Wound Care Gopi Sir

8/6/2019 Wound Care Gopi Sir

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Wound Care

By :Dr Gopikrishna .B .J

Asst Professor

Dept of P.G.Studies in Shalyatantra

S.D.M.C.A, Hassan


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Anatomy of Skin


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Skin: structure and functionLargest organ of the body

Primary function is protective

Composed of several layersOuter Epidermis and Stratum Corneum

Dermis, containing the capillary network

Subcutaneous layer (hypodermis, adiposelayer)


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Thickness varies from a thin membrane atinternal flexures (e.g. elbows), to thicker at

the soles of the feet which bearconsiderable pressures

Hair follicles, sebaceous glands, and sweatglands pass through the epidermis, but

arise from the dermal layer


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Definition

A cut or break in the continuity of anytissue, caused by injury or operation


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Classification of wounds


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According to their nature :Abrasion

Contusion

Incision

Laceration

Open

Penetrating

Puncture

Septic etc


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According to the

number of skin layers involved:

Superficial

Involves only the epidermisPartial Thickness

Involves the epidermis and the dermis

Full ThicknessInvolves the epidermis, dermis, fat, fascia andexposes bone


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According to contamination

Clean - (non traumatic)

Clean contaminated

Contaminated

Dirty


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According to Grading by tissue Involvement

Grade I non-blanchable erythema of intact skin.Discoloration of the skin, warmth, oedema,

induration or hardness may also be used asindicators in people with dark skin.

Grade II partial-thickness skin loss involving

epidermis, dermis or both.The ulcer is superficialand presents clinically as an abrasion or blister.


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Grade III full thickness skin loss involving damage ornecrosis of subcutaneous tissue that may extend downto but not through underlying fascia

Grade IV extensive destruction, tissue necrosis ordamage to muscle, bone or supporting structures withor without full thickness skin loss.


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The ways in which wounds heal

Three basic classifications exist:Healing by primary intention

Two opposed surfaces of a clean, incised wound

(no significant degree of tissue loss) are held together.

Healing takes place from the internal layers outwardsHealing by secondary Intention

If there is significant tissue loss in the formation of the

wound, healing will begin by the production of

granulation tissue wound base and walls.Delayed primary healing

If there is high infection risk patient is given antibiotics

and closure is delayed for a few days e.g. bites


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Wound healing

All wounds heal following a specific sequence of phaseswhich may overlap

The process of wound healing depends on the type of

tissue which has been damaged and the nature of tissuedisruption

The phases are:

Inflammatory phaseProliferative phase

Remodelling or maturation phase


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The healing process

Day 0 5The healing response starts at the moment ofinjury the clotting cascade is initiated

This is a protective tissue response to stem blood

lossThe inflammatory phase is characterised by heat,swelling, redness, pain and loss of function at thewound site

Early (haemostasis)Late (phagocytosis)

This phase is short lived in the absence ofinfection or contamination


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Granulation

Day 3 14

Characterised by the formation of granulation tissue

in the woundGranulation tissue consists of a combination ofcellular elements including:

Fibroblasts, inflammatory cells, new capillaries

embedded in a loose extra-cellular collagenmatrix, fibronectin and hyularonic acid


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AngiogenesisCollagen first detected at day 3 and rapidlyincreases for approx. 3 weeks, then moregradually for the next 3 months

Fibroplasia (fibroblast proliferation andsynthetic activity) continues in parallel withre-vascularisation

Endothelial cells from the side of venulesclosest to the wound begin to migrate inresponse to angiogenic stimuli (angiogenesis)forming capillary buds, then loops


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EpithelialisationThe epidermis immediately adjacent to thewound edge begins to thicken within 24hrs

after injuryIn approximated incised wounds re-

epithelialisation is usually complete within48hrs.


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MaturationCan last up to 2 years

New collagen forms, changing the shape of

the wound and increasing the tensile strengthScar tissue, however is only ever approx. 50-80% as strong as the original tissue

During the remodelling process there is agradual reduction in cellularity and vascularityof the reparative tissue


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ContractionOnly undesirable where it leads tounacceptable tissue distortion and an

unsatisfactory cosmetic result

Wound contraction usually begins fromday 5 and is complete at approx. day 12

- 15


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Moist wound healingBasic concept is that the presence of exudatewill provide an environment that stimulates

healingExudate contains:Lysosomal enzymes, WBCs, Lymphokines, growthfactors..

There are clinical studies which have shownthat wounds maintained in a moistenvironment have lower infection rates andheal more quickly


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Factors affecting wound healingLocal Factors

1. Infection

2. Presence of necrotic tissue

3. Poor blood supply

4. Venous or lymph stasis

5. Tissue tension

6. Haematoma

7. Large defect or poor opposition

8. Recurrent trauma

9. X-Ray irradiated area

10. Wounds over joint & back

11. Underlying diseases like osteomyelitis & malignancy


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Complications of wound healing1. Implantation cysts

2. Painful scars

3. Cicatrisation

4. Keloid formation

5. Neoplasia


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Practical considerations

The cause of the wound

Underlying disease processesCurrent health status

Medication

Acute or chronic?Attitude to the wound

Availability of care


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Healing requirementsIdentification of the hindrance to healing

Adequate nutritional statusAdequate perfusion and oxygenation

High quality, research-based patient andwound management

Correction of the underlying cause of theproblem

Disease management


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Wound assessment

WOUND ASSESSMENT

Lab tests:TcPO2 Size, depth

& location

Wound bed:

necrosis granulation

Surrounding skin:colour, moisture,

Wound edge

Odour orexudate

Signs ofinfection


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Clinical appearance

Slough (yellow)

Necrotic tissue (black)Infected tissue (green)

Granulating tissue (red)

Epithelialising (pink)


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Sloughy wound Aim: to liquefy slough and

aid its removal

Dead cells accumulated in

exudate

Prepare wound bed for

granulation

Assess wound depth and

exudate levels Hydrogels, hydrocolloids,

alginates and hydrofibre

dressings


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Necrotic wound Aims: to debride and

remove eschar

Provide the rightenvironment forautolysis

Assess wound depthand

exudate levels

Hydrogels, hydrocolloid

dressings


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Infected wound Aims: reduce exudate,

odour and promote

healing Clinical signs of

infection

Swab wound systemicantibiotics

Treat symptomatically:exudate and odourcontrol

Change dressings daily


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Granulating wound Aims: support

granulation, protectnew tissue, keep moist

Assess depth andexudate levels

Moist wound surface non-adherent dressing

Treat over-granulation

Hydrocolloids, foams,alginates


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Wound characteristicsExudate

Odour

Condition oftissue withinthe wound

Condition ofthesurroundingskin


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The surrounding skin

Eczema

Psoriasis

Maceration/excoriation

due to exudate or

bowel contents

Self-inflicted damage


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Dressing choice

The purpose of

dressings:

To aid debridement

To remove excessexudate

To control bleeding

To protect a wound

To support healing


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The ideal dressing

A dressing that

Creates the optimum

Environment

Wound debridement

Wound cleansing

Alternative therapies


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Dressing choice

Non-adherent wound contact materials

Films

HydrogelsHydrofibre dressings

Hydrocolloids

Foams

Alginates

Miscellaneous


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Wound CleansingThe aims of wound cleansing are

to remove any foreign matter

such as gravel or soil, to remove any

loose surface debris such as necrotic

tissue and remove any remnants of

the previous dressing.


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Traditional methods:

Swabbing with cotton wool

Antiseptic solution

Dry dressings

Daily change of dressing/woundinspection


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Lotions and potions

Hypochlorites

Hydrogen peroxide

Chlorhexidine

ProflavineSaline 0.9%


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Saline 0.9%The only completely safe cleansing

agentSafe to use with wound management

products

Sachets, plastic containers and

aerosols for easy irrigation


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Necrotic woundsAim: to debride and remove eschar

Masks the full extent of the wound

Provide the right environment forautolysis

Assess wound depth and exudate

levels

Hydrogels, hydrocolloids, alginates,hydrofibre dressings


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Sloughy woundsAim: to liquefy slough and aid its

removal

Dead cells accumulated in exudate

Prepare wound bed for granulation

Assess wound depth and exudate levels

Hydrogels, hydrocolloids, alginates andhydrofibre dressings


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Infected wounds

Aim: reduce exudate, odour and promote

healing

Clinical signs of infectionSwab wound systemic antibiotics

Treat symptomatically: exudate and

odour controlChange dressings daily


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Granulating wounds

Aim: support granulation, protect new

tissue, keep moist

Assess depth and exudate levels

Moist wound surface non-adherent

dressing

Treat overgranulation

Hydrocolloids, foams, alginates


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Epith

elialising wounds

Aims: to provide suitable

conditions for re-surfacingN.A. ultra, films, hydrocolloids

Disturb as little as possible


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Film dressings

Semi-permeable primary or secondary

dressingsClear polyurethane coated with adhesive

Conformable, resistant to shear and tear

Do not absorb exudate

Examples: Tegaderm, Op-site.


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HydrocolloidsPectin, gelatin, carboxymethylcellulose and

elastomers

Environment for autolysis to debride sloughy or

necrotic wounds

Occlusive --> hypoxic environment to

encourage angiogenesisWaterproof

Different presentations e.g. Urgotul


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Foam dressings

Advanced polymer technology

Non-adherent wound contact layerHighly absorptive

Semi-permeable

Various typesAdhesive and non-adhesive


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Hydrogels

Sheets or gels

Starch and polyacrylamide (94% water)Low exudate, shallow wounds

Re-hydrates necrotic tissue

Secondary dressing needed

May cause skin maceration


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Alginates

Seaweed dressings

Form a gel over the woundModerate to high exudate wounds

Easily removed

Can cause pain

Help to debride a wound

Different presentations


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Tissue Viability

Documenting wound care

Potential for litigation

Good staff communicationContinuity of care

To assess progress or deterioration

Should be factual not subjectiveWound assessment charts


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Patient assessment parameters

Nutritional status

Level of mobilityMental attitude (compliance)

Dressing tolerance

Age

Metabolic disease

Vascular insufficiency


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Is the wound acute or chronic?

Post-operative?

Healing or non-healing?

Underlying cause?

Infected or colonised?Skin problems around the wound?


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Assessment parametersCause

Wound classification

Depth of the woundShape and size

The amount of exudate

The position of the woundThe clinical appearance

The environment of care


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Innovations in Wound Management

Biosurgery (LarvalTherapy)

VAC therapy

Warmth

Laser therapy

Leeches

MySkin

Tenderwet

Dispersion therapy

Hydrofibre dressings

Long-term usedressings

Natural skin

Growth hormones

Hyaluronic acid dressing

Myskin

Xelma


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Biosurgery(Larval therapy)


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Luciliasericata (greenbottles)

Ingestbacteriawhich are

destroyed in theirgutWide range ofinfected wounds

Removes slough and malodour

Bred assterile larvae


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2mm long special dressingtechnique

Sleeves or bags

Numbers needed

Removal

Reassessment


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Associated problems

Potentially infected larvae

Allergic reactionTickling sensation

Ethical issues

Aesthetic issues


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VAC Therapy

Provides a moist environment

Prevents bacterial activity

Evacuates excess exudate

Kills anaerobic bacteria in the woundbed

Controls odour


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Negative pressure suction drainage Not a new idea as surgeons have employed drainage

methods for years

The difference: the application

of topical negative sub-

atmospheric pressure

across the surface of the

wound


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Chronic non-healing wounds:

Pressure ulcers

Venous/arterial ulcers Diabetic ulcers

Sub-acute non-healing wounds

Dehisced surgical woundsAcute and traumatic wounds Meshed flaps and grafts Graft and flap donor sites

Indications


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Contraindications Fistula of unknown source

Opening into a body cavity

Vulnerable body organs (protect) Malignancy

Necrotic tissue with eschar

Untreated osteomyelitis


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Recommended regime Negative pressure

50-75mmHg split-skin graft, leg ulcer

125mmHg all other wounds Cycle

continuous for 48 hours then intermittentpressure

wound assessment determines cycle

Dressing changes

4-5 days (every 48 hours if infected)


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Success will depend on:

Wound selection Type of foam dressing

The degree of negative pressure

The duration of treatment


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Laser therapy

Little evidence of faster healing

Needs expert handling

May increase tensile strength

Costly

Time-consuming


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Hydrofibre dressingAquacel hydrofibre, non-woven

hydrocolloid dressing

Forms a non-sticky gelVery absorbent

Moist environment

Needs secondary dressing


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Long-term use dressingsMepitel, Omniderm, TegaporeNon-adherent

Allow passage of exudate into asecondary dressing


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Urgotul hydrocolloid andpetroleum jelly

Promogran collagen and cellulose it interferes with substances

(proteases) in the wound thatprevent it healing


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Natural skin

Vivoderm, Dermagraft, Apligraf

Expensive but cost-effective

Reduce need for skin grafts

Useful for diabetic ulcers


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Growth hormones

Proteins that direct biological

processesChronic wound deficiency

Messengers

Under research


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XelmaWhat is Xelma extracellular matrix protein?Xelma consists of amelogenin proteins, a thickening

agent propylene glycol alginate (PGA) and water.Xelma has been proven to improve healing in hard toheal ulcers.What is Xelma for?Xelma is a medical device for treatment of hard-to-

heal ulcers, primarily venous leg ulcers. It is indicatedfor use with standard compression therapy of non-infected wounds.


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XelmaHow is Xelma different from other therapies?Xelma is the first product containing extracellular matrixprotein, amelogenin, which temporarily replaces thedamaged extracellular matrix proteins in the hard-to-healwounds in order to restore wound healing.

How does Xelma work?When applied to the wound bed Xelma provides atemporary extracellular matrix protein for cell attachment.This creates favourable conditions for wound healing by

restoring vital cell functions including proliferation,migration and production of growth factors and essentialextracellular matrix proteins. Restoration of the cellularand biochemical balance is facilitated in the hard-to-healwound, which will promote granulation tissue formationand normal wound healing.


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Myskin


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Myskin case studiesPatient Profile

Mrs B 68 years oldMedical ConditionTwo chronic non-healing pressure ulcers.

The Patient

After receiving a burn to her leg Mrs Bwas left with scar tissue causing her footto become deformed. Pressure ulcersdeveloped from her corrective footwear and despiteconventional treatment they remained unhealed for threeyears. Mrs B was also awaiting surgery to correct her footwhich was not possible until the ulcers had healed.


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MyskinEvaluationMrs B has undergone three skin grafts along with conventionaltreatment all of which have failed to heal the ulcers. Mrs B was thenreferred for treatment with Myskin.For Myskin treatment, a thin biopsy (approximately 0.6mm thick,2cmx2cm) of skin is taken from the thigh area and transported to thelaboratory in sterile saline solution. The biopsy is treated with adigestive enzyme overnight. The following day the keratinocytes areisolated from the dermal/epidermal junction, multiplied in cell cultureand stored in liquid nitrogen until they are needed.Three days before dressings are required, keratinocytes are thawed andcultured on a 5cm silicone disc. These discs have a patented surfacelayer that encourages keratinocytes, to transfer from the dressing to

the wound bed and promote re-epithelialization. This cell transferprocess takes about four days after which the Myskin dressing can beremoved and a standard dressing applied.


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MyskinMrs B attended the clinic for the once weekly dressing applications which, after

four days, were removed and replaced with a standard dressing.Twenty twoweeks after the firstMyskin dressing was applied one ulcer had healed

completely and the second healed after forty five weeks.BothUlcers Healed

OutcomeAfter two applications Mrs B experienced a significant reduction in pain and oncethe ulcers had completely healed Mrs B was referred back to the orthopaedicteam. She has since had her foot deformity corrected with no complications postoperatively. Mrs B has now resumed activities which she previously enjoyed such

as swimming and has been on holiday.Due to the severity, location and age of the ulcers it was necessary for Mrs B tohave several more applications of myskin than usually required. It has beenfound that up to twelve applications are usually needed to heal a chronic woundalthough the number of applications may vary between patients.


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ANTIBIOTICS

di i


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Indications

1.Contaminated wound

2.Areas of marginal viability

3.Wounds involving joints, openfractures

4.All human bite wounds

5.Most animal bite wounds

6.Generally, wounds > 12hr. old


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SPECIALWOUNDS


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Bite Wounds

High risk of infection with involvement of

bones, joints, tendons, vessels, nervesPuncture wounds (difficult to irrigate anddecontaminate)


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Dog Bites

75% involve the extremities

Most dog bites in children involve an extremitySevere facial lacerations involve the cheeks andlips as they try to "kiss the doggie


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Closure

Dog bites scalp, face, trunk, proximal

extremities may be closed if superficial

Human bites never close primarily(delay 48 72hr.)


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Puncture Wounds

Never close

Irrigate drain, if necessaryFoot shoe on or barefoot?

Increased infection risk if shoe on


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Abscesses

Incise, drain, irrigate, loosely pack withIodoform gauzeReturn at 24 hrs. for irrigation fresh packReturn at 48 hrs. for pack removal andhealing by granulation


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New onset DM may present with abscessAntibiotics may be indicated in

addition to I&D


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Nail / Nail Bed Injury

Subungual hematoma, < 40 % nail area,nail bed injury unlikely, but distal phalanxfx. Might be presentTreatment: Battery cautery to make

drainage hole in nail, irrigate with 25ga.needle and 1% lidocaineNail Bed - requires surgical repair


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Foreign Bodies

Inert (glass, metal), may leaveunremoved if necessaryOrganic (wood), must be removed


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VamanaEix qx vT i MT

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Wound with hypergranulation,shothahaving predominance of kapha, blackishor reddish wounds vamana is beneficial.

VIRECHANA


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VIRECHANA

Wounds afflicted by Vata &

predominance of Pitta Dosha

Situated in Madhyama & Adhoshaka of the body

Non healing wounds, chronic wounds


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SIRAVYDHANA

Vrana which is predominant of Pitta andRakta

In Margavarana conditions,raktamokshanais advised

Indicated in shothayuktha, kathina,shyama, aruna rakta and vedanayuktavrana with vishalamoola.


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In pitta pradhanacondition raktha

mokshana can bedone with jalauka


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LEKHANA

Should be done in Kathina(hard), thick &rolled margins of vrana and in hard &raised granulated surface

KASHAYA


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KASHAYA

Kashaya should be used for shodhana, in

wound having foul smell, Kledayukta, Picchila,

Shodhana kashaya drugs are Shankhini,Ankhotha, Karaveera, Sumana, Suvarchala &

Aragvadhadhi gana


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KALKA

Kalka should be used for Shodhana in highlyinfected wound, foul smell, & when all

the Doshas are involved (vata & kapha)

Drugs are Haratala, Pippali, Maricha, Shunthi,

Sphatika.

SARPI


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SARPI

In Pittaja Vrana symptoms are Daha & paka,the drug are used Karpasa Phala SiddhaGhrita

TAILA

In Kaphaja Vrana if wound is UtsannaMamsa, Ruksha, Alpasravayukta the drugs tobe used Sarshapa + Tila Taila

RASAKRIYA


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RASAKRIYA

An indurated ulcer, not responding to Taila should

be purified with a dually prepared Rasakriya.

Shodhana Rasakriya - Brihati,Kantakari,Haritala, Manashila

The drugs are Salasaraadi Gana, Patola, Triphala.


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AVACHOORNA

Medhayuktha, superficial wound, foul smell

conditions choorna is used for Shodhana

Drugs are Kaseesa, Saindava, Vacha,

Rajanidwaya

UTSADANA


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UTSADANA

Utsanna mridu mamsa Kasisa

& Madhu

DARUNIKARANA

Mridu mamsa Dhava,Priyangu,Ashoka etc Avachoornana.


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C l i


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ConclusionWound care is complex

There are no easy solutions

Evidence is needed of efficacy

and cost-effectiveness

Correction of the underlying causativefactors is essential

Key principles must be adhered to withregard to basic patient and wound

assessment


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Documents

Wound Care Gopi Sir