1. Wound Breakdown, Fungating Lesions, Pressure Sores, Fistulae
Rebecca Owen

2. Objectives Stages of Wound Healing Fungating Lesions overview
Types of wound + dressing suggestions
Pressure Sores – common areas and treatment pathway
Fistulae overview
Summary

3. Stages of Wound Healing
Haemostasis
Clotting cascade
Inflammatory
Bacteria and debris phagocytosed and removed
Release of factors causing migration + proliferation
Proliferative
Angiogenesis, collagen deposition, granulation tissue formation, epithelialisation, wound contraction
Remodelling
Collagen remodelled and realigned along tension lines and unneeded cells removed by apoptosis

4. Wound Healing Phases

5. Wound Healing – Primary Intention
“Involves epidermis and dermis without total penetration of dermis healing by process of epithelialization”
When wound edges are brought together so that they are adjacent to each other (re-approximated)
Minimizes scarring
Most surgical wounds
Wound closure is performed with sutures (stitches), staples, or adhesive tape
Examples: well-repaired lacerations,well reduced bone fractures,healing after flap surgery

7. Wound Healing – Secondary Intention
The wound is allowed to granulate
Granulation results in a broader scar
Healing process can be slow due to presence of drainage from infection
Wound care must be performed daily to encourage wound debris removal to allow for granulation tissue formation
Surgeon may pack the wound with a gauze or use a drainage system
examples:gingivectomy,gingivoplasty,tooth extraction sockets, poorly reduced fractures.

8. Wound Healing – Tertiary Intention
(Delayed primary closure or secondary suture):
The wound is initially cleaned, debrided and observed, typically 4 or 5 days before closure.
The wound is purposely left open
examples:healing of wounds by use of tissue grafts.

14. Fungating Lesions Can be associated with
Pain
Pruritis
Exudate
Malodour
Bleeding
Infection
Consider topical morphine, NSAIDs (pruritis), abx,
Treat exudate + infection with appropriate dressing

15. Fungating Lesions Malodour Psychological Support
Clense and debride surface
Topical/systemic metronidazole
Live Yoghurt (topically)
Manuka Honey (Activon) (topically)
Mask odour with camphor, herbs,incense
Psychological Support

17. Skin Tear
Occurs when friction + shearing forces cause tissue layers to slide across each other breaking blood vessels
Caused by sliding patients in bed,agitated patients moving in bed, removal of adhesive dressings

18. Skin Tear Management Remove dressings using “lateral pull” technique
Mepitel dressing + dry gauze
Change Mepitel every 5-7 days
Change gauze when saturated

20. Wet Wound with Granulating Tissue
Aims
Minimise dressing changes
Relieve the pressure that caused the ulcer
If increasing exudate then consider infection
Maximise nutrition and hydration
Suggested dressing – Aquacel
Place sheets in wound bed and cover with dry dressing
Cover dressing depends on wetness
Daily – Gauze; 2-3/7 – Alldress, 3-5/7 – Allevyn/Mepilex
Multiple layers of aquacel can minimise dressing changes
Change Aquacel when it has turned into a gel

22. Cellulitis
Local infection of dermis and subcutaneous tissue characterised by spreading redness, pain and swelling.
Monitor demarcation by marking and dating the skin
Consider systemic/topical antibiotics
Use Mepitel on wound bed to reduce surface pain
Change every 7/7 or PRN

24. Sacral Ulcer Remove/prevent pressure on area Observe for infection
If problems with incontinence – consider barrier cream i.e. Cavilon
Sacral Shaped Tegasorb – dressing of choice

25. Applying a Sacral dressing
Fold sacral dressing in half
Pinch the fold to form a crease "Bookmarking"
Peel off the entire backing
Insert "bookmark" into the patient's fold, above the rectum and secure the dressing up the middle
Secure the dressing out the sides using the heat of your hand and slight pressure to help it adhere
Slowly peel away the border while securing the tegaderm with your fingers

27. Clean Wound with Granulating Tissue
Remove/prevent pressure on affected area
Maximise nutrition and hydration
Sugessted foam dressing such as Mepilex
Dressings can remain on wound for 7/7

29. Wound with Yellow Slough
Stage X as wound bed cannot be visualised
Pain management with dressing changes
2 options of treatment:
Option 1 - cut silver dressing, such as Acticoat to fit into the wound bed and moisten with sterile water. Cover with a light dressing (gauze and tape or  “island dressing” such as Alldress). Ensure daily that Acticoat dressing is moist. Change Acticoat 3/7.
Option 2 - Spread a thin layer of Iodosorb on a gauze and place in wound bed.Cover with island dressing (such as Alldress) or foam. Change dressing q 3 days, when Iodasorb changes to a creamy colour.
(NB) make sure patient doesn’t have thryroid issues—Iodosorb has iodine & contraindicated if thyroid condition or breast-feeding mother).

31. Diabetic/Neuropathic Ulcer
Most common on plantar aspect of foot,heels and over metatarsal heads
Dry,warm, cracked, fissured skin, thickened nails
Usually no oedema/exudate
Causes – peripheral neuropathy,arterial insufficiency, poor microvascular circulation, inadequate blood glucose control
Treatment – debridement plus mepilex/Allevyn + Intrasite gel

32. Pressure Sores
Several factors that increase risk of developing a pressure sore:
Mobility problems
Poor nutrition
Underlying health condition
Age >70 yrs
Urinary &/or bowel incontinence
Serious mental health conditions

34. Treatment of Pressure Sores
Changing position
Mattresses and cushions
Dressings
Creams and ointments
Antibiotics
Nutrition
Debridement
Maggot therapy
Surgery

36. Fistulae
Abnormal communication between 2 hollow organs or between a hollow organ and the skin
Aetiology
Anastomotic leaks
Trauma - often iatrogenic post surgery
Inflammatory bowel disease
Malignancy
Radiotherapy

37. Fistulae Types Rectovaginal/Rectovesical fistulas
Conservative/Surgical
Enterocutaneous fistulas
Simple
Single orifice with intact abdominal wall
Multiple
Multiple orifices in abdominal wall
Disrupted
Fistula caused by dehiscence or surgical wound/scar

38. Imaging Important to determine anatomy of fistula
Fistulography will define tract
Small bowel or barium enema will define state of intestine or distal obstruction
US and CT will define abscess cavities

42. Management of Fistulae
Usually conservative management - at least initially - consisting of:
Skin protection
Upper GI contents are very corrosive
Correction of fluid and electrolyte loss
Require careful fluid balance & restoration of blood volume
Correction of acid-base imbalance
H2 Antagonist, proton pump inhibitor to reduce gastric secretions
Somatostatin analogues (e.g. Octreotide) to reduce GI and pancreatic secretions

43. Management of Fistulae
Tissue viability review
Nutritional support
Restrict oral intake and possibly an nasogastric tube
Malnutrition corrected with either parenteral or enteral nutrition
Total parenteral nutrition given via Dacron-cuffed tunneled feeding line
Radiological screening to ensure tube in correct site
Enteral nutrition can be given distal to fistula
Control of sepsis
Abscess cavities should be drained
Antibiotics

44. Enterocutaneous fistulas will not close if:
There is total discontinuity of bowel ends
There is distal obstruction
Chronic abscess cavity exists around the site of the leak
Mucocutaneous continuity has occurred

45. Fistulas are less likely to close if:
They arise from disease intestine (e.g. Crohn's Disease)
They are end fistulae
The patient is malnourished
They are internal fistulas

46. 60% will close in one month once sepsis has been controlled with conservative treatment
Mortality associated with fistula is still at least 10%
Surgery should be considered if fistula does not close by days

47. Summary Fully assess area and cleanse thoroughly
Use appropriate dressing – if in doubt ask
Treat malodour
Be aware need of ongoing psychological support

48. Any Questions?

49. References
Symptom Management in Advanced Cancer; (2009) Twycross, Wilcock, Toller.
Blowers A L  Irving M.  Enterocutaneous fistulas.  Surgery 1992; 10.2: 27 – 31
Dubrick S J,  Maharaj A R,  McKelvey A A.  Artificial nutritional support in patients with gastrointestinal fistulas.  World J Surg 1999;  23: 
Mcintyre P B.  Management of enterocutaneous fistulas: a review of 132 cases.  Br J Surg  1984; 71: