CURRENT CONCEPTS IN WOUND CARE

Tim Brandys MD FRCSC

OUTLINE:

• Moist Wound Healing

• Acute vs. Chronic Wound

• Wound Bed Prep

• Pressure Ulcers

• Leg Ulcers

• Dressing Selection

• Cases

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

Acute vs. Chronic wound Healing:

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

Chronic Wound:

• Stuck in the Inflammatory Phase,defective remodeling of ECM,fail to reepithelialize.

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

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

Wound Bed Prep

Wound Bed Prep.:

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

Wound Bed Prep.:Three Pronged Attack

1. Debridement

2. Decrease Bacterial Burden

3. Manage wound Exudate

Debridement:Purpose: 1. To remove “Necrotic Burden”and

restore acute wound healing.

2. To allow proper wound assessment.

Surgical Debridement:

Advantages: • Remove large amounts

necrotic tissue fast.• Allows bone, tissue cultures• Leaves healthy vasc. Bed

Disadvantages: • Painful• Can remove too much

Enzymatic Debridement:

Collagenase selectively digests collagen types 1 & 3 in necrotic tissue

Advantages: Easy,Not painful

Disadvantage: Slow

Decrease Bacterial Load:• All Chronic wounds sit somewhere along a

bacterial continuum.

Contaminated Colonized Increased bacterial burden

Infected

Infection:

Risk = Bacterial x Virulence

Infection Burden Microorganism

Host Resistance

Infection Concepts:

• Host Resistance : Immunocompromised,

Malnutrition

• Bacterial Burden: >10 5th microbes/g

• Biofilm: Microcolonies of Bacteria secrete protective glycocalyx

Manage Wound Exudate:Chronic Wound Exudate :

Inhibits: Proliferation Fibroblasts,Keratinocytes,Endothelial cells

Contains MMP’s,Serine Proteases

Fibrinogen &Fibrin bind and inactivate growth factors

Hospital Wounds:

Pressure Ulcers:

Leg Ulcers:

Dressing Selection:

THERE IS NO UNIVERSAL WOUND DRESSING

THE DRESSING MUST FIT THE WOUND

DRESSINGS MUST BE REASSESED FOR EACH PHASE OF WOUND HEALING

Dressing Selection:

INFECTED Antimicrobial:

ACTICOAT:Ionized silverBroad spec. MRSA/VREIODOSORB: Cadexomer IodineBroad spec.Decr. Foul odourAbsorbent

Dressing Selection:

LOW EXUDATE

HYROGEL:

Moist env.

Autolysis

Decrease pain

Dressing Selection:

ESCHAR,SLOUGH ENZYMATIC

DEBRIDEMENT:

Collagenase-selective

Digestion types 1 and 3 collagen in necrotic tissue

Dressing Selection:

LIGHT EXUDATE HYDROCOLLOID:

Duoderm

Wound granulating

Dessing Selection:

Moderate to heavy exudate

FOAM:

Allevyn

Hydrophillic polyurethane foam

Absorbs up to 4 days

Dressing Selection:

Moderate to Heavy Exudate

ALGINATES

-Seaweed

-Turns to gel

-Moist Wound Environment

-Hemostatic

-Can be drying

Dressing Selection:

Moderate to Heavy Exudate

HYDROFIBER

AQUACEL

-Turns into gel

-Moist wound Environment

Dressing Selection:

VENOUS ULCER COMPRESSION BANDAGE

Profore-4 layer compression

ABI >.8

Dressing Selection:LARGE WOUND

CAVITY

1.Allevyn Cavity

2.THE VAC

Sponge with suction unit

-stimulates angiogenesis,causes wound contraction

CASES

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?

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?

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?

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?

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 ?