Wound care

Background

Stages of Wound Healing

Stage	Day	Description
Hemostasis	0 to 3	Clotting and vasoconstriction leads to cessation of bleeding
Inflammation	1 to 25	Redness, swelling, warmth, and pain result from cytokine release, vasodilation, phagocytosis
Proliferation	1 to 25	New blood vessels grow, wound closes
Maturation	20 to 365	Further remodelling with scar tissue fulling developing

Etiology

• Most common chronic wounds result from arterial ulcers, diabetes, pressure injury, and venous stasis

Assessment

• MEASURE acronym
  • Measure (length, width, depth, and area)
  • Exudate (quantity and quality): serous, serosanguineous, sanguineous, seropurulent, purulent
  • Appearance (wound bed, including tissue type and amount): granulation, fibrin, slough, eschar
  • Suffering (pain type and level)
  • Undermining (presence or absence)
  • Reevaluate (monitoring of all parameters regularly)
  • Edge (condition of edge and surrounding skin)
• NERDS (for assessing biofilm and colonization)
  • Non-healing
  • Exudative
  • Red and bleeds easily
  • Debris
  • Smell
• STONEES (for infection)
  • Size increasing
  • Temperature increased
  • Os (probes to bone)
  • New areas of breakdown
  • Exudative
  • Erythema and edema
  • Smell

Management

Care Plan

• Appropriate management includes patient factors, local wound factors, and environmental measures, and requires regular reassessment

Patient Factors

• Manage comorbidities (e.g. diabetes, arterial disease, etc)
• Address risk factors when possible
• Optimize nutrition and hydration
• Manage other infections
• Treat symptoms
• Provide psychosocial support
• Prescribe appropriate antibiotics
• Create and individualized management plan
• Educate the patient and family

Local Wound Factors

• See below for more information
• Prevent infection using aspetic technique and universal precautions
• Drain wounds
• Ensure good wound hygiene and protection
• Manage exudate
• Optimize wound bed
  • Debride non-viable tissue
  • Disrupt biofilm
  • Clean with each dressing
  • Use appropriate antimicrobial dressings
  • Use appropriate antiseptic therapy (each should have at least a 2 week trial)

Environmental Factors

• Ensure a clean environment for wound care
• Store equipment safely
• Educate patient and caregivers
• Review policies and procedures

Regular Reassessment

• Follow wounds over time for changes
• Make adjustments as necessary to management plan

Local Wound Care

• TIME: tissue debridement, infection control, moisture balance, and edges of the wound

Wound Cleansing

• Saline, sterile water, tap water, or liquid antiseptics (povidone-iodine, etc)
  • The antiseptic solutions often disrupt or penetrate biofilm
  • Antiseptics include povidone-iodine, PHMB, OCT, HOCl/NaOCl
• If infection suspected, use antiseptic or surfactant
• Irrigate with gentle pressure; do not scrub

Debridement

• Removing necrotic or devitalized tissue, including slough, pus, debris, etc, can help healing
  • Moist necrotic tissue is an excellent medium for bacteria
• Selective (only non-viable tissue) generally preferred over non-selective debridement
• Specific techniques include:
  • Mechanical: most common. Physically removes the tissue.
    • Wet-to-dry dressing: apply wet tissue, allow to dry, then remove. This causes pain and is discouraged
    • Irrigation: with 4-15 psi can dislodge bacteria and debris. Can be done with syringe and 18-19 gauge needle
    • Polyacrylic microfibre pads: now out of favour
    • Low-frequency ultrasound
  • Autolytic: allows body's own immune system to get rid of dead tissue (e.g. liquefaction of eschar)
    • Scoring or crosshatching the eschar with a scalpel
    • Using dressings that promote autolysis
    • Must keep wound clean
  • Enzymatic: the use of exogenous proteolytic substances such as collagenase
    • Dry eschar must be kept moist for the enzymes to work
  • Surgical: converts a chronic non-healing wound into an acute wound by a surgeon in an OR
  • Conservative sharp: removal of devitalized tissue with a scalpel or scissors
  • Chemical: e.g. sodium hypochlorite (NaOCl), but is non-selective and can damage healthy tissue
  • Hydrosurgical: uses specialized tools and a surgeon
  • Biological/biosurgical: maggots

Bacterial Balance

• Antimicrobial includes both antibiotics and antiseptics
• Bacterial burden ranges from contamination to colonization, local infection, spreading infection, and finally systemic infection
  • Intervention is required for any infection
  • Biofilm should be considered for any infection

Topical Antimicrobials

• Includes gential violet, methylene blue, honey, iodine, PHMB, silver, and hydrophobic agents
  • These reduce bacterial burden or disrupt biofilm
  • May be used prophylactically, as well
  • Iodine is contraindicated in breastfeeding and pregnant women, and in renal disease, and should be used with care in patients with thyroid disease

Moisture Balance

• The goal is for the wound to be moist enough to promote healing without being so wet as to promote maceration and irritation
• Primarily done using occlusive dressings

Wound Dressing

• The primary dressing is that which is in direct contact with the wound bed, and is covered by the secondary dressing which may help to contain exudate

Selection

• By tissue type
  • Epithelium or granulation tissue
    • Healing wound
      • Dressing or combination that can remain in place as long as possible to maintain an appropriate moisture balance
      • Acrylic, calcium alginate, film/membrane, foam, gauze (used for daily dressing changes only), gelling fibre, hydrocolloid, hydrogel, non-adherent synthetic contact layer
    • Non-healing wound: acrylic, film/membrane, foam, gauze (used for daily dressing changes only), hydrocolloid
    • Non-healing wound with friable or inflamed tissue: biologic dressings with protease inhibitors, calcium alginate, silver compounds ibuprofen-impregnated dressings
    • Non-healing wound without inflamed tissue: iodine compounds, honey
  • Slough or eschar
    • Healing wound
      • Support autolytic debridement and absorb excess exudate
      • Acrylic, calcium alginate, film/membrane, foam, gauze (for mechanical debridement), gelling fibre, hydrocolloid, hydrogel, hydrophilic dressing, hypertonic
    • Non-healing
      • Gauze ± chlorhexidine derivative
      • Non-adherent synthetic contact layer ± iodine compound
• By amount of exudate
  • Wound too dry
    • Add moisture, require less frequent dressing changes, and prevent trauma with changes
    • Acrylic, film/membrane, hydrocolloid, hydrogel, hydrophilic dressing, non-adherent synthetic contact layers
  • Wound too wet
    • Absorb moisture, more frequent dressing changes, protect surrounding tissue from moisture
    • Calcium alginate, foam, gauze (daily dressing changes), gelling fibre, hypertonic
• By type of exudate
  • Serous: foams, gauze, gelling fibres
  • Serosanguineous: calcium alginate, absorbable hemostatic agents, non-adherent synthetic contact layers
  • Purulent: charcoal, antimicrobial dressings
• By periwound tissue
  • Macerated or excoriated
    • Dry and protect the periwound tissue
    • Films/membranes, hydrocolloids, hydrophilic dressing
• For infection, consider antimicrobial agents and hypertonic dressings
• For wound pain
  • Choose primary dressing to prevent adherence to the wound bed or prevent periwound maceration
  • Foam dressing with ibuprofen, hydrogel, non-adherent synthetic contact layer
• For deep, undermining, or tunneling wounds
  • Dead space should be filled by packing
  • Calcium alginate (except for tunneling wounds), specialized foam dressings, gauze, gelling fibre, hypertonic gauze ribbon

Locally-Available Brands

• Acrylic: Tegaderm Absorbent Clear Acrylic Dressings
• Foam: Mepilex Foam, Aquacel Foam
• Hydrocolloid: Tegaderm Hydrocolloid Dressings
• Non-adherent: Adaptic, Inadine

Infection

• Can assess with STONEES (above)
• Assess microbiology
  • Biopsy is most accurate but rarely done
  • Levine technique is next best: debride superficial necrotic tissue, then apply pressure with a swab while rolling it over a 1 cm square area for five seconds