1. Betadine Providone Iodine Used to “dry out” dry gangrene
Goal is to keep dry gangrene contained and free of outside bacteria
Cytotoxic

2. Dakin’s Solution Diluted bleach Completely cytotoxic
No known resistance, but no healing occurs
Never use >48-72 hours

3. Acetic Acid Diluted vinegar Excellent for pseudomonas aeruginonoa
Used during pulse lavage followed by NS rinse
Lymphedema patients=because of the rich protein, pts are prone to getting cellulitis.

4. Polyhexamethylene biguanide (PHMB)
Lavasept, Serasept (used to prep skin for s(x)
Broad spectrum
Used in foam dressing
Kill bacteria in drainage
More preventative measure than treatment
Kendall AMD, Suprasorb X + PHMB

5. Cadexomer Iodine Providone Iodine combined with cadexomer starch
Allows for a slow, sustained release
Cytotoxic to bacteria, but low levels not cytotoxic to healing cells
Iodosorb

6. Topical Ointments Silver sulfadiazine (Silvadene, burn cream)
Collagenase (Santyl)
Metronidazol Gel (MetroGel)
Mupirocin (Bactroban)
Bacitracin, neomycin, polymixin B (Triple antibiotic ointment, Neosporin)

7. Silver Sulfadiazine Silvadene, burn cream
Sulfonamide plus antimicrobial silver
Cant tolerate the concentration needed to kill some bacteria.
It’s all we had for a long time
It is cytotoxic
Particularly beneficial for:
Pseudomonas
Acute burns

8. Silver Sulfadiazine It’s cytotoxic – particularly to fibroblasts
Do not use >2 weeks
2008 Cochrane Review
Prolongs healings
Not recommended for use
Allergic reactions to sulfa
Burning and pain when applied

9. Collagenase Enzymatic debridement (Santyl) Digests necrotic collagen
Specific and selective for denatured collagen
Effective when used for long periods of time
Maintenance debridement=when gets down to healthy, helps prevent slough from building up.

10. Collagenase Considerations Cost Slow acting
Deactivated when combined with heavy metals
Silver

11. Metronidazole gel MetroGel Beneficial for anaerobic contamination
Fungating wounds (end stage breast cancer, tumor is evasive and grows out, highly vascularized.
Can be combined with Mupirocin to treat MRSA
Helps with order control from wound.

12. Mupirocin
Bactroban
Bacteriostatic (bacteria lives, but can’t replicate) or Bactericidal (kills the bacteria)
Gram positive organisms including MRSA
Resistance is developing

13. Bacitracin, Neomycin, Polymixin B
Triple antibiotic ointment, Neosporin
Available in ointment or powder
Powder can be combined with collagenase
Allergies becoming more common

14. How to Dress a Wound Moist wound healing is best
Goal of a dressing is to maintain appropriate moisture level
If necessary, lightly fill a cavity
No “packing”
Creates too much pressure
Whatever goes in, how are you going to get it out?

15. How to Dress a Wound Considerations Cost/insurance
Ease of Pt or caregiver to perform
Can you see what your applying a dressing to?
Allergies

16. Gauze - Use
Any wound!

17. Gauze - Advantages Many forms Versatile Cheap Readily available w/o Rx
4x4, 2x2, strip gauze, roll
Versatile
Flat, opened, fluffed, filling/packing
Cheap
Readily available w/o Rx
Mechanical debridement
Can be used with any topical or solution

18. Gauze - Disadvantages Traumatic/painful removal Dries out easily
Does not keep outside bacteria out
May require a secondary dressing
Leaves debris in wound bed, particularly if cut
Frequent use, longer need affects cost

19. Foams - Use Stage II-IV pressure ulcers PT, FT wounds
Infected or non-infected
Donor sites
Minor burns
Moderate to heavily exudating (Ins requirement)

20. Foams - Advantages Options Moderate to heavy drainage
Bordered vs non-bordered
Adhesive vs non-adhesive
Silver impregnated
Sheets, ropes
Moderate to heavy drainage
Safe under compression wraps

21. Foams - Disadvantage
Can macerate skin if drainage extends to wound border
Cost
Decreasing insurance reimbursement

22. Alginate/Hydrofiber - Use
Calcium alginate or synthetic hydrofiber
Stage II-IV pressure ulcers
PT, FT wounds
Moderate to heavily exudating
Tracts, undermining
Infected wounds

23. Alginate/Hydrofiber - Advantages
Keeps wound bed moist
Can be impregnated with silver, Leptospermum honey
Hemostasis properties
Atraumatic removal when fully hydrated
Variety – sheets, ropes

24. Alginate/Hydrofiber - Disadvantages
Requires secondary dressing
Can dry out and adhere to wound
Can leave debris/lint
Can macerate unprotected skin

25. Collagen Donating - Use
Donate synthetic or porcine collagen to wound bed
Provides the scaffolding for cells to populate and migrate
Attracts cells to the wound site
Increase cellular proliferation
Any wound – but needs bountiful granulation tissue

26. Collagen Donating - Advantages
Non-adherent, comfortable
Can be left on up to 7 days, need to keep wet.
Can combine with lots of different products as long as still in contact with wound bed
Does lots of great stuff for the wound bed

27. Collagen Donating - Disadvantage
Cost $30-35 per sheet
Requires a clean, non-infected wound
Requires secondary dressing

28. Transparent Film - Use Polyurethane with porous adhesive
Allows transmission of oxygen and moisture vapor
Can be primary or secondary dressing
Stage I or II pressure ulcers
Superficial burns
Donor sites

29. Transparent Film - Advantages
Visualize wound thru dressing
Impermeable to fluid and bacteria
Autolytic debridement (more on that later…)
Dressing can be on up to 7 days
Lots of different sizes
Silver impregnated available

30. Transparent Film - Disadvantage
Does not absorb drainage
Adheres to skin
Possible skin reaction
Can cause maceration

31. Hydrocolloid - Use Primary or secondary dressing
Stage I, II pressure ulcers. Shallow stage III, IV
Not how deep, but rather how deep the bone is below.
PT, FT
Superficial burns
Hydrophilic colloid forms gel on contact with wound fluid
Impermeable

32. Hydrocolloid – Advantages
Maintain moist environment
Impermeable to moisture, bacteria
Autolytic debridement
Wear 3-7 days
Self adhering and conforms to any shape
Can be impregnated with silver

33. Hydrocolloid – Disadvantage
Minimal absorption
Contraindicated in presence of infection
Can be difficult to remove, skin tears
No undermining or tracking
Stinks!
Can NOT have any sign
Infection.

34. Hydrogels - Use Donate moisture to a wound
Non-crosslinked polymers plus water and/or glycerin
Can be impregnated with silver
Can be used in any type of wound
Many forms – gel, sheets
Gel can be used with any type of dressing

35. Hydrogels - Advantages
Great for donating moisture
Radiation burns: does permanent damage to skin for rest of life with be poor healing.
Autolytic debridement
Easily removed from wound without trauma
Can reduce pain

36. Hydrogels - Disadvantages
Potential for maceration
Requires daily changes
Requires secondary dressing
Unless bordered sheet
Sheets cannot be used with heavy drainage
Cannot act as a filler

37. Miscellaneous Dressings
Methylene blue and gentian violet
Absorptive, bacteriostatic
Hydrofera Blue
Leptospermum honey
Debridement, antimicrobial, many forms
Medihoney
Cutimed Sorbact
Hydrophilic dressing that traps bacteria, bacteriostatic

38. Modalities 10-15% wound closure in one week is NORMAL wound healing
If failing to meet this on a regular basis…

39. Electrical Stimulation
One of the oldest >30 years
Strength of evidence: Level A
Medicare reimbursement only if wound is considered “chronic”
Traditional wound care >30 days without progress

40. Electrical Stimulation
How does it work in wounds?
Strong evidence it works, theory on how
“Current of Injury”
When cells are injured – they give off a negative charge
Believed that in chronic wounds – this is broken
Goal of e-stim is to mimic this current
Accelerate or “jump start” wound healing cascade

41. Electrical Stimulation
What does it do?
Stimulates fibroblasts, collagen synthesis
Increase receptor sites for growth factors
Improved tissue perfusion
Decreased edema
Increase tissue oxygen
Decrease pain
Increase tensile strength

42. Electrical Stimulation
High Volt Pulsed Current (HVPC)
Most commonly used for wound care
Monophasic waves
Studies show galvanotaxis occurs in wounds with cells required for tissue repair

43. Electrical Stimulation
Galvanotaxis by the Anode (+)
Neutrophil
Macrohages (acute inflammation)
Epidermal cells (end phase)
Endothelial cells

44. Electrical Stimulation
Galvanotaxis by Cathode (-)
Neutrophils (+ charged when wound is infected)
Fibroblasts
Need Fibroblasts for angiogenesis and proliferative phase of healing
ALWAYS START (-)!

45. Electrical Stimulation
Indications
Any type of wound
Contraindications
Basal or squamous cell carcinoma in area
Osteomyelitis
Suspected, new or if not responding to antibiotics
Pain, deep ache, infection of exposed bone, increased drainage, neuropathic and foot hurts.
Ion residue in wounds (e.g. silver)
Over electrical implants, over the heart or carotid artery, near laryngeal musculature

46. Electrical Stimulation
Duration:
45-60 minutes
Frequency
5-7 times/week done at home.
100pps
Electrode placement
12:00 and 6:00
3:00 and 9:00
Dispersive pad about 30cm from wound
Saline moistened gauze in wound bed for conduction

47. Electrical Stimulation

48. Ultrasound Contact ultrasound Non-contact ultrasound
Used in wound healing >50 years
Not so much recently
Non-contact ultrasound
Much more trendy
Next week

49. Ultrasound High frequency 3 MHz for superficial dermal wounds
1 MHz for deeper structures and periwound
1 MHz = 3-5 cm depth
3 MHz = <2 cm

50. Ultrasound Any stage of healing: Before application: Pulsed mode
20% duty cycle
Before application:
Cleanse periwound skin with mild soap and water and rinse well.

51. Ultrasound Indications: Contraindications: Locally infected wounds
Impaired circulation
Pressure, diabetic, arterial, venous, traumatic, surgical
Contraindications:
Untreated cellulitis
Metal components (joint replacement, screws, plates)
Electronic device in field
Uncontrolled pain

52. Ultrasound Full thickness wounds Partial thickness wounds
Ultrasound transmission gel to intact periwound and wound bed, then hydrogel sheet
Partial thickness wounds
Hydrogel sheet directly over the wound including 4-6 cm onto the periwound
Cleanse applicator with antibacterial agent
Ultrasound get on top of hydrogel sheet

53. Ultrasound Intensity Time: Frequency
Acute/inflammatory phase: 0.3 W/cm2
Proliferative: 0.5 W/cm2
Remodeling: 0.5 to 1.0 W/cm2
Time:
1-2 minutes per zone
Frequency
2-3 times per week