retentive, min-moderate absorbency, never use on primary surgical sites, heavy infection, heavy draining
wounds, periwound maceration, not recommended for
eschar and fragile skin; may cause odor
what is the go to for heavily draining wounds?
Alginates
Alginate descriptions
Calcium or potassium based; works by
reaction of product with the sodium in the wound; a
chemical ion exchange occurs creating a gel-like substance; derived from brown seaweed spun into various form, -the gel formed by the exudate and dressing coats and conforms to the wound evenly distributing the fluid providing a warm moist environment for healing; multiple forms in sheets, ropes, wafers
Alginates function
Supports cell migration, encourages autolysis,
Can absorb 20 times its weight in fluid, can be used with
infection, high absorbency, non adherent, never use on dry
eschar
Hydrogels description
Group of complex organic polymers with high water or glycerin content from 30-90%; Available in sheet or gel form
Hydrogels function
Encourages autolysis, reduces pain, Provides
moist environment, Softens eschar, minimal absorbency,
use with secondary dressing, never use on wet wounds,
periwound maceration; not recommended for infection
composite dressings description
combination of 2 or more physically distinct
products; multi-layer dressings consisting of inner non
adherent contact layer, absorptive middle layer, outer
semipermeable film layer. Usually collagen based
types of composite dressings
bovine- cow collagen
porcine - pig
equine - horse
ovine - sheep
multilayer compressive dressing (composite)
- two layers of absorptive
- two layers of compression (little bit of elasticity)
- go to for venous insufficient wounds
Advanced Wound Management - Growth Factors
growth promoting substances that enhance cell activity
Examples: Regranex
Advanced Wound Management - Biosynthetic Dressings
derived from natural tissues
Examples: Promogran, Oasis
Advanced Wound Management - Skin Substitutes
tissue engineered consisting of bilayered systems that mimic epidermis & dermis
Examples: Apligraf, Integra
Topical Agents
- Gentamicin
- Neosporin
- Silver Sulfate (good antimicrobial)
Review clinical decision making
