Advanced Wound Care

8/10/2019 Advanced Wound Care

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University of Alexandria

Faculty of NursingDoctorate Program

2005-2006


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The Integumentary System

Te s!in is largest organ in te "ody# $t as many functions including %rotection&

containment and tem%erature control#

The two principle parts of the skin:

Dermis

'%idermis (outer layer) as five layers

*tratum corneum+ ardened& flattened dead cells ,ic are constantly "eing sed

*tratum lucidum+ denucleated cells "ut not com%letely ard

*tratum granulosum+ cells ave a distinct nucleus "ut cell mem"ranes are dying

*tratum s%inosum+ cells are living and mem"ranes are intact

*tratum germinativum+ %rimary site of mitosis in te s!in contains melanin#

The functions of all the structures contained within the dermis

specialized cells: fibroblasts:%roduce areolar tissue& collagen and

elastin damaged "y U. ligt#

Mast cells:%roduce istamine as an allergic

res%onse and e%arin& an anticoagulant#

Histiocytes+ also %roduce istamine

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Leucocytes:/ite "lood cells ,ic el% figt

infection and disease#

Nerve endings:Alert te "rain to eat& cold& %ressure and %ain#

Sweat glands:t,o !inds+ - eccrine+ excrete ,atery s,eat and control

"ody tem%erature#

-a%ocrine+ excrete mil!y fluid found in groin

and axilla#

Hair follicles+ travel troug te dermis and te e%idermis erector %ili muscles %ull

airs u%rigt to tra% eat and tus control "ody tem%erature#

Sebaceous glands+ connected ,it air follicles %roduce se"um& a fatty acid ,ic

lu"ricates air safts and el% to regulate te % of te s!in (%15#6-6#5)

Blood supply+ a system of "lood vessels including microsco%ic ca%illaries ,ic are

one cell tic!#

Lymphatic capillary+ ,or!s in conunction ,it te "lood su%%ly to collect excess fluid

and lea!ed %lasma %roteins from te cells and return te su"stances to te circulatory

system#

Papilla:*mall& conical %roections at te "ase of te air containing "lood vessels and

nerves ,ic su%%ly te air ,it nutrients#

WO!" H#$LI!%

Te entire ,ound ealing %rocess is a com%lex series of events tat "egins at te

moment of inury and can continue for monts to year# $t leads to restoration of tissue

continuity#

&hases of wound healing:

3# $nflammatory %ase#

2# Proliferative %ase#

4# aturation and emodeling %ase#

'( Inflammatory phase:

$nitial res%onse to tissue inury& it ta!es 3-7 or 5 days& it includes+

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a- Hemostasis:

$t is te %rocess of sto%%ing "leeding "y+

o 'xtravasations

o $nitiation of %latelet activities and "lood coagulation#

o .asoconstriction

o 8eucocytes

b- nflammation:

o elease of %rostaglandins and activated com%lement %roteins

o Attraction of neutro%ils and monocytes to te ,ound #

o Activation of neutro%ils

o onocytes undergo a %enoty%ic cange to te activated macro%age

)( &roliferati*e phase:

- $t is te gro,t or re%roduction of ne, connective tissue (granulation tissue)#

- $t starts after first stage and lasts a"out 4 ,ee!s (or longer)#

- Formation ne, ty%e of cell called fibroblast"y te macro%ages#

- Fi"ro"last %roduces a net,or! of collagensurrounding te neovasculture of te

,ound#

- 9ranulation tissue formation "eings after several days#

- During %roliferation& t,o oter %rocesses are ta!ing %lace simultaneously&

e%iteli:ation and contraction#

- '%iteli:ation ; resurfaces te ,ound "y regenerating of e%itelium#

- /ound retraction ; decrease te si:e of ,ound

+,Maturation and -emodeling phase:

- $s te final stage of ealing& ,ic "egins rougly 4 ,ee!s after inury#

- $s a %rocess of remodeling of te collagen fi"ers laid do,n during te %roliferation

%ase#

- During tis %ase& ty%e $$$ collagen& a soft gelatinous collagen& is gradually

re%laced ,it stronger& more igly organi:ed collagen#

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Modalities in wound care:

a. /on*entional or standard therapy:

ytotoxic to ealty cells and granulating tissues#

= 'ffervescent cleansing action el%s to lift de"ris from te ,ound surface ,en used at

full strengt# $f used full strengt& irrigation ,it normal saline after use is recommended#

= $neffective at !illing "acteria#

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= Do not use on ,ounds ,it sinus tracts#

Sodium Hypochlorite 1"akin Solution.:

= >ytotoxic to ealty cells and granulating tissues#

= ?actericidal effect against most organisms commonly found in o%en ,ounds#

= Fre@uently used in %ressure ulcers ,it necrotic tissue to el% control infection#

= ccasionally used over cancerous gro,ts to control "acteria and minimi:e odor#

=*ould not "e used for %eriods longer tan B-30 days#

2. Wound "ebridement

Types: a. $utolytic "ebridement:

"escription: Autolysis uses te "odyCs o,n en:ymes and moisture to re-ydrate& soften

and finally li@uefy ard escar and sloug#

2est ses+

$n stage $$$ or $. ,ounds ,it ligt to moderate exudates

b.#n3ymatic "ebridement:

4"escription+ >emical en:ymes are fast acting %roducts tat %roduce sloug of necrotic

tissue#

2est ses:

n any ,ound ,it a large amount of necrotic de"ris#

'scar formation

c.Mechanical "ebridement:

"escription+ Tis tecni@ue as "een used for decades in ,ound care# Allo,ing a

dressing to %roceed from moist to ,et& ten manually removing te dressing causes a form

of non-selective de"ridement#

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2est ses: /ounds ,it moderate amounts of necrotic de"ris

d.Surgical "ebridement:

"escription+-*ar% surgical de"ridement and laser de"ridement under anestesia are te

fastest metods of de"ridement#

-*urgical de"ridement can "e %erformed in te o%erating room or at "edside& de%ending

on te extent of te necrotic material#

2est ses:

/ounds ,it a large amount of necrotic tissue#

$n conunction ,it infected tissue#

/."ressing products:

'.$lginates

/haracteristics 5 6unctions:

Alginates are made of soft non-,oven fi"ers derived from sea,eed#

Tey are usually in te forms of %ads& ro%es or ri""ons#

Alginates a"sor" ,ound exudates and form a gel-li!e covering over te ,ound&

maintaining a moist ,ound environment#

2est ses:

-/ounds ,it moderate to eavy exudates#

$d*antages:

's%ecially useful for %ac!ing exudating ,ounds

Tey do not %ysically ini"it ,ound contraction as ,ould gau:e

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igly a"sor"ent

"isad*antages:

e@uires a secondary dressing

>an "e too drying if ,ound as a lo, volume of exudates

).6oam "ressings

/haracteristics 5 6unctions

Foams are igly a"sor"ent dressings generally made from ydro%ilic

%olyuretane foam#

Tere are various a"sor%tion rates of te different foams on te mar!et# *ome ave

adesive ta%es surrounding an CislandC of foam#

igly a"sor"ent foams may allo, te caregiver to cange dressings less

fre@uently# Foams tat a"sor" exudates and !ee% it off te ,ound ,ill decrease

maceration to te surrounding tissue#

2est ses

For eavily exudating ,ounds - es%ecially during te inflammatory %ase follo,ing

de"ridement and deslouging& ,en drainage is at its %ea!

Dee% cavity ,ounds - as %ac!ing to %revent %remature closure ,ile a"sor"ing

exudates and maintaining a moist environment#

/ee%ing ulcers& suc as venous stasis#

$d*antages

.ery a"sor"ent& can fre@uently "e left undistur"ed for 4 - 7 days#

>omforta"le and conforma"le


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"isad*antages

>an cause a drying effect on te ,ound if tere is too little drainage

+./ollagen

>ollagen is a natural "iomaterial tat as uni@ue %ro%erties and as "een used for

ealt care since te ancient 'gy%tian civili:ation# $t is te most a"undant %rotein

found in te "ody#

>ollagen %lays an integral %art during eac %ase of ,ound ealing and is an

excellent omeostatic agent# $t a"sor"s 70 - 60 times its ,eigt in fluid#

Te most a"undant and ,ell caracteri:ed collagen is ty%e 3 extracted from "ovine

(co,) ide# ter sources include %orcine (%ig)& cic!en tendon& "ovine tendon& etc#

/en a%%lied to a ,ound& collagen initially acts as a aemostatic agent# >ontinued

a%%lication seems to aid and asten te "odyCs o,n re%air mecanisms#

Products !vailable "#edifil$ S%in &emp'(

7.#n3ymatic "ebriding $gents

'n:ymatic de"riding is relatively selective in removing te necrotic tissue#

?y loosening te necrotic de"ris& surgical de"ridement may "e avoided#

'n:ymatic de"riding agents act on any one or all of tese materials+ collagen&

%rotein& fi"rin& elastin and E or nucleo%roteins# >ec! ,it eac %roduct as to its

metod of action#

Tunneling ulcers are %articularly suita"le for tese %roducts as tey remove de"ris

,ic may "e difficult to visuali:e and E or reac#

All re@uire a %rescri%tion

Products !vailable: "!ccuzyme$Panafi'

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8.Hydrocolloid "ressings


ydrocolloids are occlusive and adesive ,afer dressings ,ic com"ine a"sor"ent

colloidal materials ,it adesive elastomers to manage ligt to moderate amounts

of ,ound exudates#

ost ydrocolloids react ,it ,ound exudates to form a gel-li!e covering ,ic

%rotects te ,ound "ed and maintains a moist ,ound environment#

ydrocolloid %o,ders and %astes are also availa"le ,it increased a"sor%tive

ca%acity

2est ses

9ranulating and e%iteliali:ing ,ounds tat are draining lo, to moderate amounts

of exudates#

ydrocolloid seets el% %romote autolytic de"ridement "y !ee%ing ,oundexudates in contact ,it necrotic tissue (sloug G escar)#

$d*antages

>onforma"le for easy a%%lication and el% reduce %ain at te ,ound site

"isad*antages

oderate to eavily exudating ,ounds may over,elm te ydrocolloid dressing&

usually ,itin a fe, days

?rea! do,n of te %roduct may %roduce a residue of varying colors and %ossi"le

foul odor# Tis sould not "e confused ,it an infectious %rocess#

Products !vailable: "&egasorb'.

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9.Hydrogels "ressings


/ound gels are excellent for el%ing to create or maintain a moist environment

some ydrogels %rovide a"sor%tion& deslouging and de"riding ca%acities to

necrotic and fi"rotic tissue#

ydrogel seetsare cross-lin!ed %olymer gels in seet form# *ome are availa"le

,it an adesive "order

2est ses

el%s %rovide and maintain a moist ,ound environment

?y increasing moisture content& ydrogels ave te a"ility to el% cleans and

de"ride necrotic tissue

For ,ounds ,it minimal or no exudates

$d*antages

'ffective in ydrating ,ound surfaces and li@uefying necrotic tissue on te ,ound

surface

Non-aderent and can "e removed ,itout trauma to te ,ound "ed

H*ootingH effect %romotes %atient acce%tance

"isad*antages

Not too a"sor%tive& terefore& ydrogels or ydrogel seets may not "e an

a%%ro%riate coice for moderate to igly exudating ,ounds

e@uiresecondary dressings

Products !vailable "&egagel$ !merigelt &opical )intment'(

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b. $dunct wound care products 1!ew, Old therapeutic

modalities.:

I.Wound ;($(/(TM ' 1;acuum $ssisted /losure.

/ound care o%tions tat are effective include te /ound .acuum Assisted >losure#

Using su"-atmos%eric %ressure tat can "e constantly a%%lied to ,ounds in a continuous

or intermittent fasion& ,ound ealing is often %romoted and facilitated# A ,ide range of

,ounds may "e treated and tis usually increases %atient comfort and ,ell-"eing&

decreases overall cost and mor"idity of te ,ound and decreases os%itali:ation#

Indications:

Acute ,ounds

Traumatic ,ounds

*u"-acute ,ounds (i#e# deisced incisions)

Pressure ulcers

>ronic o%en ,ounds

esed s!in grafts

Fla%s

/ontraindications

Fistulas to organs or "ody cavities

Untreated osteomyelitis

>ancer in ,ound margins

Presence of necrotic tissue

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ver ex%osed arteries& veins& nerves& visceral or similar organs# in tese areas#

UN$.'*A8 P'>AUT$N* A' U*'D AT D'**$N9 >AN9'*#

/are and Safety Tips-$t is recommended tat te .#A#># device not "e turned off

from %atient use for more tan 2 ours %er day# /en te .#A#># suction device is turned

off& te .#A#># dressing sould "e removed from te %atient#

-Al,ays use sterile dressings %ac!aged "y I>$ for .#A#># use# $ns%ect ,ound at eac

dressing cange and ,atc for signs of deterioration and infection# *igns of infection

include "ut are not limited to fever& redness& s,elling& itcing& ras& discarge& ,armt&

odor#

-Dressings may adere to te ,ound and may ave to "e moistened ,it saline first#

Ada%ticT may "e %laced "et,een te ,ound and te s%onge to decrease aderence& but be

careful to remove it at dressing changeas it may get "uried in te a"undant granulation

tissue tat forms#

-$f used on infected ,ounds& dressings sould "e canged every 32-27 ours and te

.#A#># use sould "e guided"y a %ysician ,o is o"serving te ,ound at fre@uentintervals#

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&roduct Specifications and se

-.#A#># is availa"le in %orta"le& "attery %o,ered& and larger ,all %lug-in versions# Tey

are often& "ut not necessarily& intercangea"le#

-Te "asic set u% consists of a vacuum %um%& collection canister& connecting tu"ing and

dressing sets# Te dressing set consists of one of availa"le s%onges& %lastic seal dressing

and tu"ing to incor%orate in continuity ,it te s%onge#

->urrent foam dressings are "lac! %olyuretane and ,ite %oly vinyl


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1Wound after debridement.(

/ound .#A#># ,as a%%lied in te o%erating room at te end of te surgery# A "lac! large

%ore s%onge ,as trimmed ,it scissors to fit te ,ound ,itout forci"ly com%ressing te

s%onge to get it in# *mit and Ne%e, *!in Pre%J ,as %laced around te s!in edges and

allo,ed to dry#

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1Wound with sponge inserted and Skin &rep< applied around the edges.(

Te clear adesive dressing from te .#A#># dressing !it ,as trimmed to cover te ,ound

,it am%le (B-32cm) overla% of te s!in to %rovide a lasting seal# Te clear dressing ,asa%%lied to te s%onge (,it an incor%orated tu"ing connecter in contact ,it te s%onge)

and carried out over te s!in# $t ,as a%%lied as a covering and so as not to com%ress te

s%onge or %lace tension on te s!in#

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1;($(/( dressing applied.(

Te dressing and s%onge are connected to te vacuum %um% "y tu"ing tat connects

troug te dis%osa"le drainage canister on te %um%#

$n tis case& a %orta"le unit ,as used and te %atient ,as discarged to ome care# After 32

days a"out 60K of te ,ound ad granulated in#

1&ortable= battery powered ;($(/( connected to the wound.(

3B
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1!ote that after only se*en days= the abo*e wound by actual measurement

is >?@ filled in by granulation tissue.(

1&ortable ;($(/(( Supplied in a portable case and consisting of a fannypack to carry the apparatus around while connected= batteries= canister(

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http://woundhealer.com/VacWeb1/portvac.htm


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1Larger ;($(/( is shown here( This one reAuires an electric outlet(

"ifferent tubing= canisters and slightly different adhesi*e dressing are

used.(

).Warm B p therapy system

$s a tem%orary tera%y tat increases te tem%erature of te ,ound "ed#

Indications:

-Acute or cronic ,ound

-Full or %artial tic!ness

)ne e*ample of warmth therapy---+#oist Heat Pac%s+

oist eat %ac!s are te most common metod of eating te tissues#

Tese %ac!s vary in si:e from 6 "y in# to tose tat ,ill cover a large

%ortion of te "ac!# Tey also come in s%ecific sa%es and si:es to fit

te nec!& soulder& and oter irregularly sa%ed areas#

Indications:

-Decrease %ain& muscle s%asm& cronic edema

-$ncrease soft tissue mo"ility#

-%rior to oter treatment suc as oint mo"ili:ation& massage& range of motion exercises#

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Its idea: Te %ac!s are filled ,it finely ground sand and are stored in a unit tat eats

tem to a%%roximately 360L F# ?ecause tey are so ot& your caregiver ,ill %lace te %ac!

inside of a terry clot cover andEor cover te %ac! ,it to,eling# /en te moist eat

%ac! is %laced on your s!in& it sould comforta"le ,arm& "ut not so ot to "urn te s!in#

Mour clinician ,ill cec! "ac! ,it you regularly to ma!e sure tat te tem%erature does

not "ecome too great# $f at any time you feel tat you are "eing "urned& remove te ot

%ac! and summons assistance# oist eat treatments are usually a%%lied for 20 to 40

minutes#

/ontraindications:

Tird degree "urn-

+. Hydrotherapy:

,arm ,hirlpool

ts idea:-

/irl%ools use a system of air ets and ,ater %um%s to

circulate ,ater and %roduce air "u""les to massage and

relax te treated area#

Benefits: -*oftens tissue

-emove de"ris

-$m%roves "lood flo,

ndications -8arge surface area

-/ounds ,it toug& "lac! escar#

-Painful ,ounds#

ontraindication:infection& edema& "o,el or "ladder incontinence

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-/arm ,irl%ools are normally used ,it a tem%erature range of 300L F to 330L F# $f only

te extremities are "eing treated ,armer tem%eratures are used if te entire "ody (or

larger %ercentage of te "ody is immersed) a cooler tem%erature is used# *ince te "ody

floats in ,ater& ,irl%ools are an ideal environment to %ractice range of motion exercises#

/arm ,irl%ool treatments last "et,een 35 to 40 minutes#

71Therapeutic light:

.-/ltaviolet"/0'

ndications: - cronic& slo, ealing ,ound

-$nfected ,ound

-Necrotic ,ound

Contraindications: Pulmonary T#?& cardiac& renal& e%atic diseases#

1-laser therapy:

ndications:

-*lo, ealing ,ounds

-Nerve regeneration

-Pain relief

ontraindications: include treatment over:

Te eye& a emorrage& a malignancy& a

%regnant ,omanCs uterus& %otosensitive s!in#

81Lar*al therapy 1Maggot therapy.

-Tera%eutic maggots used most commonly

today are tose of te green"ottle fly (Lucilia

sericata)& a facultative %arasite tat& in umans&

only attac!s necrotic tissue#

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-Te maggots atc from eggs laid "y mature adult flies# Tese initial maggots (first

instars) gro, from 3-2mm to -30mm& moulting t,ice to "ecome tird instars some five

days later# Tey ten %u%ate in a dry location and undergo metamor%osis to adult flies

after a furter ,ee!#

-Tey can only "e used in ,ound de"ridement during te maggot stages& ,en tey are

inca%a"le of re%roduction metamor%osis to adult flies only occurs outside te

recommended time limits for teir clinical a%%lication#

Method of applications+

-A%%lication of to%ical silver sul%adia:ine (Flama:ine) to soften te escar#

-For maggots to function o%timally tey re@uire a moist environment saline soa!s ,ere

terefore a%%lied for 7 ours to moisten te ,ound and remove excess silver

sul%adia:ine %rior to a%%lication of maggots#

-Tree "atces of 8arvae ' ,ere a%%lied to te ,ound& eac remaining in-situfor tree

days#

# aggots constitute a living "iological dressing& ,ic acts in a num"er of ,ays#

2enefits:- aggot secretions a%%ear to am%lify te ealing effects of ost e%idermal

gro,t factor and $8-6 in addition to teir aemostatic %ro%erties

-*ecretions include allantoin and urea (antimicro"ial activity)& calcium car"onate

(stimulation of %agocytosis)& and %roteolytic en:ymes (slougEnecrotic tissue

"rea!do,n)# Te resultant en:ymatic degradation %roducts are su"se@uently ingested and

digested "y te maggots#

-$ni"it and destroy a ,ide range of %atogenic "acteria including Staphylococcus aureus&

grou% A and ? stre%tococci& 9ram %ositive& aero"ic and anaero"ic strains

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-icromassage of te ,ound "y maggot movement is tougt to stimulate te formation

of granulation tissue and ,ound exudates "y te ost

# Te net effects of maggot tera%y are accelerated de"ridement of sloug and necrosis and

a reduction in te "acterial load of te ,ound& leading to earlier ealing& reduced ,ound

odor and less %ain#

!(2: nce a%%lied& maggots remain local to te ,ound and ave no systemic adverse

effects# Tey rely on air for res%iration and act in te a"sence of good "lood su%%ly#

Tis ma!es maggots %articularly useful in ,ounds ,ic are oter,ise unsuited for

surgical treatment#

/ontraindications+

active emorrage

excess ,ound exudates

,ounds in "ody cavities or in close %roximity to large vessels#

91Hyperbaric o0ygen

ntroduction:

y%er"aric medicine is an acce%ted medical %ractice for te treatment of numerous

%ysical and neurological inuries and dysfunctions#

Hy%erH is sim%ly an increase& ,ile H"aricH refers to te %ressure# y%er"aric is te

increase of atmos%eric %ressure around te "ody#

"efinition: $s a medical treatment tat uses te administration of 300 %ercent oxygen

at a controlled %ressure (greater tan sea level) for a %rescri"ed amount of time-usually 60

to 0 minutes# $t el%s te "ody eal itself "y ma!ing oxygen availa"le to "ody tissues& or

organs& ,ic are not receiving an ade@uate su%%ly "ecause of illness or trauma#

Physiological Basis:

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-/en ,e normally "reate air (,it 23K 2) at sea level %ressure& most tissue needs of

xygen are met from te xygen com"ined to "& ,ic is 5 K saturated# 300 ml "lood

carries 3 ml 2 com"ined ,it " and 0#42 ml dissolved in %lasma# At tis same

%ressure if 300K 2 is ins%ired& 2 com"ined ,it " increases to a maximum of 20 ml

and tat dissolved in %lasma to 2#0 ml#

-Te iger %ressure during y%er"aric oxygen treatment %uses more oxygen into

solution#

-Te amount of 2 dissolved in %lasma increases to 7#7 mlEdl at a %ressure of 2 ATA and

to 6# mlEdl at 4 ATA#

-Tis additional 2 in solution is almost

sufficient to meet tissue needs ,itout

contri"ution from 2 "ound to emoglo"in

and is res%onsi"le for most of te "eneficial

effects of tis tera%y#

#echanisms of action:

-Te air ,e normally "reate contains

a"out 23K oxygen& ,ic is carried

trougout our "odies "y red "lood cells in

"lood#

-During ?T& te 300K oxygen ,e "reate& com"ined ,it iger %ressure& delivers

u% to 35 times te oxygen content to all "ody fluids& including %lasma& cere"ros%inal

fluid surrounding te "rain and s%inal cord& lym%& and intracellular fluids#-Tis allo,s oxygen levels to increase even in areas ,it "loc!ed or com%romised

"lood su%%ly as a result of inury or illness& as ,ell as in areas of tissue damage#

$ncreasing tissue oxygen levels %roduces several im%ortant long-term tera%eutic

"enefits including enanced gro,t of ne, "lood vessels &increased a"ility of ,ite

"lood cells to destroy "acteria and remove toxins# $ncreased gro,t of fi"ro"lasts #(

#ethod of !dministration:#onoplace chamber

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Accommodate one %atient and are %ressuri:ed ,it 300K oxygen tat te %atient

"reates directly#

2ualplace chambers

Accommodate t,o %atients simultaneously#

#ultiplace chambers

Accommodate multi%le %atients simultaneously#

Some systems may accommodate up to 13 patients#

-?ot te dual%lace and multi%lace cam"ers are %ressuri:ed ,it air and %atients "reate

oxygen using a ood or mas!#

-Te treatment control %anel controls te tera%y

and monitors te %atient during te treatment#

-ost tera%y is given at 2 or 4 ATA

and te average duration of tera%y is

60 to 0 minutes#

-During ,ic you can ,atc videos&

or read# For te first fe, minutes& your

ears ,ill adust& te same as in an

air%lane ta!e-off& so you can ce,

gum (or s,allo,)#

-Num"er of tera%ies may vary from 4-5 for

acute conditions to 50-60 for radiation illnesses#

Mou ,ear te oxygen mas! over your nose#>ildren can ,ear a %lastic elmet tat loo!s li!e an astronaut elmet

&o*ic 4ffects5 omplications:

/en used in standard %rotocols y%er"aric oxygen tera%y is safe#

>ommonest side effect may "e+

*ligt %ain in te ears (aural "arotraumas) due to a "loc!ed 'ustacian tu"e#-

-Pneumotorax and air em"olism and transient reversi"le myo%ia after %rolonged? tera%y are rare com%lication

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An occasional %atient may "e claustro%o"ic- #

-Fire is a realistic a:ard "ut %reventa"le "y strict safety %rocedures

&herapeutic 4ffects of HB):

-$mmune stimulation "y restoring /?> function and enancing teir %agocytic

ca%a"ilities

-Neo-vasculari:ation in y%oxic areas "y augmenting fi"ro"lastic activity and

ca%illary gro,t#

0asoconstriction+

educes edema and tissue s,elling ,ile ensuring ade@uate xygen delivery and is

tus useful in acute trauma ,ounds and "urns#

Bactericidal:

-For anaero"ic organisms G ini"its gro,t of aero"ic "acteria at %ressures 3#4 ATA#

$t $ni"its %roduction of al%a-toxin "y > /elcii and is synergistic ,it Amino

glycosides and Ouinolones#Tus it is life saving in gas gangrene and severe necroti:ing

infections#

-educes alf-life of >ar"oxyaemoglo"in from 7 to 5 ours to 20 minutes or less and

is te treatment of coice for >ar"on onoxide %oisoning in fire victims#

#echanical effects:

Direct "enefit of increased %ressure el%s reduces "u""le si:e in Air 'm"olism and

Decom%ression $llnesses#

6eactivates 7sleeping cells8 in the penumbra region around central dead neuronal

tissue(Tis is te "asis of its use in neurological conditions# $t also reduces aderence

of /?>s to ca%illary ,alls and may"e useful in acute "rain and s%inal cord inury#

ndications of HB):

,ounds:

-Pro"lem& non-ealing ,ounds and ulcers (dia"etic& venous etc)#

-$nfective ,ounds - gas gangrene& refractory osteomyelitis& necroti:ing soft tissue

infections#

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Acute traumatic iscemia& crus inuries& com%artment syndromes#-

->om%romised s!in grafts and fla%s#

-Termal "urns#

)ncology:

8ate radiation induced tissue damage and com%lications due to endarteritis#-

-Pro%ylactically adunctive to tera%eutic radiation& for %re%aration of surgery or im%lant

%rocedures in %reviously irradiated fields#

Primary Line of &reatment:

-Air or gas em"olism#

Decom%ression *ic!ness#-

->ar"on onoxide %oisoning& smo!e inalation

/ontraindications:

$bsolute: -Untreated tension %neumotorax#

-*ome ty%es of congenital eart disease#

-Astma#

-elati*e: - u%%er res%iratory tract infection

-'m%ysema

-Pregnancy

->laustro%o"ia

-*ei:ure disorder#

c.!ew ad*anced wound ther?apy:

'.#L#/T-I/$L STIML$TIO!:

"efinition:Te use of an electrical current to transfer energy to

a ,ound#

Te ty%e of electricity tat is transferred is controlled "y te electrical source)# 'lectrical

stimulation involves te transfer of electric current troug an a%%lied surface electrode

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%ad tat is in ,et (electrolytic) contact ( ca%acitatively cou%led) ,it te external s!in

surface and Eor ,ound "ed#

Te %ulse ,idt varies ,it a range from 20-200 microseconds# $t is a very safe current

"ecause itCs very sort %ulse duration %revents significant canges in "ot tissue % and

tem%erature#

I!"I/$TIO!S :

Pressure Ulcers *tage $#

Dia"etic ulcers due to %ressure& insensitivity and dysvascularity

.enous Ulcers

Traumatic /ounds

*urgical /ounds

$scemic Ulcers

.asculitic Ulcers

Donor *ites

/ound Fla%s

?urn ,ounds

/O!T-$I!"I/$TIO!S:

3-Presence of a cardiac %acema!er

2-Placement of electrodes along regions of te %renic nerve

4-Presence of malignancy

7-Placement of electrodes over te carotid sinus

5-Placement of electrodes over te laryngeal musculature

6-Placement of electrodes over to%ical su"stances containing metal ions

B-Placement of electrodes over osteomyelitis

TH#O-C $!" S/I#!/# O6 TH# TH#-$&C

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$n 37& te Agency for ealt >are Policy and esearc (A>P) %anel issued treatment

of Pressure Ulcers "y using of electrical stimulation as an adunctive tera%y for *tage $$$

and $. %ressure ulcers tat ave %roved unres%onsive to conventional tera%y# Te %anel

found tat data from 5 clinical trials involving 37B %atients to su%%ort te effectiveness of

tis tera%y for %ressure ulcers#

2ioelectric System

Te "ody as its o,n "ioelectric system# Tis system influences ,ound ealing "y

attracting te cells of re%air& canging cell mem"rane %ermea"ility &enancing cellular

secretion troug cell mem"ranes and orientating cell structures# A current termed te

Hcurrent of inuryH is generated "et,een te s!in and inner tissues ,en tere is a "rea! in

te s!in# Te current ,ill continue until te s!in defect is re%aired# ealing of te inured

tissue is arrested or ,ill "e incom%lete if tese currents no longer flo, ,ile te ,ound is

o%en# A moist ,ound environment is re@uired for te "ioelectric system to function (,it

normal ( 0#K ) saline & amor%ous ydrogels and occlusive dressings

Inflammation phase

$nitiates te ,ound re%air %rocess $ncreases "lood flo,

Promotes %agocytosis

'nances tissue oxygenation

educes edema

Attracts and stimulates fi"ro"lasts and e%itelial cells

*timulates DNA syntesis

>ontrols infection

*olu"ili:es "lood %roducts including necrotic tissue

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&roliferation phase

*timulates fi"ro"lasts and e%itelial cells

*timulates DNA and %rotein syntesis

$ncreases ATP generation

$m%roves mem"rane trans%ort

Produces "etter collagen matrix organi:ation&

*timulates ,ound contraction

#pitheliali3ation phase

*timulates e%idermal cell re%roduction and migration

Produces a smooter& tinner scar

&-#/$TIO!S:

-*igns of adverse effects ,ere evaluated in te various clinical trials and none ,ere found

exce%t some s!in irritation or tingling under te electrodes in a fe, cases#

-Patients ,it severe %eri%eral vascular occlusive disease (P.D) may ex%erience some

increased %ain& usually descri"ed as tro""ing& in te leg after electrical stimulation#

igure '(As%ect of te ,ound caused "y an

utomo"ile accident& one ,ee! after te

ccident#

6igure )( /ound ealing %rogress atsession in te same %atient#

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igure +( $nserted needles encircling te ,ound

session 3#

6igure 7( utcome of te treatment after

2B sessions of electrical stimulation#

). ltrasound:

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"efinition:$s a mecanical vi"ration delivered at a fre@uency a"ove te range of uman

earing#

.>linical ultrasound units currently "eing manufactured ty%ically deliver ultrasound at

fre@uencies of 3 and 4 : ,it duty cycles ranging from 20 to 300 %ercent# Duty cycles

less tan 300K are usually termed %ulsed ultrasound ,ile a 300K duty cycle is referred

to as continuous ultrasound#

2enefit

3# Inflammatory &hase

-Degranulation of mast cells resulting

in te release of istamine#

),&roliferati*e &hase

-'ffect fi"ro"lasts and stimulate tem to secrete collagen I# Tis can accelerate te

%rocess of ,ound contraction and increase tensile strengt of te ealing tissue

- >onnective tissue ,ill elongate "etter if "ot eat and stretc are com"ined#

- >ontinuous ultrasound at iger tera%eutic intensities %rovides and effective means

of eating dee%er tissue %rior to stretc#

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9reuency: !s the freuency of ultrasound is increased$ the penetration of the signal

decreases( 9or most dermal wounds$ it is preferable therefore$ to utilize a freuency of ;

#Hz( . #Hz wound be more effective on deeper structures or periwound s%in(

/onsiderations in the use of ultrasound

As ,it oter medical devices& ina%%ro%riate use can result in serious com%lications# &he

basic precautions should be ta%en:

3# Treat at te lo,est intensity tat ,ill %roduce te desired result#

2# Assure tat te a%%licator is !e%t in constant motion trougout treatment and tat

te %ro%er acoustic cou%ling medium is used#

4# educe te intensity or terminate treatment if te %atient com%lains of any increase

in %ain#

$pplication of ultrasound to wounds:

- Prior to ultrasound treatment& remove dressings and clean ,ound of foreign de"ris or

dressing residue#

-A ydrogel seetsould "e %laced in direct contact ,it te ,ound "ed and ,ound

margins& %aying s%ecial attention to removing any air "u""les tat migt "e %resent

"eneat te dressing# emove any %rotective %lastic covering on te ydrogel seet#

-$n cases ,ere a cavity ty%e of ,ound exists tat %revents com%lete contact "et,een te

ydrogel seet and te ,ound "ase& as sterile a@ueous ydrogel filler sould "e used#

Te cavity is filled ,it te a@ueous gel& and ten covered ,it te ydrogel seet#

emove all underlying air "u""les "et,een te a@ueous ydrogel and ydrogel seet#

-nce te ydrogel seet is in %lace& a%%ly an ultrasonic cou%ling gel on to% of te seet#

--*elect te a%%ro%riate si:ed a%%licator# (Te area treated sould "e no larger tan 3#5 to 2

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times te si:e of te a%%licator)# $f a relatively large ,ound is "eing treated& it ,ould need

to "e divided into sections#

-*et te ultrasound macine to a 20 K duty cycle at a fre@uency of 4 :#

-A%%lying ligt %ressure& te sound ead is %laced in contact ,it te cou%ling medium on

to% of te ydrogel seet and moved in a slo, and deli"erate manner using eiter a linear

or circular tecni@ue#

-*et te intensity to less tan 0#5 ,atts %er s@uare centimeter (usually 0#4 ,attsEcm 2)#

educe te intensity if te %atient ex%eriences %ain or eat#

-Treatment duration is suggested to "e a"out 3 to 2 minutes %er :one#

-Acute ,ounds are treated 3 to 2 times %er day until acute sym%toms (inflammation)

su"side# Treatments can ten decrease to 2 to 4 times %er ,ee!

$pplication of ultrasound to periwound tissue

/en it is desired to %rovide mild eating to te %eri,ound tissue in order to stimulate

circulation& iger intensity ultrasound can "e given# 'xtreme are sould "e used&

o,ever& to assure te tissue is ca%a"le of andling te termal levels delivered#

To treat %eri,ound tissue& 3 :& continuous ultrasound is usually em%loyed# Again& an

ultrasound a%%licator 3#5 to 2 times te si:e of te treatment area sould "e used# /it an

a@ueous cou%ling medium in %lace& te sound ead is %laced ligtly against te s!in

surface and moved in a slo, and deli"erate manner#

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Te intensity is ty%ically set to "et,een 3 and 3#5 ,atts %er s@uare centimeter# Tis

%arameter is extremely varia"le and de%ends on te %atientCs circulatory& sensory and

mental status#

!(2:,Termal ultrasound sould never "e used in situations ,ere im%aired %erce%tion

%revents te %atient from sensing eat or %ain#

-$f at anytime during te treatment te %atient sould ex%erience an increase in %ain&

te intensity sould "e turned do,n or te treatment discontinued#

Treatment duration is sligtly longer tan tat of %ulsed ultrasound since a mild termal

effect is desired# $nitial treatment is a"out 2-4 minutes %er :one and can "e increased "y 40

second increments to a maximum of 5 minutes %er :one and delivered 4 times %er ,ee!#

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Documents

Advanced Wound Care