1. ‘Understanding Skin And Wound Care’ Injecting Injuries and Wound Care Causes and Treatment Alison Coull Lecturer Department of Nursing and Midwifery, University of Stirling Honorary Specialist Nurse, Harm Reduction Team, Lothian Note- patient images have been removed to protect confidentiality and conform to consent agreements.

2. Aims u To provide context for skin problems in injectors u To identify main problems u To differentiate between minor and major wounds u To discuss treatment options

3. Context u 86% of users attending medical clinics report cutaneous adverse effects u Access to wound care services may be poor u Perceived confidentiality related to service use u Some serious illness manifests itself initially in the skin

4. Injecting Drug Use The use of drugs to support addiction which are injected through the skin. People who are involved with drugs may have multiple social and medical problems which may impact on skin condition.

5. Background of Poor Systemic Health u Malnutrition u Poor Hygiene u Blood-borne viruses u Thrombosis u Mental health issues u Low Self-esteem

6. Implications of Injecting u Breach of protective barrier u Skin damage and scarring u Vein and vascular damage u Clostridia infection u Necrotizing Fasciitis u Osteomyelitis

7. Common types of wounds seen in drug users include: u Lumps and bumps u Abscesses u Injuries related to self harm u Traumatic wounds u Groin sinus u Chronic leg ulcers

8. Vascular Background u Arteries have thicker walls and work at higher pressure – they carry blood to the peripheries u Veins have thinner walls and carry blood back to the heart and lungs u Vein valves stop blood pooling as a result of gravity u Women have thinner veins

9. Injecting technique: venepuncture, skin and muscle popping u Injecting into the vein allows the drug to go straight into the bloodstream. The blood contains many white cells to deal with ‘foreign’ organisms. u Injecting into the subcutaneous tissues or into muscle allows the drugs to linger causing micro- organisms to thrive and tissue death

10. Problems with injecting u Drug – heroin / cocaine / benzodiazepines u Micro-organisms u Skin hygiene u Acid u Undissolved particles u Poor technique u Filter materials

11. Lumps u Poor injecting technique u Layered vein wall u False Aneurysms u Raised hardened lumps u Usually not red, hot or painful

12. Abscesses u Painful, red, raised lumps u Hot to touch u Filled with pus u Usually caused by micro-organisms

13. Chronic Leg Ulceration u Wounds on the leg which are present for 4 weeks or more u May be independent of injection site u Require different assessment

14. Chronic wound: Groin Sinus u Femoral vein is larger, and thicker u More tolerant of repeated venepuncture u A sinus can develop allowing repeated use u Occasional arterial misadventure

15. Life threatening symptoms u Necrotizing Fasciitis (clostridia) u Often begins with a cellulitic response from an established break in the skin but may start in deeper tissues u Erythema, bruising, grey discolouration, purple areas. u Vesicles containing foul smelling watery fluid known as ‘dishwater pus’

16. Wound Botulism u Double vision / Drooping eyelids u Slurred speech / Difficulty swallowing /Dry mouth

17. Deep Vein Thrombosis u Injecting may cause inflammation u Inflammation may promote clotting u This leads to swelling u Vein valve damage u Clot may break off and lodge in lungs

18. Post-Thrombotic Syndrome u Prolonged swelling u Heavy aching leg u Multiple venous ectasia u May lead to ulceration u Can be prevented / relieved by compression therapy

19. Assessment 1 History u When was it injected? u What was injected? u How was it injected? u How is it now, compared to yesterday?

20. Assessment 2 Examine the patient u Any new changes u Raised temperature? u Malaise? u New systemic signs? u Compare limbs

21. Assessing lumps and bumps Examine the area : warning signs u Redness heat swelling u Generally malaise u Spreading redness u Pus u Malodour

22. Examine the wound: Infected Caused by micro- organisms which evade the victims immunological defences, enter and establish themselves within the tissues of the person and multiply successfully.

23. Infection: Common signs u Infection tends to be painful and hot u Redness is spreading u Sometimes pus / malodour u Requires antibiotics

24. Healthy Wounds Aim for this! u Clean u Healthy u Bright red u Normal surrounding skin u Granulating

25. Principles of wound healing u Moist and warm environment speeds healing by improving cell division and migration u Always dress a wound that is wet u Very small scabbed areas or dry surgical stitch lines can be left exposed to the air

26. Managing wounds : cleansing u Tap water u Irrigate u Don’t clean with anything that leaves fibres behind u Do not rub u Do not dry wounds

27. Slough u A mixture of dead white cells, dead bacteria, re- hydrated necrotic tissue and fibrous tissue. u Can be soft or fibrous u Often yellow, green or grey

28. Black necrotic / red healing u Dead Tissue u May be due to ischaemia, infection, disease, or injury. u May appear blue- black, grey, or yellow.

29. Infection u May be managed with a topical antiseptic u Antibiotics – need to be taken at regular intervals and often don’t mix with alcohol

30. Open Abscesses u Pack with dressing such as alginate u Cover with absorbent foam or low adherence dressing u Keep moist and warm

31. Filling Space u Wounds heal from the base up u Cavities should be filled loosely with packing material - NOT ribbon gauze. u This allows the wound to drain, and for the base to fill with granulation tissue, but prevents a pocket forming with skin healing over.

32. Alginates e.g. Kaltostat, Seasorb, Sorbsan, Algisite M u Manufactured from seaweed u Forms soft flexible gels u Causes mild inflammatory reactions u Highly absorbent u Haemostatic u Lowers bacterial count

33. Hydrocolloids Granuflex, Duoderm, Comfeel,Tegasorb u Waterproof u Absorbent - light to moderate exudate u Can be left in place for 7 days u Suitable for desloughing / debridement

34. ‘Holes’ u Moist and warm u If large enough to ‘fill’ pack with alginate u If small, cover with a low adherence dressing

35. Low-adherence Dressings e.g. Mepore, Melolin,Release u Simple fibrous absorbent layer enclosed in porous plastic film u Minimal absorbency u May shed fibres u Suitable for temporary cover u Cheap

36. Black and red inflamed wound u Aim to remove black necrosis u Soften with water based hydrogel u Treat spreading red cellulitis with antibiotics

37. Hydrogels e.g. Granugel, Intrasite, Purilon, Sterigel u In contact with the wound, creates a moist environment, absorbing exudate and allowing rehydration of necrotic tissue. u 80% water u Can be left in place for 3 days

38. Foams e.g. Allevyn, Lyofoam, Tielle u Polyurethane foam u Highly absorbent u Non-adherent u May reduce pain u Comfortable

39. Legs may be different! u Leg wounds tend to become chronic in drug users because of venous damage u If remaining unhealed at 4 weeks they require vascular assessment u Usually require compression bandaging

40. Typical characteristics of venous disease in injecting drug users u Multiple small puncture sites u Skin staining u ‘Congested’ feet u High ABPI

41. Compression Therapy e.g 4-layer bandaging, hosiery

42. Managing wounds u Universal precautions – gloves and apron u Stop any bleeding with pressure u Cleanse any debris u Cover with a simple dressing (mimic the skin) u Provide a barrier against micro- organisms

43. Summary u Injecting Drug Users have both minor and major skin problems u Assessment is important – injection, history, cause, site u Infection can be serious u Referral should be considered but may not always be appropriate.