1. Kelly D. Moore P.T., MBA, CWS, DPT
Wound Care Quickies
Kelly D. Moore P.T., MBA, CWS, DPT

2. Objectives Be able to identify types of chronic wounds
Understand NPUAP staging changes for pressure ulcers
Determine what’s important in dressing choices
Options for debridement other than sharp

3. What’s This? A. Arterial ulcer B. Pressure ulcer C. Venous Ulcer
D. Diabetic Ulcer
* content/uploads/2013/07/venous-stasis-ulcer

4. Venous Ulcer Most likely
Shallow, wet, gaiter area of the leg, hemosiderin around periwound, coke bottle shaped LE
What is the most likely cause?
* content/uploads/2013/07/venous-stasis-ulcer

5. Venous Ulcer Poor arterial blood flow Pressure Venous HTN Diabetes
* content/uploads/2013/07/venous-stasis-ulcer

6. What Else? What tests would we do prior to treating this wound?
Temperature
ABI
MRI
Sed rate
* content/uploads/2013/07/venous-stasis- ulcer

7. Treatment? How do we treat, if all tests are negative? Leave it alone
Gauze
Hydrocolloid
Multilayer Compression
* content/uploads/2013/07/venous-stasis- ulcer

8. Multilayer Compression
Contact layer
Layer 1- padding, absorbs exudate, protects bony prominences, slight redistribution of pressure, overlap each layer 1/2
Layer 2- Light conforming bandage, adds absorbency and smoothes out the 1st layer, preserving the elastic energy, overlap each layer ½
*Smith-nephew.com

9. Multilayer Compression
Layer 3- compression bandage, usually very conformable to accommodate different shapes, stretch to 50%, use figure 8 for this layer, cut off left over bandage
Layer 4- Coban like wrapping, apply with 50% tension, adheres to itself
*Smith-nephew.com

10. Compression Compression increases healing rates*
Multicomponent systems are more effective than single component*
2-component appear to be as effective as 4 component*
*O’Meara, S, Cullum N, Nelson EA, Dumville JC, Compression for venous leg ulcers. Cochrane Database Syst Rev Nov.14; 11

11. What’s This A. Arterial Ulcer B. Venous Ulcer C. Pressure Ulcer
C. Neuropathic Ulcer
*WOCN Image Library

12. Arterial Ulcer Most likely
Dry, cold, tips of extremities, due to poor arterial flow from atherosclerosis
*WOCN Image Library

13. Tests What do we need to test? Pedal Pulse ABI Doppler
C-reactive protein
a., b., c.
*WOCN Image Library

14. How Do We Treat? If this is the isolated issue what do we do?
Leave it alone, protect
Debride till it bleeds
Calcium alginate
Foam dressing
*WOCN Image Library

15. What else could it be? Thromboangiitis obliterans- Buerger’s disease
Still don’t know why certain smoker’s react this way to tobacco
No cure, stop smoking
*cdc.gov/tobacco

16. What’s This? Arterial Ulcer Venous Ulcer Pressure Ulcer
Neuropathic Ulcer
*Picture: Jeavons_fig3r2

17. Neuropathic Ulcer What are important tests? ABI
Semmes-Weinstein/28 Hz vibration
Sed Rate
Temperature
a., b., d.
*Picture: Jeavons_fig3r2

18. Neuropathy

19. How do we treat it? A. Wound vac B. Trim callus, total contact cast
C. Leave it alone and it will heal on its own
D. Local dressing with CROW walker boot
E. B & D
*Picture: Jeavons_fig3r2

20. How do we treat it? Gold standard is Total Contact Casting
If untrained, we must offload this foot
CROW walker, Boot with Rocker bottom
*Picture: Jeavons_fig3r2

21. What are these?

22. Blue Healers! 

23. Back to Wound Care! What’s This?
Neuropathic Ulcer
Venous Ulcer
Pressure Ulcer
Arterial Ulcer
*WOCN Image Library

24. Pressure Ulcer
NPUAP has addressed new standards for pressure sores as of
Friction is no longer a word associated with Pressure, but Sheer continues to be in the language.
@NPUAP.org
*WOCN Image Library

25. NPUAP Staging
NPUAP.org

26. What Stage is This? Stage I Stage II Stage III Stage IV Unstageable
Suspected deep tissue injury
*HPIM0096.jpg

27. What Stage is This? Stage I Stage II Stage III Stage IV Unstageable
Suspected deep tissue injury
*ouhsc.edu/geriatric/medicineeducation/pu/dti_s mall.jpg

28. How Do We Treat? Remove the pressure
Control the micro environment with debridement and dressing choices
Support the host
Educate
*WOCN Image Library

29. Wound Bed Preparation 2015*
Paradigm
Healable wounds
Maintenance wounds-potential to heal, but co-morbids, patient adherence, or healthcare resources limitations
Non-healable wound-cannot heal due to irreversible causes or associated illnesses, including critical limb ischemia or nontreatable malignancy*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp

30. Wound Bed Preparation 2015*
Local wound care is dependent on:
Debridement-removal of all necrotic tissue
Inflammation and infection- recognition and management
Moisture balance- in the wound bed interface, clean and moist*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp

31. Recognize Inflammation/Infection
NERDS- if three or more present treat topically
Nonhealing wound
Exudative wound
Red and bleeding wound surface
Debris (yellow or black) on surface
Smell or unpleasant odor from wound*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp
STONEES- if three or more are present treat systemically
Size is bigger
Temperature of 3 degrees or more versus mirror image
O Probe to or exposed bone
New or satellite areas of breakdown
Exudate is increased*

32. Debridement Autolytic Sharp Mechanical
Chemical/enzymatic- Santyl-Collagenase*
Maggots
Low frequency ultrasound- no touch
High frequency ultrasound- touch
Lavage
*smithandnephew .com

33. 5 Types of Antimicrobial Dressings
Silver- see next slide
Polyhexamethylenebiguanide (PHMB)
Iodine
Methylene blue/crystal violet
Honey- see next slide
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp

34. Silver and Honey Roll is to provide antimicrobial effect in wounds
Of the previous five, these two have an anti- inflammatory effect as well^
When patient setting of high nosocomial infection, silver provides good barrier against MRSA and other hospital born bugs*
Manuka Honey has been studied and appears to have antimicrobial properties as well*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp
*Hamm,RL, Text and atlas of wound diagnosis and treatment, McGraw Hill, p , 2015

35. Characteristic of Ideal Dressing
1. Provide moist wound environment
2. Manages exudate
3. Facilitates autolytic debridement
4. Provides antimicrobial properties
5. Prevents contamination, impermeable
6. Compatible with support needs
7. Controls temperature
8. Prevents particulate or allergen contamination
9. Is easily applied and removed
10. Cost effective and available*
*Hamm, RL, Text and atlas of wound diagnosis and treatment, McGraw Hill, p. 347, 2015

36. Moisture Balance
Hydrogels- donates moisture, bioresorbable, can be combined with silver, cadexomer iodine
Films- semipermeable, protective layer, moisture neutral, autolytic
Hydrocolloids- Water-binding and water-repelling components, absorbs a small amount of moisture, autolytic*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp

37. Moisture Balance
Hydrofibers- bind small to moderate amounts of moisture, fluid lock, nonbioresorbable, autolytic
Calcium alginates- absorb moderate amounts of exudate, fibers are bioresorbable, they release calcium and resorb sodium to form hydrogel with fluid. Can be used with silver or honey*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp

38. Moisture Balance
Foams- polyurethane, absorb moderate to large amounts of exudate
Superabsorbents- polymer-containing for highly exudative wounds, same technology as diapers and feminine hygiene, fluid lock prevents peri-wound maceration
Non-stick dressings- usually petroleum coated, allows wound to drain or bleed without pain of removal*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp

39. Moisture Balance
NPWT- Closed, airtight system, promotes a moist wound bed by keeping humidity incased in wound
Studies demonstrate increased blood flow as compared to normal dressings, due to the vacuum effect removing cytotoxic compounds from the wound bed as part of the wound fluid.
Mechanical deformation- physical stretching of the cells increases mitotic activity via the “mechanical stress theory
There is a significant decrease in the levels of MMP-2 and 9 with NPWT, these delay angiogenesis*
*Wound Healing Evidence-Based Management, 4th edition, McCulloch & Kloth

40. How do we determine dressing?
Primary- part touching the wound bed
Secondary- may cover primary or fill space
Drainage
Necrotic tissue
Eschar
Granulation tissue
Epithelial tissue
Weight bearing/pressure*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp

41. Drainage Amount, color, odor important
Use absorptive dressings such as calcium alginate, foam, hydrofibers
May use secondary dressing for occlusiveness like hydrocolloid or transparent dressing
If bleeding, may need non-stick dressing on wound surface such as Xeroform or Adaptic or Telfa
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp
^xeroform, adaptic and telfa- product names

42. Necrotic tissue Black Dry Wrap with gauze and protect
If re-vascularized, may debride
If good pulses and blood flow, debride

43. Eschar/Slough Appears wet Yellow, brown or green
Can become dry and blackish as it dries
Need to debride,
How?
*medetec.co.uk

44. Collagenase
Only product on the market approved by the FDA for enzymatic debridement
Papain- Accuzyme, Allanfil, Allanzyme, Gladase, Panafil- taken off the market in 2008
Papain taken off due to harmful or near fatal effects including anaphylaxis, cardiovascular symptoms*
*fda.gov/Drugs/GuidanceComplianceRegularotyInformation

45. Granulation Tissue
Small buds of extracellular matrix forming in the base of the wound
Protect, keep moist
*Medscape.com

46. Epithelialization Movement of cells across the wound base
Stops by contact inhibition *
*files.forensicmed.webnode

47. So, What Type of Dressing?
First, what must we know?
Non-adherent, short stretch bandage
Vasoline impregnated gauze, short stretch bandage
Non-adherent, 4 layer compression wrap
Hydrocolloid
* /547_Venous%20ulcer.jpg

48. How do we dress this? What must we know first?
Negative pressure wound therapy
Compression with four layer system
Short stretch bandage
Leave it alone and protect it with a lot of gauze
*wourldwidewounds.com/2002/december/Leaper /images/heel.jpg

49. How do we treat? What is it? Debride callous, total contact cast
Compression with short stretch bandage
Hydrocolloid
Protect callous and add pressure
*WOCN Image Library

50. Quickie Reminder
If you see a blister it is usually caused by friction or a shear force
If you see a callus, this is usually a pressure based issue*
*Sibbald, GR, Elliott, JA, Ayello, EA, Somayaji, R, Optimizing the Moisture Management Tightrope with Wound Bed Preparation 2015, Advances in Skin & Wound Care, Vol. 28, 10, Oct. 2015, pp

51. How do we treat this? Top wound? Hydrocolloid Gauze Calcium alginate
Depends on drainage amount
Lower wound?
Pack with calcium alginate/hydrocolloid
Just hydrocolloid
Pack with gauze/cover with gauze and tape
Pack with iodoform gauze and cover with ABD pad and tape
*img.medscape.com granulation

52. Debridement Autolytic- let the wound fluid debride
Sharp- scalpel, scissors and tweezers
Mechanical-wet to dry- ouch!
Chemical/enzymatic- Santyl-Collagenase*
Maggots- works great, hard to get
Low frequency ultrasound- no touch
High frequency ultrasound- touch
Lavage
*smithandnephew .com

53. Low Frequency US Benefits
Cellular changes via cavitation and microstreaming
Increased energy delivery compared to high frequency US during same treatment time
Fluid mobilization in interstitial tissue
Decreased wound pain
Increased cellular permeability
Non contact application for wound cleansing and tissue stimulation
Bacterial killing and removal*
*Hamm,R, Text and atlas of wound diagnosis and treatment, McGraw Hill Education, p

54. Low Frequency MIST Ultrasound
*claridenhealth.com

55. What’s This?
*diseasespictures.com

56. Pyoderma Gangrenosum
Independent auto-inflammatory disease, related to inflammatory bowel disease
Presents on LE’s
Wounds break down quickly and demonstrate violaceous, boggy borders with erythema
Center develops yellow fibrinoid exudates
Must treat with immunosuppression and steroids
*Wound Healing Evidence-Based Management, 4th edition, McCulloch & Kloth

57. Pyoderma Gangrenosum DO NOT DEBRIDE
*Wound Healing Evidence-Based Management, 4th edition, McCulloch & Kloth

58. DO NOT DEBRIDE WHEN? Pyoderma Gangrenosum No arterial blood supply
Medically unstable patient
Caution: Blood thinners and bleeding issues
*Wound Healing Evidence-Based Management, 4th edition, McCulloch & Kloth

59. Necrotizing Fascitis
Usually group A strep, klebsiella, Clostridium, e-coli, staph aureus, aeromonas hydrophila
Must be aggressive with wound care, begin antibiotics as quickly as possible*
*cdc.gov/Features/NecrotizingFasciitis/index.html