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DESCRIPTIONthis is presentation talks about basic & updated advanced wounds care,,,,,,,2nd presentation in my internship..i hope you will get benefit from it ......Dr/ Wadie Madi
Prepared & presented by: Dr :WADIE MADI
مادي: وديع د
General Surgery Department.Abosleem Trauma Hospital. UNIT C.
Classification of wounds
Types of wound
Skin: structure and function:
General Functions: Each skin layer has its own unique function:
Epidermis = protection
Dermis = nourishment of epidermis
Hypodermis = Composed mostly of adipose tissue insulation.
Skin: structure and functionSkin: structure and function:
Protects deeper tissues from: Mechanical damage ( bumps & cuts).
Chemical damage (acids & bases).
Thermal damage (heat & cold).
Ultraviolet radiation (sunlight).
A wound can be defined as: “A cut or break in the continuity of any tissue, caused by injury
Classification of Wounds:
Cuts,Abrasion,LacerationsContusionsPucntureSkin flaps and
Bitesbenbow ( 2005)
They passes through the normal healing process readily
Fail to pass through normal healing process
Any wound >3 months considered
Wound Types and Characteristics
CLOSED• Contusion ( Bruise) – Tissue injury without breaking of skin. Purple contusion 5x7 cm on left face(see figure)
• Hematoma – Tissue injury that disrupts a blood vessels; pooling of blood under the unbroken skin hematoma on left face (see figure)
•Sprain –twisting of a joint with partial rupture of its ligaments; causes swelling.
OPEND• Incision (Surgically) made
separation of tissues with clean, smooth edges.
(Approx.3-inch incision on R lower quadrant of abdomen well approximated clean and dry with sutures intact(see figure).
• Laceration – Traumatic separation of tissues with clean, smooth edges 2 in jagged (pointy, uneven) laceration app 4 cm deep on Lt sole foot.(see figure)
• Abrasion- Traumatic scraping away of surface layers of skin. (raw appearing abraded area diameter on lateral aspect of lower
• Puncture – Wound made by sharp, pointed object through skin or mucous membranes and underlying tissue, (Small circular entry wound on Rt palm from sharp pointing nail see figure)
OPEND: Penetrating- Variable -size open wound through skin and underlying tissues made by a bullet , metal or wood fragment may extend deeply into body Jagged Deep wound 10cm in
posterior on L leg(see figure).
• Avulsion – Tearing away of a structure or a part, such as a fingertip, accidentally or surgically.(Avulsion of L leg from Vent Aspect. Attach only by skin.)
OPEND: • Ulceration – Excavation of skin and/or underlying tissue from
injury or necrosis.
(Ulceration on L sole foot 4 cm x 5 x 2 cm deep. Yellow drainage present. Wound edges reddened) see figure below:
Wounds according to the depth:
Involves only the epidermis Injury is usually
result from fiction, shearing (cut) or burn.
Involves the epidermis and the dermis, Wounds heal more quickly.
Involves the epidermis, dermis, fat, fascia and exposes bone In order to heal, all dead tissue must be removed so that granulation tissue can gradually fill in the defect.
1-serous -clean, watery.
2-Purulent - thick, yellow, green, tan or brown.
3-Sanguineous - bright red, indicative of active bleeding.
4-Serosanguineous -pale, red, watery mixture of serous and sanguineous.
Types of wound drainage:
-All wounds heal following a a specific sequence of phases which may overlap.
-The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption.
-The phases are:1-Inflammatory phase
3-Remodeling or maturation phase
Exposure of plasma to injured site Release of Histamine
Inc bld Flow
Activation of Hageman Factor
Phases of wound Healing:
1-INFLAMMATORY PHASE:Starts immediately after injury and lasts 3-6 days or 4-6 days.
(2 major processes occur during this phase:
A-Hemostatic and B-phagocytosis
A- Haemostatic Tissue and capillaries are destroyed, plasma and blood leaks. Area blood vessels
constrict, platelets aggregates and bleeding stops, scabs ( rough protective crust) forms, preventing entry of infectious organisms.
B- Inflammation & Phagocytosis
Characterized by oedema, erythema, pain, temperature increase blood flow, to wound resulting localized redness and edema, attracts WBC and wound
growth factors. ( Wbc arrive-clear debris from wound).
2- PROLIFERATIVE PHASE
-extends from day 3 to about day 21 post injury.
-Macrophages continue to clear the wound debris, Stimulates Fibroblast to synthesize collagen 9 main ingredient For tissue scaring)
-(New capillary networks are formed).
3- REMODELLING OR MATURATION PHASE
-final healing stage may continue for I year or more.
-Remodelling of scar tissue to provide wound strength.
Cont..Phases of wound Healing:
Natural wound healing process
A B C
Haemostasis & Inflammatory
Types of wound healing:
1-first intention healing: partial thickness wounds.
-a clean incision is made with primary closure, minimal scarring.
-expected when the edges of clean surgical incisions are sutured together, tissue loss is minimal or absent if the wound is not contaminated with microorganism. e.g.-abrasion or skin tear.
2-second intention healing:-granulation.
-accompanies traumatic open wounds with tissues loss or wounds with a high microorganisms count.
-go through a process involving scar tissue formation a heal slowly because of the volume of tissue needed to fill the defect.
e.g.-contaminated surgical wound, pressure ulcer.
Note also there is:(Delayed primary healing If there is high infection
risk – patient is given antibiotics and closure is delayed for a few days e.g. Bites)
2-Blood glucose levels (impaired white cell function).3-Hydration (slows metabolism).
5-Lifestyle- enhances bld circulation.
6-Nutrition .7-Blood albumin levels (‘building blocks’ for repair, colloid
osmotic pressure - oedema).
8-Oxygen and vascular supply.
9-Medication- Corticosteroids (depress immune function).
Factors affecting wound healing:
A- Acute Wounds
-heal very easily.
-It passes phases of wound healing.
-Collagen building phase.
Aim of management:
-Healing without complications such as infection and disfiguring.
-(Wound care) includes:
2-Dry or wet to dry dressing to cover the wounds
3-Suturing if acute.
4-Bites -give Prophylaxis.
A- Acute Wounds:
> Uses of ABO in Acute wounds
Only indicated if contaminated or evidence of infection is demonstrated.
>Evidence of infection (local)
Note : (Acute wounds with abscesses if they are large need to be drained, Smaller once – can manage with antibiotics). Betadine*, Hydrogen Peroxide*, Saline, Spirit can be used to
cleanse the wound .
Healing of acute wound : -Wounds with minimal gaping – heals readily with scarring.
-Wounds with gaping or skin loss – heals with Scar tissue formation and retraction.
Q1- if there is no improvement ???
Q2-When Does a Wound Become Chronic?
(healthy individuals with no underlying factors an acute wound→ heal within three weeks remodelling → over the next year or so...)
NOTE: When wound does not follow the normal trajectory it may
become stuck in one of the stages and the wound becomes chronic.
B- Chronic wounds
Working Definition: wound lasting >3 months
Chronic wound – Fail to heal due to various local and systemic causes.
-Healing process arrests at different levels of healing.
-Wound may appear at different colours.
-Remains at same stage without progressing to wound healing.
-Often an underlying cause remains undetected.
Chronic woundsThe wound healing cascade impairs and arrests at different stages
Minutes Hours Days Weeks Months Years Time
Local and systemic factors that impede wound healing
• Local factors • Inadequate blood supply **
• Increased skin tension
• Poor surgical apposition
• Wound dehiscence
• Poor venous drainage **
• Presence of foreign body and foreign
• Continued presence of micro-organisms
& Infection **
• Excess local mobility, such as over a joint
• Systemic factors• Advancing age and general immobility **
• Obesity ***
• Malnutrition ***
• Deficiency of vitamins and trace elements ***
• Systemic malignancy and terminal illness Shock of any cause
• Chemotherapy and radiotherapy
• Immunosuppressant drugs, corticosteroids, anticoagulants
• Diabetes and CRF***
Chronic Wounds Appearance
approach has been criticised for being too simplistic as wound healing is a continuum and wounds often contain a mixture of tissue types.
Wound healing continuum
Wound Healing Continuum (Gray et al. 2005) havebeen developed. This tool incorporates intermediate colour combinationsbetween the four key colours
Common Chronic Wounds
Common Chronic Wounds
PressureDiabetic / NeuropathicArterialVenousSurgical
This staging system was developed by the NPUAP (National Pressure Ulcer Advisory Panel) and classifies only pressure ulcers based on anatomical depth of soft tissue damage.
Appears as defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, this ulcer may appear with persistent red, blue or purple hues.
If it doesn’t become pale with pressure aka blanch, this is considered a Stage I pressure ulcer.
Pressure on anterior tibialis tendon from compression wrap applied incorrectly
Stage 2-Partial thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.PinkPartialPainfulNo slough, eschar or undermining
Stage 3- Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to but not through, underlying fascia.
The ulcer presents clinically as deep crater with
or without undermining of adjacent tissue.
Stage 4Stage IV—Full thickness skin loss with extensive
destruction, tissue necrosis, or damage to muscle, bone or supporting structures (ie. Tendon, joint capsule)
Undermining and sinus tracts may be associated w/ stage IV ulcers
Can differentiate from stage III ulcers because it will go PAST the Fascia.
Stage 4Plantar heel:past subcutaneous level and goes to the calcaneous bone
Sacrum, eschar, past sub-cutaneos tendon exposed
Deep Tissue Injury
Purple or very dark areas that are surrounded by profound redness, edema, or induration suggest that deep tissue damage has already occurred and additional deep tissue loss may occur.
• The deepest level of tissue must be visible in order to stage a pressure wound.
Management of Pressure Ulcers
Offload Dress Protect
Group 1 Pressure Relief Group 1 mattress overlays preventative (Qualifications):1. Completely Immobile Or
2. Limited mobility
3. Any stage pressure ulcer on the trunk or pelvis.(plus 1 of the below)
4. Impaired nutritional status.
5. Fecal or urinary incontinence.
6. Altered sensory perception.
7. Compromised circulatory status.
Low Air Loss/Alternating Pressure Mattress
(Aggressive pressure ulcer treatment)Qualifications:
(1 large or multiple stage 3 or 4 pressure ulcer(s) on trunk or pelvis)
(Recent flap or skin graft for pressure ulcer).
Group 2 Pressure Relief
Diabetic foot ulcer
Etiology: Diabetic Facts:
Diabetic foot ulcer:
7th leading cause of death in the USA
16 million (6% of population) people in the USA have diabetes
Each year: 798,000 new cases of DM diagnosed
15% of all diabetics will develop diabetic foot ulcers
14-20% patients with DFU require amputation
Grade 1 Grade 2 Pre-ulcerative
callus, no open lesion
Superficial diabeticFoot ulcer
Penetrates to ligament tendon, bone, joint, fasciaNO Abscess, NO Osteo
Grade 3 Grade 4 Grade 5Deep UlcerWith Abscess/Osteoarthritis
Gangrene portion of Midfoot
Extensive Gangrene of wholeFoot. ONLY treatable with amputation
Corns and Calluses Nails: Thickened or Atrophic, Ingrown ,Color of nail bed,
Discharge, Fungal infections Edema: poor fitting shoes, impedes healing Pulses Color & temperature of feet HgbA1c Goal for HgbA1c of <7
Etiology: Treatment of DFU
Blood sugar CTRL
Manage Bacteria HBOT
)if criteria met(
Lower Extremity Ulcers
Intermittent claudication to sharp, unrelenting pain. Diminished or absent pulses. Pallor and coolness. Loss of hair. Tight shiny skin. Thickened nails.
Characteristics of Arterial Insufficiency
Characteristics of Arterial ULCER
Located in areas of pressure, tips of toes
Deep, may involve joint.
Usually circular in appearance.
Wound base pale to black.
Little, if any, edema
Pain Intermittent claudication – crampy pain associated
with activity. Rest Pain.
Pulses. Skin appearance. Skin temperature. Edema. Hair Growth on Toes. ABI’s, Waveforms.
ABI 0.9-1.30 Normal Study
ABI 0.8 - 0.9 moderate PVD ABI 0.5 - 0.8 claudication ABI < 0.5 critical ischemia
Always check ABI with LE ulcers
Ankle—Brachial Index (ABI)
Etiology: Treating Arterial ulcer
Pain ControlMoist Wound
ACE Inhibitors—(Lisinopril, Captopril, etc). (Vasodilators & Decrease Plaque Formation) Pletal (Cilostazol).(Relaxes smooth muscle & vasodilators.).
Achy, cramping pain Pulses present Hyperpigmentation of skin Lots of edema Inverted Champagne Leg
Lipodermatosclerosis—tissues become ´woody´ in texture and the leg narrows near the ankle
Venous Insufficiency Characteristic
Irregular Wound Edges.
Moderate to heavy exudate.
Partial to full thickness.
Venous Ulcer Characteristics
Elimination of Edema -Compression -Elevation.
Moist Wound Care.
Management of Venous Disease
Non-Healing Surgical Wounds
Surgical Wound Complication
Treatment of Surgical Wound
History & Assessment
Advanced wound care
Basic wound care
First…Listen to Your Patient…..
Surrounding skin :
colour, moisture ,
Signs of infection
Lab Work – CBC, HgbA1C, Albumin.
Vascular Testing - Doppler, Angiography, measures, Arteriogram.
Infection Assessment - X-ray, Bone Scan, Tissue Biopsy, MRI.
Physical Assessment – Vital Signs, Pain, Weight, Psychological, Community Resources.
In Addition to Wound Measurements…
Basic Wound Care
Assessment.Cleaning &Covering.Dressings.Debridement.ABO ?
Treating the Whole patient versus treating the Hole in the patient
DRESSINGS - material applied to wound with or without medication, to give protection and assist in healing.
(-what are the purposes?) Protect from contamination. Prevent trauma. Absorbs drainage. Debrides. Provides medication, moist healing environment, etc.
When picking out your dressings, remember the Cardinal Rule:
(Keep Moist tissue Moist and Dry tissue Dry!)
1-DRY TO DRY DRESSINGS
-used primarily for wounds closing by primary intention.
-offers good protection, absorption & provide pressure
-they adhere to the wound surface when drainage dries.
- when remove can cause pain and disruption of granulation tissue.
-What are the types of dressings?
2-WET TO DRY DRESSINGS
-used for untidy or infected wounds that must be debrided and closed by secondary intention.
how can it be done?
- gauze saturated with sterile saline or antimicrobial sol's. is packed into the wound, the wet dressing are then covered by dry dressings
(Q-when to changed?) (As-when it becomes dry.)
3-WET TO WET DRESSINGS
- used on clean open wounds or on granulating surfaces.
- provide a more physiologic environment (warmth moisture) which can enhance the local healing processes and assure greater patient comfort.
- surrounding tissues can become ulcerated .
) high risk for infection.(
Examples of methods used in dressing
Hydrogels are indicated for
management of pressure ulcers,
skin tears, surgical wounds, and
burns, including radiation
therapy burns. Because they
contain up to 95% water,
hydrogels cannot absorb much
exudate and should be reserved
for dry wounds or wounds with
minimal to moderate drainage.
-Because they are occlusive, hydrocolloid dressings do not allow
water, oxygen, or bacteria into the wound. This may help facilitate
angiogenesis and granulation. Hydrocolloids also cause the pH
of the wound surface to drop; the acidic environment can inhibit
Like hydrogels, hydrocolloids can help a clean wound to
granulate or epithelialize and encourage autolytic ( distruction of
cells by own enzymes) debridement in wounds with necrotic
tissue. However, because of their occlusive nature, hydrocolloids
cannot be used if the wound or surrounding skin is infected.
3-Alginate Dressings :Used in wounds with moderate to heavy drainage, the alginate forms a gel when it comes in contact with wound fluid. Capable of absorbing up to 20 times its weight in fluid, an alginate can be used in infected and noninfected wounds. Because an alginate is highly absorbent, it should not be used with dry wounds or wounds with minimal drainage; it could dehydrate the wound, delaying healing.
Indications: Highly exudative wound requiring a non-stick surface (e.g. venous stasis)
Highly absorbent (20 times weight) Non-adherent wound contact layer, hydrocellular
foam, waterproof outer layer. Allows for autolytic debridement and
Can be left in place for 72 to 96 hours.
Explain the procedure to the patient. Hand washing before and after the procedure. Clean from least contaminated to the most
contaminated area. Use separate cotton for each stroke. Start from the center going outward. Observe aseptic technique.
Sterile gloves Picking forcep Dressing forcep Bandage scissor Adhesive tapes Dry cotton balls Waste receptacle sterile gauze
Cotton balls with cleanser
Cotton balls with antiseptic
Normal Saline Solution (NSS)
C-Procedures: include(14 steps)
1-Check physician's order for specific wound care and medication instructions.
Helps to plan for proper type and amount of supplies needed.
2-Secure equipment and wash hands thoroughly.To save time and effort. Reduces transmission of pathogen
3- Assess the existing dressing Indicates types of dressing or applications to use.
4-Explain the procedure to the patient and instruct Pt not to touch wound area or sterile supplies.
Decreases anxiety and to gain cooperation. Sudden unexpected movement on Pt‘s part could result in contamination of wound and supplies.
5-Loosen and remove the dressing with the use of the dressing forcep.( If the dressing adheres to the wound, loosen it by moistening with sterile NSS).
Microorganism can be transferred by direct contact from dressing to hands. An intact scab is a body defense and can be damage if not handled gently.
6-Observe the dressing for the amount type, color and odor of the drainage.
Provides estimate of drainage amount and assessment of wound's condition.
7. Discard the soiled dressing in the waste receptacle. Reduces the transmission of microorganism.
8-Clean the wound aseptically using the dressing forcep from the center going outward in
circular motion with:A. Betadine cleanserB. Dry gauzeC. Betadine antiseptic solution(use each gauze for only one stroke)
9-Apply a new dressing by gently placing the gauze sponges at the wound center and moving progressively outward to the edges of the wound site.
Promotes proper absorption of drainage and protects wound from entrance of microorganism.
10. Secure the edges of the dressing to the patient’s skin with strips of adhesive tapes.
Ensures that dressing remains intact and covers wound.
11-Make the patient feel comfortable and tidy the unint. Promotes Pt's sense of well-being. Enhances comfort.
12-Do the aftercare of the equipment. Soak the dressing forceps in 5% lysol solution for 30
minutes, then wash them with soap and water, Rinse them then dry ,Send them for sterilization..
13. Wash hands(Prevent spread of microorganism).
14-Chart: site of wound, character of wound/ discharges, treatment given if any(e.g. ointment used) and reaction of patient.
For proper documentation and legal purposes.
Growth FactorsBioengineered Tissue.Curative Surgery.Cellular Tissue Products.Hyperbaric Medicine.
Advanced Wound Care
Indication: Diabetic foot ulcer Activates endothelial cells and fibroblasts Stimulates vascular proliferation, migration, new
blood vessel formation People who use 3 or more tubes of
REGRANEX® Gel may have an increased risk from cancer.
Can be very effective Have a new “360” program to help patients obtain
medication and monitor progress.
Oxidized Regenerated Cellulose (ORC)
Indicated in Stalled Wounds ORC inactivates MMPs and Elastace
-Silver Foam.-3 layer
4 WeekHas decreased more than half in wound surface area
withContinue same care
Measured for Compression
Cellular Tissue Products (CTP)
So many, so little time Apligraf Dermagraf Oasis Graft Jacket Primatrix Integra And so many more….
Day of application
2 Days post Application
4 weeks post initial App2 wks s/p 2nd Oasis Application
Cellular Tissue Products (CTP)
Hyperbaric Medicine (HBOT)
Hyperbaric Oxygen Therapy (HBOT) is breathing 100% oxygen while the entire body is pressurized to a point greater than sea level
What Is It?
This is usually 2to 2.4 absolute
atmospheres(the equivalent ofthe pressureexerted by a33-45
foot dive into sea water)
Multiplace Hyperbaric Chamber
Approved by FDA
UHMS Indications for HBOT
1-Air or Gas Embolism. 2-Carbon Monoxide Poisoning(Co Poisoning Complicated By Cyanide Poisoning).3-Clostridial Myositis and Myonecrosis (Gas Gangrene).4-Crush Injury, Compartment Syndrome and Other Acute Traumatic Ischemia.5-Decompression Sickness.6-Arterial Insufficiencies: Central Retinal Artery Occlusion. Enhancement of Healing In Selected Problem Wounds.7-Severe Anemia.8-Intracranial Abscess.9-Necrotizing Soft Tissue Infections.10 -Osteomyelitis (Refractory).11 -Delayed Radiation Injury (Soft Tissue and Bony Necrosis).12 -Compromised Grafts and Flaps.13 -Acute Thermal Burn Injury .
Adjunctive HBOT and Problem Wounds
HBOT is only one component of a comprehensive wound healing program.
Non-healing wounds are evaluated to determine underlying conditions which might interfere with healing.
More conservative measures should be tried first.
What We Will Cover Today?
Radionecrosis.Failing Graft/Flap.Gas Gangrene.Diabetic Foot Ulcer.Arterial Insufficiency.
Vascular Changes from Radiation: Edema . Medial thickening (progressively depletes the blood supply to
the irradiated tissue). Collagen deposition may also cause severe scarring and
further blood vessel obliteration, resulting in tissue hypoxia and necrosis.
Effects of Ionizing Radiation on the Cell: Rapid cell death with heavy doses. DNA Synthesis impaired, mitosis delayed.
Soft Tissue Radionecrosis
Radionecrosis from treatment for Cancer of Larynx 05/02/02
Same neck, 07/09/02after 40 hyperbaric treatments
Long-term survival of skin grafts and flaps depend on angiogenesis. When the wound bed does not have enough oxygen supplied the graft may partially fail. HBO2 can help by assisting in the preparation and salvage of skin grafts and compromised flaps.
Gas gangrene infection
Clostridium bacteria. High amounts of oxygen can inhibit the replication, migration, and production of endotoxin. Advantages of using HBOT as adjunct to for gas gangrene:
life-saving because exotoxin production is rapidly halted. limb and tissue-saving. preventing limb amputation that might otherwise be
Diabetic Foot Ulcer:
Wagner Grade 3. Used in conjunction with standard wound care, offloading. Improved results compared to routine wound care.
Left Lower Extremity Ulcer, before and after 40 treatments of HBOT
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References continued :
References continued :