Primary Wound Management Current Concepts in Topical Therapy

Primary Wound ManagementPrimary Wound Management

Current Concepts in Topical Therapy

Priority # 1: Correct Priority # 1: Correct Causative FactorsCausative Factors

Pressure/Shear: Support surface + repositioning guidelines

Friction/Shear: Gentle skin care; minimal tape use; measures to prevent “scrubbing”

Venous: Leg elevation + compressionArterial: Revascularization? Measures to

optimize perfusion/protect limbsNeuropathy: offloading

Priority # 2: Systemic SupportPriority # 2: Systemic Support

Measures to optimize perfusion– Pain control; warmth; edema control; oxygen if

needed

Must have sufficient blood flow to heal—if wound poorly perfused & revascularization not an option, consider HBOT

Systemic SupportSystemic Support

Nutritional Support– 30 – 35 cal/Kg/day– 1.2 – 1.5 gm protein/Kg/day (glutamine & l-

arginine)– MVI– Zinc only if needed and only short-term– Consider oxandrolone for pt with significant wt

loss who does not respond to standard therapy


Tight Glucose Control– Goal: Normoglycemia– Impact of glucose >180– Implications: check glucose records each visit;

constantly reinforce link between glucose levels and ability to heal


Measures to minimize effects of high-dose steroids: topical Vit A to wound bed (25,000 – 100,000 IU daily, depending on size of wound)

Note limited research on this topic

Priority # 3: Principle-based Priority # 3: Principle-based Topical TherapyTopical Therapy

Goal: Promote wound healing by creating local environment that favors repair

Inflammatory phase: wound cleanup (debridement and bacterial control)

Proliferative phase: rebuilding (formation of granulation tissue to fill defect + new epithelium to resurface)

History of Wound CareHistory of Wound Care

Dominant Principles and Concepts– Limited knowledge re: wound healing– Primary focus: infection control

Common Approaches– Gauze dressings with antiseptic solutions– Aggressive cleansing– Mgmt refractory wounds: “more of the same”

vs. experimental agents

Shift to Moist Wd HealingShift to Moist Wd Healing

Winter’s Research: 40% reduction in time to epithelialization with moist surface

Subsequent studies: improved rates of healing full-thickness wounds; no increase in infection rates

Gradual shift in focus: from preventing infection to creating favorable environment for repair

Principle-Based Topical Principle-Based Topical TherapyTherapy

Eliminate impediments: necrotic tissue, excess bioburden, wound exudate, closed wound edges

Keep wound moist, insulated, and protected

Topical Therapy AcronymTopical Therapy Acronym

D = Debride necrotic tissue I = Identify and treat infection P = Pack dead space, lightly A = Absorb excess exudate M = Maintain moist wound surface O = Open wound edges P = Protect healing wound I = Insulate healing wound

Topical Therapy: Decision-Topical Therapy: Decision-Making GuidelinesMaking Guidelines

Wound Assessment:– Location– Dimensions and depth– Undermined/tunneled areas– Status of wound base: granulating? clean but

not granulating? necrotic?– Exudate– Status of wound edges/surrounding tissue

Necrotic WoundsNecrotic Wounds

When to debride:

--Anytime the goal is repair

--Anytime the wound is infected

OASIS Assessment OASIS Assessment ChallengesChallenges

Open Wounds:– Granulating vs. clean but not granulating– Closed versus open wound edges

Closed Incisions– Presence/absence of healing ridge– Epithelialization

Necrotic WoundsNecrotic Wounds

Debridement Options:– Surgical– Conservative sharp wound debridement– Enzymatic– Chemical– Autolytic

Infected WoundsInfected Wounds

Guiding Principle: must intervene when – there is invasive infection of soft tissue or bone

or– the bacterial loads on the surface of the wound

are sufficient to interfere with repair


Wounds involving infection of soft tissue: – Clinical S/S: redness, heat, edema, pain,

exudate– Treatment: systemic antibiotics (culture based

if possible)

Wounds involving osteomyelitis:– Clinical S/S: exposed bone; nonhealing tunnel– Treatment: systemic antibiotics

Infected Wounds:Infected Wounds:

Culture guidelines:– Purpose: to determine infecting organism and

antibiotics to which it is sensitive– Procedure:

Wound biopsy (punch culture) OR

Modified swab: flush with N/S

swab 1 sq cm of viable tissue

till exudate produced


Wounds with sufficient bacterial load at wound surface to interfere with repair:– Clinical S/S: deterioration in quantity or

quality of granulation tissue; persistent high volumes of exudate; pain

– Treatment: topical agents to reduce bacterial loads (cleansers, sustained release iodine or silver dressings)


Topical Agents for Bacterial Control– Necrotic wounds: consider Dakin’s – Technicare cleanser for wd with daily dsg

changes (kills 99% of bacteria within 2 min): Caretech Labs

– Sustained release iodine (Healthpoint)– Sustained release silver agents (Acticoat,

Silvasorb, Aquacell Ag, Contreet, Actisorb)

Create/maintain open wound Create/maintain open wound edgesedges

Cauterize with silver nitrate

Refer for excision of wound edges

Dressing SelectionDressing Selection

Goals:– Wick and absorb exudate– Maintain moist wound surface– Provide bacterial barrier/protection against

trauma– Insulate


Assessment parameters:– Wound depth > 0.5 cm?– Tunnels or undermined areas present?– Volume of exudate?


Classify wound:– Deep and wet: > 0.5 cm deep (or tunnels or

undermining) + mod – lg amt exudate– Deep and dry: > 0.5 cm deep (or tunnels or

undermining) + minimal or no exudate– Shallow and wet: < 0.5 cm deep (no tunnels or

undermined areas) + mod – lg amt exudate– Shallow and dry: < 0.5 cm deep (no tunnels or

undermined areas) + minimal or no exudate

Dressing OptionsDressing Options

Deep and wet:– Filler dressing: alginate rope or hydrofiber

rope or damp gauze (least effective option); note Nugauze or Mesalt rope best for narrow tunnels

– Cover dressing: adhesive foam; gauze + tape or transparent adhesive dressing (consider need for bacterial barrier—e.g., pt who is incontinent and has trunk wound)


Deep and dry:– Filler dressing: layer of wound gel + damp

fluffed gauze; gel-soaked gauze– Cover dressing: gauze + transparent adhesive

dressing (maintains hydration and provides bacterial barrier)


Shallow and wet– Alginate + foam or gauze– Hydrofiber + foam or gauze– Nonadherent contact layer + gauze – Adhesive foam alone


Shallow and dry– Solid gel (glycerine-based gels better for

wounds with exudate)– Hydrocolloid– Nonadherent + wrap gauze (for wound on

extremity)– Transparent adhesive dressing (if no exudate)

Refractory WoundsRefractory Wounds

Definition: Wound that fails to show measurable progress for 2 consecutive weeks despite appropriate management

Management:– Assure correction etiologic factors– Assure adequate systemic support– Assure clean protected wound bed– Consider use of active wound therapy

Active Wound TherapyActive Wound Therapy

Definition: Agent that actively stimulates the repair process

Options:– Electrical Stimulation– Negative Pressure Wound Therapy– Growth Factors– Human Skin Equivalents

SummarySummary

Key goals:– Correct causative

factors– Provide systemic

support– Establish clean moist

wound bed– Monitor for progress– Intervene for failure to

progress!

Documents

Primary Wound Management Current Concepts in Topical Therapy