1. Wounds in General

2. 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.

3. What the mind does not know
The eyes do not see

4. Dermafacta confusiformis
What is

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

6. LFM-CICC
Say it as LFM-Kick!!

7. LFM
Look, Feel, Measure

8. 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)

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

10. 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)

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

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

22. Further imaging
CT scan
MRI
Bone scan/gallium scan

23. Classify Wounds
Acute
Chronic (>4wks)

24. Wound management
Describe
Document
Dress appropriately
Refer

25. Key Common Dressings
Adaptic
Inadine
Aquacell
Mepilex
Honey

27. Surface wound consider non-adherent dressing

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

29. 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

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

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

32. 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

37. 10 Wound Scenario Quiz (Brief history provided)
What is this??
What will you assess??
What will you do??

38. Case 1

39. 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

48. Top tips for Wounds in General

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

50. 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!!

51. 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

52. When in doubt perform a punch biopsy

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

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

55. Always consider doing culture swabs or tissue culture where possible

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

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

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

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

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

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

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

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

65. Raised, heaped edge
Consider Skin cancer

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

67. 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

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

69. 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

70. Special wounds Diabetic Pressure ulcers
Necrotizing soft tissue infections

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

72. Cavity wound consider NPWT

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

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

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

76. Vascular intervention??
Good for macroangiopathy
Will not address microangiopathy

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

78. 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