1. CURRENT CONCEPTS IN WOUND CARE
Tim Brandys MD FRCSC

2. OUTLINE: Moist Wound Healing Acute vs. Chronic Wound Wound Bed Prep
Pressure Ulcers
Leg Ulcers
Dressing Selection
Cases

3. Moist Wound Healing: George Winter 1960’s Advantages:
-inc.rate reepithelialization
-inc. production collagen
-inc. angiogenesis
-allows autolytic debridement
-Decrease pain
-Dry dressings peel off healing layers
-accelerates healing 50% vs.air dry

4. Acute vs. Chronic wound Healing:

5. Acute Wound Healing: Orderly sequence Repair
4 Phases: Hemostasis,Inflammation,Proliferation,
Maturation.
Each Phase=Cell Type dominate
Hemostasis=Plt.,Inflamm.=Neutrophil,
Prolif.=Fibroblast,Maturation
All regulated by growth factors,cytokines,&chemokines

6. Chronic Wound:
Stuck in the Inflammatory Phase,defective remodeling of ECM,fail to reepithelialize.

7. CHRONIC WOUND Usual Molecular & Cellular processes disrupted
Neutrophils dominate: release MMP’s in excess-digest extracellular matrix
Leaky capillaries- release excess Fibronectin binds & inactivates growth factors

8. Chronic Wound:
Fibroblasts become senescent fail to respond to normal wound healing signals
Neutrophils continue to stimulated (by systemic or local factors) and wound is left in a viscous circle of inflammation.
Other Chronic wounds are stuck in the proliferative phase again due to unresponsive cells

9. Wound Bed Prep

10. Wound Bed Prep.:
Goal: Convert the Chronic wound into an Acute wound and allow normal healing to take place.

11. Wound Bed Prep.: Three Pronged Attack
1. Debridement
2. Decrease Bacterial Burden
3. Manage wound Exudate

12. Debridement:
Purpose: 1. To remove “Necrotic Burden”and restore acute wound healing.
2. To allow proper wound assessment.

13. Surgical Debridement:
Advantages:
Remove large amounts necrotic tissue fast.
Allows bone, tissue cultures
Leaves healthy vasc. Bed
Disadvantages:
Painful
Can remove too much

14. Enzymatic Debridement:
Collagenase selectively digests collagen types 1 & 3 in necrotic tissue
Advantages: Easy,Not painful
Disadvantage: Slow

15. Decrease Bacterial Load:
All Chronic wounds sit somewhere along a bacterial continuum.
Contaminated
Colonized
Increased bacterial burden
Infected

16. Infection: Risk = Bacterial x Virulence Infection Burden Microorganism
Host Resistance

17. Infection Concepts: Host Resistance : Immunocompromised, Malnutrition
Bacterial Burden: >10 5th microbes/g
Biofilm: Microcolonies of Bacteria secrete protective glycocalyx

18. Manage Wound Exudate: Chronic Wound Exudate :
Inhibits: Proliferation Fibroblasts,Keratinocytes,Endothelial cells
Contains MMP’s,Serine Proteases
Fibrinogen &Fibrin bind and inactivate growth factors

19. Hospital Wounds:

20. Pressure Ulcers:

21. Leg Ulcers:

22. Dressing Selection: THERE IS NO UNIVERSAL WOUND DRESSING
THE DRESSING MUST FIT THE WOUND
DRESSINGS MUST BE REASSESED FOR EACH PHASE OF WOUND HEALING

23. Dressing Selection: INFECTED ACTICOAT: Ionized silver
Antimicrobial:
ACTICOAT:
Ionized silver
Broad spec. MRSA/VRE
IODOSORB:
Cadexomer Iodine
Broad spec.
Decr. Foul odour
Absorbent

24. Dressing Selection: HYROGEL: Moist env. Autolysis LOW EXUDATE
Decrease pain
LOW EXUDATE

25. Dressing Selection: ESCHAR,SLOUGH ENZYMATIC DEBRIDEMENT:
Collagenase-selective
Digestion types 1 and 3 collagen in necrotic tissue

26. Dressing Selection: LIGHT EXUDATE HYDROCOLLOID: Duoderm
Wound granulating

27. Dessing Selection: Moderate to heavy exudate FOAM: Allevyn
Hydrophillic polyurethane foam
Absorbs up to 4 days

28. Dressing Selection: Moderate to Heavy Exudate ALGINATES -Seaweed
-Turns to gel
-Moist Wound Environment
-Hemostatic
-Can be drying

29. Dressing Selection: Moderate to Heavy Exudate HYDROFIBER AQUACEL
-Turns into gel
-Moist wound Environment

30. Dressing Selection: VENOUS ULCER COMPRESSION BANDAGE
Profore-4 layer compression
ABI >.8

31. Dressing Selection: LARGE WOUND CAVITY 1.Allevyn Cavity 2.THE VAC
Sponge with suction unit
-stimulates angiogenesis,causes wound contraction

32. CASES

33. CASE 1:
70 yo smoker admitted with pancreatitis to the ICU.Required prolonged stay on the ventilator.Physical exam reveals absent pedal pulses and a painful necrotic left heel ulcer.
What do you do now?

34. CASE 2:
40 yo male paraplegic admitted to medicine with UTI .Develops a large ischial ulcer while in hospital.Surgery is consulted.
WHAT DO YOU DO NOW?

35. Case 3 :
Otherwise healthy 35 yo female suffers lacerations to right leg during accident with farming equipment.Transferred to plastic surgery after failure to heal wounds in peripheral hospital.
WHAT DO YOU DO KNOW?

36. CASE 4:
50 yo diabetic male is referred to the orthopedic surgeon with a non healing ulcer over the plantar surface 1st metatarsal head left foot.
WHAT DO YOU DO NOW?

37. CASE 5:
65 yo female comes to the Vasc.Surg clinic with a large left ankle ulcer.It is painless and has a lot of exudate.The ulcer has failed to heal despite wet to dry saline dressings.
What Do You Do Now ?