1. Enzymatic Debridement
Collagenase (Santyl)
Digests necrotic collagen
Specific and selective for denatured collagen
Effective when used for long periods of time
Maintenance debridement
Tends to be a slow acting drug

2. Collagenase Considerations Cost Slow acting
Deactivated when combined with heavy metals
Silver:Loses 50% of it’s efficacy when combined with silver.
Can be combined with polysporin powder: good when you’re worried about localized infection.

3. Autolytic Debridement
Autolysis:
Natural degradation of devitalized tissue using endogenous enzymes
Moisture retentive or moisture donating dressing
Occlusive dressing
Eschar and slough are liquefied by rehydration and activity of lysosomes

4. Autolytic Debridement
Indications:
Wounds with necrotic tissue
**No infection (you’re creating a Petri dish)
Wounds with dry eschar particularly benefit
Cross hatching eschar facilitates
Considerations
It’s gross
It stinks
If biofilm gets too aggressive, it means an infection is starting to grow No Autolytic debridement!

5. Autolytic Debridement
Contraindications
Dry gangrene
Poor circulatory support
Not enough lysozomes to make the debridement work but it won’t cause any harm.
Infection

6. Autolytic Debridement
Advantages
Non-invasive
Selective
Does not disrupt healthy tissue
Easy: leave on hours, rinse wound with saline and apply another.
Painless
Stays on for hours before you change it.

7. Autolytic Debridement
Disadvantages
SLOW
Potential to grow bacteria
Can macerate surrounding skin
Watch for sensitivity to adhesive

8. Biological Debridement
Maggot Therapy!
Biosurgical debridement, Larval Debridement Therapy
Role
Debridement (maggots secret collagenase and eat liquefied tissue)
Disinfection (secretions that maggots give off having antimicrobial properties)
Promotes wound healing (Maybe???)

9. Biological Debridement
Initial research published in 1929
But remain widely unused/unpopular
“Ick” factor
Cost
Slow
Removal and disposal questions
Studies limited
DFU 33% slough – traditional, 0% - maggots
VI cost effective compared to hydrogel

10. Biological Debridement
Sterile, medical grade maggots placed in wound
Covered with dressing
Allows oxygen exchange
Contains maggots
Hydrocolloid most commonly used
dressing
In place 1-4 days, make sure you get them ALL out!

11. Sharp Debridement Most widely used – particularly by PT
Scalpel, forceps, scissors (blunt to cut dressings, or sharp to remove tissue), curette (least popular tool)

12. Sharp Debridement Research supports: 2009 retrospective study DFU, VI
Frequent debriders (>2x/12 wks) vs Infrequent debriders (<2x/12wks)
241 wounds
Frequent debriders showed a greater decrease in surface area of wound
Frequent debriders had better median healing rates
Research SUPPORTS sharp debridement!!!!

13. Sharp Debridement Research support: 2009 study of DFU
Growth factors alone vs growth factors with debridement
Growth factor plus debridement healed faster

14. Sharp Debridement Advantages Fast
Method of choice for thick, adherent or large amounts of slough, eschar
Method of choice in presence of infection
If sepsis, surgeon will perform debridement, not PT!
Selective
Can be combined with many techniques
Inexpensive, but questionable reimbursement
Every 20 square cm $25

15. Sharp Debridement Considerations Pain Anticoagulants/bleeding disorder
Blood loss
Silver nitrate to stop bleeding
Enough blood flow?
Potential for infection
Know your anatomy!
Comfort level

16. Sharp Debridement Modified Sterile Technique Sterile gloves
Sterile equipment
Sterile field
NOTE: Sterile gauze is individually packaged. Clean gauze is packaged in bulk in a single package.
Any time you are setting something down, you need to set onto your sterile field. If you set down on a towel etc, you cannot use that tool again!!!

17. Sharp Debridement Things to remember
Position patient and self comfortably!
This can take minutes in some cases!
Wash hands!
Explain the procedure (before bringing in equipment)
ESPECIALLY the first time to reduce anxiety
“only interested in removing dead/harmful tissue, some blood is ok because it means the circulation to the area is good but it is NOT our goal to make you bleed”
Stay sterile
Flush with saline
Dispose of material properly

18. Sharp Debridement Tips: Hold scalpel like a pencil The blade is sharp!
Cut parallel to the surface
Particularly along edges
If you aren’t sure – don’t do it
If not in use - have your safety on!
Take a THIN layer off, you can always go back and remove more, but you cannot replace accidently removed tissue!

19. Debridement
Before Debridement

20. Debridement
After
Debridement
(1 hour later)

21. Negative Pressure Wound Therapy
NPWT
Suction applied to wound via open-celled foam sponge
Foam secured with vapor permeable drape
Suction attached to canister to collect excess drainage

22. Negative Pressure Wound Therapy
Benefits
Edema reduction
Increase perfusion distance = blood flow increase
Increase perfusion
31% to wound bed, 15% to periwound
Stimulates granulation tissue formation
Microdeformation
Removal of exudate
? Bacterial colonization
Increased angiogenesis
Perfusion distance: how far the nutrients go out from the wound bed.

23. Negative Pressure Wound Therapy
Suction mmHg
150 mmHg is common for abdominal wounds
50-75mmHg for feet
Lower pressure on distal wounds
Continuous or intermittent
Intermittent over graft sites or distal foot wounds with poor circulation
Commonly use continuous
Clean application bedside, sterile application in OR
Lots of sponsored research
Increased speed of healing negates cost
Cost of vac is $ per day

24. Negative Pressure Wound Therapy
How it works:

25. Negative Pressure Wound Therapy
Indications
Any type of wound
Size minimum
2.5cm in one direction
Enough room to place a sponge

26. Negative Pressure Wound Therapy
Considerations
Cost
Carry around
Change 2-3x/week
Can Pt self fix?
Can be combines with some other products
Silver is most common
Infection

27. Negative Pressure Wound Therapy
Contraindications
Malignancy in wound
Untreated osteomyelitis
Fistulas/tracts – do you know where they end?
Bleeding: stop bleeding before using suction
Know your anatomy!
No blood vessels, nerve endings, anastamosis, most organs
Can put a vac over exposed bowel (seen a lot with compartment syndrome of the abdomen)

28. Negative Pressure Wound Therapy
How to apply
IMPORTANT!!!! Count the number of foam pieces that you use so you make sure to remove ALL of them!!!!

29. Hyperbaric Oxygen
Inhaled 100% oxygen delivered to patient in enclosed environment pressurized to >1.4ATA
Typically ATA
Easily transported via RBC and hemoglobin
Goal is to increase aerobic cellular metabolism
Growing trend because it is a MONEY MAKER!
2 types of chambers: single placed clamber (right) or multiplaced chamber (Left)
Multi-have to wear masks to breathe in 100% oxygen

30. Hyperbaric Oxygen
0.3 volume percent of oxygen is dissolved in plasma at sea level (1 ATA) breathing RA
6.9 volume percent of oxygen is dissolved in plasma at 3 ATA breathing 100% O2
Increased volume percent = increased diffusion radius = more O2 gets to the tissues
When tissues have more oxygen, they heal faster!

31. Hyperbaric Oxygen So what? Re-establish normal cellular metabolism
Promote angiogenesis
Increase granulation tissue formation
Debate: Salvage marginal tissue?
Decrease tissue edema
Meet increased demand of tissue

32. Hyperbaric Oxygen Indications
Refractory osteomyelitis: (osteomyelitis that has been treated for 30 days with antibiotics but has not responded.)
Acute traumatic ischemic injury/Crush Injury
Compromised skin grafts and muscle flaps
Necrotizing fasciitis
Gas gangrene
Life threatening. Get to surgeon to Debride or amputate immediately!!!
Others:
CO poisoning, smoke inhalation, decompression sickness, arterial gas emboli, cyanide poisoning

33. Hyperbaric Oxygen Contraindications Strongly consider
Untreated pneumothorax
Strongly consider
Fever (signs of septic infection)
Claustrophobia
COPD, CHF
High FiO2 (don’t give them MORE oxygen as it may supress their respiratory drive)
Chemotherapy
It takes 5-7 minutes to decompress the chamber. It can cause Ben’s decompression Syndrome if not given adequate time to decompress.
Full Drive 2-3 hours, 5-6 times a week
Must be prescribed by physician and MD must be on site while performing

34. Skin Grafting Performed by MD or PA
Should be considered with healthy wound beds that are failing to heal
Adequate blood supply
Ability to tolerate
Too much wound exudate is a problem
Will flood out the graft and it won’t take
Graft or flap will not survive if blood supply is inadequate.

35. Skin Grafting Autograft Allograft
From Pt’s own tissue (thigh or buttocks)
Full thickness (rare to take)
Partial thickness (most common)
Allograft
Created from same species (cadaver graft)
Done in OR, usually a hospitalization

36. Skin Grafting Xenograft Performed in office Multiple applications
Created from different species (animal origin)
Oasis Wound Matrix
Dry product (long shelf life)
Performed in office
Multiple applications

37. Skin Grafting Bioengineered Tissue Apligraf, Dermagraft
Living bilayered skin substitute
Epidermal layer formed by human keratinocytes
Dermal layer composed of human fibroblasts in bovine collagen matrix
Contains matrix proteins and expresses cytokines
But no melanocytes, macrophages, lymphocytes, blood vessels, hair follicles or sweat glands
Never looks like normal skin!
Short shelf life, very expensive, have to be kept at a certain temperature

38. Skin Grafting Bioengineered Tissue
Full thickness wounds without exposed structures
Non-infected VI with compression
Used in conjuncture with good wound care
Debridement
Non-infected
Good blood supply** KEY
Without this, the graft won’t take
Off-loading and compression

39. Muscle Flap Flap surgery Musculocutaneous when need to fill depth
Skin grafts on the other hand are superficial
Provides rich vascular tissue
May also require skin grafting
Usually gluteus maximus
If successful, muscle atrophies, but blood supply remains to feed skin
Success rate is 50%

40. Muscle Flap Surgical debridement IV antibiotics x6-8 weeks
Ensure no osteomyelitis
NPWT to maintain health of wound edges
Surgical procedure + hospitalization
Air fluidized bed x6-8 weeks-non-weight bearing
Bed is filled with sand that is constantly circulated to reduce pressure areas. Very expensive! And HEAVY

41. Muscle Flap Muscle atrophies Who? NOT for cushioning
Pressure relief is necessary**
But how did they get the wound in the first place?
May have to do MORE pressure relief than before!!!
Who?
Usually SCI patients
Function can be compromised in ambulatory patients

42. Total Contact Casting Diabetic Foot Ulcer – gold standard
GOAL: Need to offload the foot for healing to occur
Most patients are neuropathic
Can protect foot from further trauma
Can’t feel if it isn’t a good fit
Best if can eliminate 2/3 of weight bearing time

43. Total Contact Casting Benefits
Decreases plantar pressures by increasing weight bearing over entire lower leg
Redistribute pressure
Prevent trauma
Reduce edema
Immobilize joints and soft tissue
Helpful to prevent shear forces

44. Total Contact Casting Considerations
Gold standard, but only 45% of wound clinics perform some sort of offloading
If you do it wrong – can seriously harm
No room for absorption
No where for the fluid to go so it can cause maceration to the whole area!
Close follow-up needed
By patient-time consuming
By clinician
Risk of infection!

45. Total Contact Casting How performed Ulcer covered with gauze
Cotton b/w toes
Stockinette applied
¼ thick felt along malleoli and ant tibia
Foam padding around toes
Plaster shell molded
Walking heel can be attached
Finished with fiberglass roll around plaster
MUST use water between degrees!
Cast hardens in 20 minutes!
Cast is pretty wet when you apply it.
There is a BIG RED line on the outside (make sure that it is straight!)
Easiest to apply if patient is prone!

46. Total Contact Casting Alternatives TCC-EZ
Making TCC easier?
Hard enough to walk on in 20 minutes (enough to get to the car/home) etc but pt needs to let harden for a couple of hours before doing any significant amount of walking.

47. Total Contact Casting Alternatives Cam walker Off the shelf
Better than nothing
Neuropathic Walker (aka: bivalve boot)
Custom molded
Optional rocker sole
Easily removed by patient
Positive and negative attribute
Poor compliance

48. Unna’s Boot
Heavy gauze impregnated with Calamine lotion, zinc oxide paste, glycerin, gelatin
Apply lotion to skin
Start applying wrap
Start at metatarsal heads
50% overlap
No stretch
Circular slightly angled wrap (no figure 8 wrap, not beneficial for edema)
Stop ~1 inch below knee

49. Unna’s Boot Application Stays on 5-10 days
Takes ~1 hour to dry
Can cover with kerlix and ace wrap
Not very firm
Stays on 5-10 days
Removes easily with scissors

50. Unna’s Boot Indications Benefits
Most commonly used for Venous Insufficiency wounds
Benefits
Mandatory compliance
Will moisturize skin
Passive edema control

51. Unna’s Boot Considerations Heavily draining wounds Maceration
Neuropathic patients
Balance-can throw off gait pattern
Infection which can start without notice because it’s on for 5-10 days
Compliance
Dry?
Contact dermatitis
Poor fit with fluctuating edema
Put on for 5-10 days

52. Becaplermin Regranex Gel Platelet derived growth factor Indications
Lower extremity diabetic neuropathic ulcers extending into subcutaneous tissue and beyond
Adequate blood supply
Lots of off label use

53. Becaplermin Should be combined with: 15 gram tube ($600-$800)
Good wound care
Sharp debridement
Must have contact with receptors
Infection control
15 gram tube ($600-$800)
Must be refrigerated
Cannot get heated AT ALL!!!
Diabetic patients are always at increased risk for developing infection!

54. Becaplermin Contraindications Known hypersensitivity
Necrotic Tissue: growth factors won’t be exposed to appropriate tissues
Infection
Neoplasm at the site
Black Box Warning (but NOT pulled from the market)
>3 tubes = increased incidence of cancer**
No specific type
FDA Black Box Warning

55. Pressure Ulcer Prevention
A big part of what we do – unique perspective
Pressure ulcer
Can develop anywhere
Particularly boney prominences
Ischial tuberosity
Sacrum
Greater trochanter
Vertebrae
Scapula
Head/face
Etc, Etc, Etc

56. Pressure Ulcer Prevention
4 main causes of pressure ulcers
Pressure
Shear
Friction
Moisture

57. Pressure Ulcer Prevention
Intensity
Duration
Tissue tolerance: health of overall skin in relation to the pressure it can tolerate
Have to do pressure relief!

58. Pressure Ulcer Prevention
Positioning
Turns at minimum every two hours
Specific to the patient
If poor skin quality or lots of bony prominences, they will need to be turned more often!
Offloading
Occiput, heels, elbows
Wear schedules for splints, braces
Frequent skin checks!!!!
Caution with different skin tones
The darker the skin tone, the harder it is to pick up little changes in the wound

59. Pressure Ulcer Prevention
Positioning
30 degree side turn
HOB <30 degrees
NO DONUTS!
Mattress replacement
Group 1 (static)
Group 2 (dynamic)
Group 3 (fluidized)
less than 30 degrees (ventilator associated pneumonia if on a vent); greater than 30 degrees: increased pressure

60. Pressure Ulcer Prevention
Positioning
In sitting – weight shift every 15 minutes
People naturally weight shift every 7-8 mins
Cushions
But be careful…
Avoid sitting >1 hour if existing ulcer

61. Pressure Ulcer Prevention
Shear
Interplay of gravity and friction
Shearing forces stretch blood vessels, decreasing amount of pressure needed to occlude them
Deep fascia levels over bony prominences
Leads to undermining
If shear is occurring, you develop pressure ulcers MUCH faster!

62. Pressure Ulcer Prevention
Friction
Significant factor in pressure ulcer development
Works with shear to create wounds
Friction alone = blister
Friction + Shear = much bigger problem
Creates huge pressure ulcers.
Draw sheets – but be careful
Pull the patient up too high, then raise the HOB to lower them down…this is where the problem occurs!

63. Pressure Ulcer Prevention
Moisture
Microclimate of the skin
Greatly alters resiliency of epidermis
Incontinence Associate Dermatitis (IAD) vs Pressure Ulcer
IAD
Diaper rash
Skin protectant (zinc oxide, barrier cream)
Management of incontinence

64. Pressure Ulcer Prevention
Nutrition
Malnutrition is a significant risk factor
Malnutrition is a significant factor in wound healing (patient must have an adequate amount of protein for proper wound healing)
Catabolic vs Anabolic
Tests for malnutrition
Albumin: 20 day look at protein intake
Sensitive to hydration, kidney/liver function
Pre-Albumin: short half life
Protein intake hours, effected by kidney failure NOT hydration
History