Wounds in General

Conflict of Interest Declaration: Nothing to Disclose Presenter: Dr. Sajay Azad Title of Presentation: Wound Care I have no financial or personal relationship related to this presentation to disclose.

What the mind does not know The eyes do not see

Dermafacta confusiformis What is this?!@£$%^&*()_+

Content-Wound in General Wound Basics—Theory and Practice 10 Wound Scenarios—Q&A session Top Tips for wound management

LFM-CICC Say it as LFM-Kick!!

LFM Look, Feel, Measure

Simple techniques to assess wounds---Skin System First step---LFM LOOK(site/size/edge/floor/surrounding skin) FEEL (slough (loose/tough),underminings/suppleness/induration/odor/adherence to bone and tendon/ lymphadenopathy/joint mobility/neurovascular status) MEASURE (length/width/depth)

Culture/Investigate/Control/Consult CICC (Kick) Culture/Investigate/Control/Consult

Second step---CICC CULTURES (aerobic/anaerobic)---deep tissue/bone cultures. Blood cultures as well INVESTIGATE (Hgb/WCC/ESR/CRP/HbA1c/Wound or bone biopsy/CT Scan/MRI scan/Bone scan etc) CONTROL (DM/smoking/obesity/IVDU/cardiac) CONSULT (Wound care/ ID/CCDC/Physio/OT/family/Nutritionist/ ICU/Psychologist/Vascular/ortho/plastics/derm)

Undermining Indicate disease process Need for ‘hidden area debridement’ Indicates no healing of tissues due to lack of healing potential More complicated process

Culture, Investigate, Control and Consult CICC “The Kick” Culture, Investigate, Control and Consult

Further imaging CT scan MRI Bone scan/gallium scan

Classify Wounds Acute Chronic (>4wks)

Wound management Describe Document Dress appropriately Refer

Key Common Dressings Adaptic Inadine Aquacell Mepilex Honey

Surface wound consider non-adherent dressing

Dressings can cause allergic reactions Watch out for this especially tape which is notorious for blisters and contact allergies

Dressings Wet to dry dressings---defunct Packing---deeper cavity wounds? Adherence control---Adaptic/Inadine Exudate control---Alginates/Hydrogel/Hydrocolloid Smell control---Metronidazole gel Healing…………..Hopefully

Frequency of dressings Infected/oozy/smelly-Daily Not overtly infected wound---Alternate day dressings Burn/Stable wound---twice a week

NPWT Not the answer to every wound Not substitute for flap Best in deeper wound with discharge Cannot remove deep slough

NPWT No concrete evidence to suggest type of sponge/pressure/mode makes any difference. No evidence to support use of antibiotic infusion or irrigation modes

10 Wound Scenario Quiz (Brief history provided) What is this?? What will you assess?? What will you do??

Case 1

Cases Diabetic foot Pyoderma gangrenosum Pressure ulcer Necrotic skin cancer Cellulitis of the hand Leg ulcer Granulating wound Deep sloughy wound Bruised hand due to thin skin Necrotizing soft tissue infection

Top tips for Wounds in General

Any wound not healing after 3-4wks should be considered a problem wound Why is it not healing

Never forget the ‘Skin system’ in your regular clinical examination Twice a week on rounds Highlight to residents/nurses/therapist THIS PATIENT HAS A SKIN SYSTEM PROBLEM!!

Factors worth addressing Personal hygeine Smoking Diabetes Substance abuse Vascular issues Foreign body in wound (retained stitch) Positioning issues Family support Educating the patient regarding the wound

When in doubt perform a punch biopsy

Shallow slough versus deep, adherent slough When deep it probably needs surgical debridement

Deep yellow or black tissue requires debridement Thin yellow tissue on wound should be ok, but always think of Biofilm

Always consider doing culture swabs or tissue culture where possible

When in doubt consider using non-adherent dressing like Adaptic or Jelonet

Wound washing Desirable---clears surface debris, promotes hygiene, facilitates healing

Pain relief critical To aid compliance To facilitate dressing changes Must be non-addicting Facilitates mobilization Overall better healing plan

Establish boundaries of care Compliance is critical to improvement Wound treatment Establish boundaries of care Compliance is critical to improvement

Deep wound Complex wound, vital structures involved, probably plastic surgery intervention for closure

Any wound without exposed deeper structures and less than a ‘looney size’ will heal typically with good wound care

Exposed bone/tendon/cartilage/nerve/blood vessel/joint Flap---piece of tissue with its own blood supply

Rapid disease progression Necrotizing soft tissue infection---NSTI (Nec Fasc)

Raised, heaped edge Consider Skin cancer

Frequency of labs Twice a week adequate for most Hgb/Albumin/ESR/CRP/WCC Cultures at most dressing changes

Urgency of specialist review NSTI---Immediate Infected and discharging wound---Urgent Gr A strept---Urgent Chronic wound/leg ulcers---Non-urgent (2-3days) Pressure ulcers---Non-urgent (2-3days) Large wound---review in ambulatory care by specialist

Streptococcus spells trouble and must be cleared before any reconstruction Because of fibrinolysis, ability to spread infection, high graft and flap failure

Amputation versus salvage for Diabetic foot Hind foot bone involvement Multiple deep plane involvement Severe N-V compromise Smoker Diabetes ++ Lack of compliance Failure of trial of limb salvage for 3months Limb salvage Forefoot and mid foot involvement Non smoker Well controlled DM Motivated and compliance receptive Contralateral limb amputation

Special wounds Diabetic Pressure ulcers Necrotizing soft tissue infections

If no suspected cancer or deep slough in a deeper wound Black sponge NPWT at pressure of 75-100mmHg at either Continuous/Intermittent mode Intermittent mode is better when wound is starting to granulate

Cavity wound consider NPWT

All specialists feel that it is not their total domain? Wound care would be useful to consult to direct patient care

MRP status issue? Specialist find it useful to have FP/Internal medicine input as MRP status requires that broad expertise

Dry, shrivelled toe or finger?? Betadine application daily Natural autoamputation Proximal infection---Surgical removal and drainage Significant chance of Whole Limb Loss

Vascular intervention?? Good for macroangiopathy Will not address microangiopathy

Wound healing not complete?? Complete wound healing is aim but partial wound healing is reality and should be emphasized to patient and family

Is this wound palliative?? Frail/elderly/severe cardio-pulmonary disease/DM++/protein deficient despite full intervention/smoker/non compliant/IVDU/2 failed major reconstructions/lack of family support