Wound care

Epidemiology: 9% of all hospitalized patients for pressure sore 15% of D.M. patients will have foot ulcer Even with successful treatment of ulcer healing, the recurrent rate can be high as 66% and 12% may need amputation

Etiology: DIDN’T HEAL: 1. Diabetes  C.O↓, PP↓, phagocytosis↓ 2. Infection 3. Drugs: steroids & antimetabolites 4. Nutritional problems : protein,Vit A,C, Zn 5. Tissue necrosis 6. Hypoxia 7. Excessive tension on wound edges 8. Another wound 9. Low temperature: distal aspects (1-1.5°C ↓)

Special etiologies: Arterial insufficiency Venous insufficiency Lymphedema Neuropathy Pressure ulcers Neoplasms Radiation damage Atheroembolism syndrome Pyoderma gangrenosum

Special etiologies: Sickle cell Calciphylaxis Necrobiosis lipoidica Vasculitis wounds Anticoagulant-induced skin necrosis Actinomycosis Yaws Mucormycosis Cutaneous anthrax

Systemic obstacles: Poor wound healing D.M. sorbitol & hyperglycemia- associated nonenzymatic glycosylation Hypothyroidism T3,T4↓  fibroblast function↓  colla gen ↓ Age Growth factor↓  inflammation & proliferation phases↓ Pain Adrenergic  vasoconstri ction Tissue perfusion↓ Trauma, burn, sepsis, organ failure Inflammation respon.↑, clotting cascades↓ vasoconstriction, microvas. thrombosis Nutrition Arg. Met.↓  inflamma.↑ Gln↓  Φ, neutrophils↓ Vit, Cu, Se, Mg↓  coll↓ Zn↓  reepithe. & coll↓ Genetic syndrome Others Smoking↑  all – affects of wound healing, corticosteroids  coll.↓ Radiation, Chemo  coll↓

Types of wound: Acute wound: 1. Not yet gone through the normal healing phases 2. Cleansed of contaminants & dead tissues ASAP (Better with N/S; adding antibiotics  no benefits) 3. Culture may needed and with antibiotics 4. Compartment syndrome 5. In ER or in OR for initial debridement  serial debridement every hrs until only viable & soft tissues without erythema  ready for closure 6. 1-week golden period  get wound ready for reconstruction

Types of wound: Chronic wound: 1. Know the source & extent of infection. 2. The edge of the erythema around the wound should be delineated and timed as a reference point for antibiotics or debridement. 3. Pay attention of gas product of anaerobics.  especially for the diabetic foot with gas agngrene are frequently missed. 4. Debridement should be limited to removing only frankly necrotic tissue until the limb has adequate revasculization.  unless gas gangrene or rapidly ascending infection

Types of wound: Infected wound: 1. Know the source & extent of infection. 2. The edge of the erythema around the wound should be delineated and timed as a reference point for antibiotics or debridement. 3. Pay attention of gas product of anaerobics.  especially for the diabetic foot with gas agngrene are frequently missed. 4. Debridement should be limited to removing only frankly necrotic tissue until the limb has adequate revasculization.  unless gas gangrene or rapidly ascending infection

Types of wound: Chronic wound: 1. Superficially colonized with bacteria and may harbor a deeper infection. 2. Debridement may not necessarily the first step. e.g.: vasculitic ulcers (treat the underlying disease) 3. After the cause of the wound is determined and treated, debridement of the ulcer should be the next step.  serial debridement until bleeding, soft, normal- colored tissue is reached.

Types of wound healing: Primary healing: clean laceration or surgical incision is closed primarily with sutures, Steri-Strips, or skin adhensive. Secondary healing: wound is left open to heal by granulation, contraction and epithelialization Delayed primary healing: wound that are not clean enough for primary closure. The wound is left open for 5-10 days; then suture closed to decrease the risk of wound infection.

Phases of wound healing: Hemostasis and inflammation: 1. From immediately upon injury through days 4 to 6 2. Clotting cascade, chemotaxis and activation Proliferative phases: 1.Epithelization, angiogenesis and provisional matrix formation 2.Day 4 through 14 Maturation and remodeling: 1. Deposition of collagen in an organized and well-mannered network. 2. From day 8 through year 1

Factors affect wound healing: 1. Endothelial cell apoptosis by TNF- α 2. Neutrophil activity↓ 3. Fibroblast activity↓ 1.Prolonging the inflammatory phase. (collagen degradation) 2.>10 5 organisms/g tissues or β-hemolytic Strep.  no heal 1.Prolonging inflammation. 2.Can’t contract, repopulate with capillaries, epithelize. 1.↑capillary closure on critical closing pressures.  cell death, tissue necrosis and no heal of the wound 2. Interstitial pressures↑  perfusion↓  impaired healing

Adjuncts to wound healing: Bioengineered skin replacements: -- providing growth factors, cytokines, collagen matrix Electrostimulation: -- skin surface always negative (-40mV than deeper skin) -- imitating natural electrical current that occurs in skin when it is injured. -- ↑migration of cells vital to wound-healing process Hydrotherapy: -- pulsed lavage↑granulation tissues formation Hyperbaric oxygen: -- Normal subcutaneous tissue oxygen tension: 30~50 mmHg -- Controversial. (some--↑failure; others--↑NO then heal)

Adjuncts to wound healing: Lasers: --Low-energy laser (Biostimulation)  ↑0.1~0.5°C  ↑cellular activity (↑VitC uptake, stable membrane) ) Light-emitting diodes: -- wavelength 680,730,880nm simutaneously -- therapy for neural cancers, leikemia, lymphomas Negative pressure therapy: -- remove interstitial fluids  tissue oxygenation -- granulation tissues↑& <10 5 organisms / g tissues -- Contraindication: (1) Wound contain necrotic tissue (2) Untreated osteomyelitis (3) body cavity or organ fistula (4) malignancy in wound (5) foam dressing directly on exposed arteries & veins.

Adjuncts to wound healing: Ultrasound: -- the lower the frequenct, the deeper the penetration -- non-thermal: change cell membrane permeability -- thermal: improve scar condition -- ↑cellular recruitment, collagen synthesis, angiogenesis, contraction, proliferative healing phase Dressing: -- maintain high humidity at the wound/dressing interface -- remove excess exudate & gaseous exchange -- provide thermal insulation -- impermeable to bacteria -- keep the wound free of particles and toxic -- Be removable wothout causing trauma

Dressing & wound healing: Unbroken skin: -- pressure relief -- increasing local circulation Epithelializing wound: -- moist wound bed allows for better healing -- hydrogels, silver ion- impregnanted dressings ( in previously heavily colonized wound bed that is begging to progress through stages of healing)

Dressing & wound healing: Exudative wounds: -- fluids released lead to deeper infection or pocket of devitalized tissue and peri-wound skin -- Foams, gel-coated dressings support autolytic debridement in wounds -- Macerated and dehisced incision can be treated using cadexomer iodine, a versstile product that cleanses wound by absorbing pus, exudates, bacteria, enzymes and cellular residue.

Dressing & wound healing: Fibrinous wounds: -- Fibrin is a natural byproduct of proteins that develops in wound beds. -- If it’s left in place  delay wound healing by blocking the formation of granulation tissues.  a great medium for bacteria growth  excessive metallopreteinases -- occlusive or semiocclusive dressing for autolytic debridement ( hydrogel, hydrocolloid, transparent film dressing or with topical enzymatic debriding agents)

Dressing & wound healing: Infected or critically colonized wounds: -- Critical colonization refers to a condition where the bacterial bioburden in the wound reaches a level that interferes with healing but do not produce the classic signs and symptoms of infection. -- Clean infected wound: 1. Do not use antiseptics 2. Use wet dressing or silver- containing dressing. -- Dirty infected wound: Use antiseptics -- Both can use topical antibiotic ointments

Dressing & wound healing: Necrotic wounds: -- hydrocolloids, enzymatic debriding agents, antimicrobials and antiseptics can be used. -- Slough: (1) devitalized connective tissue that is moist, stringy & yellow (2) sharp debridement -- Eschar: (1) thick, leathery and black. (2) debridement

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