1. Wound Care Interventions
Kate McKenney PT CWS
June 4, 2013

2. Images
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Images can only be used for educational purposes.

3. Contact Ultrasound – Slide 97
Full thickness wounds
Ultrasound transmission gel to intact periwound and hydrogel to 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

4. (Suspected) Deep Tissue Injury
DTI
Purple or maroon localized area of discoloration
Blood filled blister
May evolve rapidly into a very bad pressure ulcer, or may not evolve at all
Looks like a big bruise especially over a bony prominence.

5. (Suspected) Deep Tissue Injury

6. What we’ve covered Cleansing the wound Debridement Topicals Dressings
PLWS, Syringe Lavage, Whirlpool
Mechanical, Selective vs Non-Selective
Topicals
Dressings
Contact Ultrasound
Electrical Stimulation

7. Contact Low Frequency Ultrasound
Ultrasound assisted wound therapy, ultrasound assisted debridement, Arobella, Qoustic Wound Therapy System
Low frequency kHz (vs 1-3 MHz)
Non-thermal
Creates cavitation
Acoustic streaming

8. Contact Low Frequency Ultrasound
Cavitation
Creation of miniscule gas bubbles in the tissue fluid and coupling medium
Bubbles expand/contract with variation in ultrasound field pressure levels
Bubbles implode; tiny shock waves
Necrotic tissue tensile strength < viable tissue
Shock waves liquefy necrotic tissue, biofilm
No major harm to tissue unless you concentrate on a single area

9. Contact Low Frequency Ultrasound
Acoustic Streaming
Movement of fluids along the acoustic boundaries
Bubbles or cell membrane
Increases cell membrane permeability
Increases vascular wall permeability
Increase protein synthesis

10. Cavitation and Acoustic Streaming
Believed to be responsible for stimulatory effects of cells.
Believed to modulate cell activity
Increase cellular proliferation
Increase collagen deposition*
Increase growth factor activity
Bottom line:
Good for healthy cells*
Bad for bacterial, senescent and devitalized cells

11. Contact Low Frequency Ultrasound
WARNING!!!!! Don’t eat before or during this video!!!
Contact low frequency US provides Therapeutic and bactericidal effects

12. Contact Low Frequency Ultrasound
Indications:
All wounds that require debridement

13. Contact Low Frequency Ultrasound
Benefits:
Immediate results- removal of slough
Selective
Less painful that sharp debridement???
Considerations:
$$$$, no “extra” reimbursement
Can be painful
Be careful, used for “excisional” debridement
Debridement of living tissue
Physician only! (not in scope of practice of PT)
When performing this technique over living tissue, move the contact head more quickly so it doesn’t result in excisional debridement.
Aerosolization and PPE

14. Contact Low Frequency Ultrasound
Contraindications:
All ultrasound contraindications
Malignancy, cardiac area in CHF, etc.
Untreated, advancing cellulitis
Signs of systemic infection
Metal components
Electrical device within treatment area
Uncontrolled pain: know what’s causing this!
DVT, emboli (can break up clot and cause a stroke)

15. Non-Contact Low Frequency Ultrasound
MIST Therapy
Same principles as Contact Low Frequency Ultrasound
No contact = no pain
Reduces pain???
Can be used for maintenance debridement
No harm to healthy tissue
Disposable; 3-5 minutes total
No aerosolization: mist does not come out at high enough PSI to create aerosolization
MUST wear PPE
Some patients reports less pain after MIST therapy, even though the FDA has not stated this technique is for pain relief

16. Non-Contact Low Frequency Ultrasound
Results in stimulated blood low and increased cell proliferation
Cell walls of bacterial will crack open/break down and wash away.
Hold tool perpendicular to the wound
Be as close as possible without touching the applicator tip to the wound
Intermittent bubbling may occur
For wounds greater than 30 cm2 refill saline and monitor.

17. Non-Contact Low Frequency Ultrasound
Indications:
Suspected DTI (deep tissue injury that hasn’t opened up)
Plus any wound
Considerations:
$$$$ (18-25K)
CPT code coming January 1, 2014! (reimbursement to be determined still)

18. Non-Contact Low Frequency Ultrasound
Contraindications
Same as Contact Low Frequency Ultrasound
Less concern with harming living cells because you are not in contact with the tissues

19. Debridement Removal of tissue or foreign material Indications:
Conservative – removal of senescent, dead or devitalized tissue
Aggressive or excisional – removal of living tissue
Done by surgeon/physician in OR
Indications:
Any time there is something that needs to be removed!

20. Debridement Benefits Decrease bacterial load Stimulates growth factors
Exposes cell receptors for growth factor interface
Remove senescent cells
Facilitate angiogenesis
Allow full determination of depth and character of wound bed (which will help with setting a prognosis)
Restart inflammatory or proliferation phase of healing

21. Debridement Considerations Pain Anticoagulants/Bleeding disorder
Know your anatomy!
If you don’t know, don’t remove!
ABI?
Some texts say not to do on anyone with ABI less than 0.5 because there may not be enough blood flow to support debridement
Have to use good clinical judgment to determine whether to do this
Think about what you are doing to increase circulation IF choosing to do this on someone with a low ABI
If less than 0.7 send to see a vascular surgeon to see if they can get a stent, meds etc.
EXPLAIN to the patient what you’re going to do to help minimize pt anxiety.

22. Debridement No – leave it alone! Granulation tissue
Viable or potentially viable tissue
Stable eschar (see picture)
Dry gangrene
Pyoderma Gangrenosum
Muscle, tendon, ligament, capsule, fascia, nerves, blood vessels (things you need!)
Intact blisters

23. Pyoderma Gangrenosum Poorly understood skin condition
1 in 100,000 (rare, but you will see in wound clinic)
Wound that will Rapidly enlarge with trauma and debridement of wound bed (ie: removing a dressing that is stuck to the wound bed, etc)
Unknown etiology
Associated with inflammatory conditions
(bowel disease, RA, immune disorders)
50% of cases are idiopathic
Reoccurrence rate 30%
Almost like an allergic reaction to dressing

24. Pyoderma Gangrenosum Typically lower legs
Edges elevated with undermining
Violaceous borders
Looks similar to hemosiderin staining
Cribiform scarring
Criss cross scarring pattern
Diagnosis by exclusion
There is NOT test for this
In normal wounds, undermining will be associated with flat wound edges, NOT raised!

25. Pyoderma Gangrenosum Treatment Months to years to heal
If suspect, stop debridement and get to dermatologist ASAP!
Wound will appear worse after first treatment
Elevated edges will be worse
Oral steroids
Topical steroids, antibiotic and sometimes immunosuppressant
Months to years to heal
Because you cannot do debridement
Steroids=delayed healing
Get patient a non-adherent dressing and send them to a dermatologist!

26. Debridement We’ve already covered some: PLWS Syringe lavage Whirlpool
Irrigation
Selective vs Non-selective

27. Debridement Additional means: Enzymatic Debridement
Autolytic Debridement
Biological Debridement
Sharp Debridement

28. Debridement What are we trying to do? Necrotic tissue
Eschar (firm, thick)
Slough (yellow, white, tan. Can be easy or hard to remove)
Debris (dressing residue)
Residual topicals
Foreign material
Callus DEFINITELY get rid of!
Biofilm/Bioburden?
Can’t see this but needs to be removed because it can cause infection
Senescent cells
Macerated tissue?
Occurs when wounds get too wet.

29. Debridement Callus (yes) Blister (no)
NEVER NEVER NEVER debride an intact blister no matter what it’s filled with
Debride callus because it’s dead tissue that is building up uncontrollably
3 Problems with calluses:
If callus grows over wound bed, you’re covering it with dead tissue and abcess will grow up into the body
If it continues to grow uncontrollably, it forms a hard core in the center which can create a pressure ulcer under the callus (noted by the blood formation in the callus)
If an open would and the callus is near the wound bed, it creates a donut around the wound (intense ring of pressure around the wound that can break down the wound bed)

30. Debridement Granulation tissue (no)
Do NOT debride. This is viable living tissue!

31. Debridement Slough (yes)
Need to remove so you can visualize the wound bed
Slough can be very adherent and hard to remove
Venous insufficiency wound ( heavy exudate) full of fibrin (protein)= very fibrous, adherent and hard to remove
If you can’t remove with sharp debridement, you can cross hatch the top of the wound to help open up the slough
Reveal as much of the wound bed as you can before you make a prognosis!

32. Debridement Slough (yes)
Slough can also be very loose and easy to remove!

33. Debridement Stable eschar (no) Unstable eschar (yes)
Stable: See pic. Firm. If you push on it, nothing oozes out from around the edges. If the edges are coming up, you can turn it back.
Unstable: very boggy. Liquefied slough will ooze from around the wound if pushed on. This is a sign that debridement is needed!

34. Debridement Tendon (no) Look for striations! This is a TENDON!
IMPORTANT!!! Keep exposed bone and tendon MOIST!
Tendon will start to fray/bone will start to crumble if too dry!

35. Debridement Dry Gangrene (No)
Looks a lot like stable eschar but is thicker, darker and harder. Will eventually shrivel up and fall off. Most patients don’t have sensation so it won’t bother them.