Wound Care

By : Dr Gopikrishna .B .J Asst Professor Dept of P.G.Studies in Shalyatantra S.D.M.C.A, Hassan

Anatomy of Skin

Skin: structure and function

Largest organ of the body Primary function is protective Composed of several layers
Outer Epidermis and Stratum Corneum Dermis, containing the capillary network Subcutaneous layer (hypodermis, adipose layer)

Thickness varies from a thin membrane at internal flexures (e.g. elbows), to thicker at the soles of the feet which bear considerable pressures Hair follicles, sebaceous glands, and sweat glands pass through the epidermis, but arise from the dermal layer

Definition
A cut or break in the continuity of any tissue, caused by injury or operation

Classification of wounds

According to their nature :

Abrasion Contusion Incision Laceration Open Penetrating Puncture Septic etc

According to the number of skin layers involved Superficial

Involves only the epidermis

Partial Thickness
Involves the epidermis and the dermis

Full Thickness
Involves the epidermis, dermis, fat, fascia and exposes bone

According to contamination
Clean - (non traumatic) Clean contaminated Contaminated Dirty

According to Grading by tissue Involvement Grade I non-blanchable erythema of intact skin. Discoloration of the skin, warmth, oedema, induration or hardness may also be used as indicators in people with dark skin. Grade II partial-thickness skin loss involving epidermis, dermis or both.The ulcer is superficial and presents clinically as an abrasion or blister.

Grade III full thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia Grade IV extensive destruction, tissue necrosis or damage to muscle, bone or supporting structures with or without full thickness skin loss.

The ways in which wounds heal

Three basic classifications exist:
Healing by primary intention Two opposed surfaces of a clean, incised wound (no significant degree of tissue loss) are held together. Healing takes place from the internal layers outwards Healing by secondary Intention If there is significant tissue loss in the formation of the wound, healing will begin by the production of granulation tissue wound base and walls. Delayed primary healing If there is high infection risk patient is given antibiotics and closure is delayed for a few days e.g. bites

Wound healing
All wounds heal following a specific sequence of phases which may overlap The process of wound healing depends on the type of tissue which has been damaged and the nature of tissue disruption The phases are: Inflammatory phase Proliferative phase Remodelling or maturation phase

The healing process

Day 0 5 The healing response starts at the moment of injury the clotting cascade is initiated This is a protective tissue response to stem blood loss The inflammatory phase is characterised by heat, swelling, redness, pain and loss of function at the wound site Early (haemostasis) Late (phagocytosis) This phase is short lived in the absence of infection or contamination

Granulation
Day 3 14 Characterised by the formation of granulation tissue in the wound Granulation tissue consists of a combination of cellular elements including: Fibroblasts, inflammatory cells, new capillaries embedded in a loose extra-cellular collagen matrix, fibronectin and hyularonic acid

Angiogenesis
Collagen first detected at day 3 and rapidly increases for approx. 3 weeks, then more gradually for the next 3 months Fibroplasia (fibroblast proliferation and synthetic activity) continues in parallel with re-vascularisation Endothelial cells from the side of venules closest to the wound begin to migrate in response to angiogenic stimuli (angiogenesis) forming capillary buds, then loops

Epithelialisation
The epidermis immediately adjacent to the wound edge begins to thicken within 24hrs after injury In approximated incised wounds reepithelialisation is usually complete within 48hrs.

Maturation
Can last up to 2 years New collagen forms, changing the shape of the wound and increasing the tensile strength Scar tissue, however is only ever approx. 5080% as strong as the original tissue During the remodelling process there is a gradual reduction in cellularity and vascularity of the reparative tissue

Contraction
Only undesirable where it leads to unacceptable tissue distortion and an unsatisfactory cosmetic result Wound contraction usually begins from day 5 and is complete at approx. day 12 - 15

Moist wound healing

Basic concept is that the presence of exudate will provide an environment that stimulates healing Exudate contains:
Lysosomal enzymes, WBC s, Lymphokines, growth factors ..

There are clinical studies which have shown that wounds maintained in a moist environment have lower infection rates and heal more quickly

Factors affecting wound healing

Local Factors 1. Infection 2. Presence of necrotic tissue 3. Poor blood supply 4. Venous or lymph stasis 5. Tissue tension 6. Haematoma 7. Large defect or poor opposition 8. Recurrent trauma 9. X-Ray irradiated area 10. Wounds over joint & back 11. Underlying diseases like osteomyelitis & malignancy

General Factors
Age Obesity Vitamin deficiency Anaemia Malignancy Uraemia Jaundice Diabetes, metabolic diseases HIV & immunosuppressive diseases Steroids & cytotoxic drugs Neuropathies of different causes

Complications of wound healing

1. Implantation cysts 2. Painful scars 3. Cicatrisation 4. Keloid formation 5. Neoplasia

Practical considerations
The cause of the wound Underlying disease processes
Current health status

Medication Acute or chronic? Attitude to the wound Availability of care

Healing requirements
Identification of the hindrance to healing Adequate nutritional status Adequate perfusion and oxygenation High quality, research-based patient and wound management Correction of the underlying cause of the problem Disease management

Wound assessment
Signs of infection
Lab tests: TcPO2

Size, depth & location

Odour or exudate

WOUND ASSESSMENT

Wound bed: necrosis

Wound edge

Surrounding skin: colour, moisture,

granulation

Clinical appearance
Slough (yellow) Necrotic tissue (black) Infected tissue (green) Granulating tissue (red) Epithelialising (pink)

Sloughy wound
 

Aim: to liquefy slough and aid its removal Dead cells accumulated in exudate Prepare wound bed for granulation Assess wound depth and exudate levels Hydrogels, hydrocolloids, alginates and hydrofibre dressings

Necrotic wound
 

Aims: to debride and remove eschar Provide the right environment for autolysis Assess wound depth and exudate levels Hydrogels, hydrocolloid dressings

Infected wound


  

Aims: reduce exudate, odour and promote healing Clinical signs of infection Swab wound systemic antibiotics Treat symptomatically: exudate and odour control Change dressings daily

Granulating wound


   

Aims: support granulation, protect new tissue, keep moist Assess depth and exudate levels Moist wound surface non-adherent dressing Treat over-granulation Hydrocolloids, foams, alginates

Epithelialising wound


Aims: to provide
suitable conditions for re-surfacing , films, hydrocolloids Disturb as little as possible

 

Wound characteristics
Exudate Odour Condition of tissue within the wound Condition of the surrounding skin

The surrounding skin Eczema Psoriasis Maceration/excoriation due to exudate or bowel contents Self-inflicted damage

Dressing choice
The purpose of dressings: To aid debridement To remove excess exudate To control bleeding To protect a wound To support healing

The ideal dressing

A dressing that Creates the optimum Environment Wound debridement Wound cleansing Alternative therapies

Dressing choice
Non-adherent wound contact materials Films Hydrogels Hydrofibre dressings Hydrocolloids Foams Alginates Miscellaneous

Wound Cleansing
The aims of wound cleansing are to remove any foreign matter such as gravel or soil, to remove any loose surface debris such as necrotic tissue and remove any remnants of the previous dressing.

Traditional methods: Swabbing with cotton wool Antiseptic solution Dry dressings Daily change of dressing/wound inspection

Lotions and potions Hypochlorites Hydrogen peroxide Chlorhexidine Proflavine Saline 0.9%

Saline 0.9%
The only completely safe cleansing agent Safe to use with wound management products Sachets, plastic containers and aerosols for easy irrigation

Necrotic wounds
Aim: to debride and remove eschar Masks the full extent of the wound Provide the right environment for autolysis Assess wound depth and exudate levels Hydrogels, hydrocolloids, alginates, hydrofibre dressings

Sloughy wounds
Aim: to liquefy slough and aid its removal Dead cells accumulated in exudate Prepare wound bed for granulation Assess wound depth and exudate levels Hydrogels, hydrocolloids, alginates and hydrofibre dressings

Infected wounds Aim: reduce exudate, odour and promote healing Clinical signs of infection Swab wound systemic antibiotics Treat symptomatically: exudate and odour control Change dressings daily

Granulating wounds
Aim: support granulation, protect new tissue, keep moist Assess depth and exudate levels Moist wound surface non-adherent dressing Treat overgranulation Hydrocolloids, foams, alginates

Epithelialising wounds
Aims: to provide suitable conditions for re-surfacing N.A. ultra, films, hydrocolloids Disturb as little as possible

Film dressings
Semi-permeable primary or secondary dressings Clear polyurethane coated with adhesive Conformable, resistant to shear and tear Do not absorb exudate Examples: Tegaderm, Op-site.

Hydrocolloids
Pectin, gelatin, carboxymethylcellulose and elastomers Environment for autolysis to debride sloughy or necrotic wounds Occlusive --> hypoxic environment to encourage angiogenesis Waterproof Different presentations e.g. Urgotul

Foam dressings Advanced polymer technology Non-adherent wound contact layer Highly absorptive Semi-permeable Various types Adhesive and non-adhesive

Hydrogels
Sheets or gels Starch and polyacrylamide (94% water) Low exudate, shallow wounds Re-hydrates necrotic tissue Secondary dressing needed May cause skin maceration

Alginates
Seaweed dressings Form a gel over the wound Moderate to high exudate wounds Easily removed Can cause pain Help to debride a wound Different presentations

Tissue Viability
Documenting wound care Potential for litigation Good staff communication Continuity of care To assess progress or deterioration Should be factual not subjective Wound assessment charts

Patient assessment parameters Nutritional status Level of mobility Mental attitude (compliance) Dressing tolerance Age Metabolic disease Vascular insufficiency

Is the wound acute or chronic? Post-operative? Healing or non-healing? Underlying cause? Infected or colonised? Skin problems around the wound?

Assessment parameters
Cause Wound classification Depth of the wound Shape and size The amount of exudate The position of the wound The clinical appearance The environment of care

Innovations in Wound Management

Biosurgery (Larval Therapy) VAC therapy Warmth Laser therapy Leeches MySkin Tenderwet Dispersion therapy Hydrofibre dressings Long-term use dressings Natural skin Growth hormones Hyaluronic acid dressing Myskin Xelma

Biosurgery
(Larval therapy)

Lucilia sericata (greenbottles) Ingest bacteria which are destroyed in their gut Wide range of infected wounds Removes slough and malodour Bred as sterile larvae

2mm long special dressing technique Sleeves or bags Numbers needed Removal Reassessment

Associated problems Potentially infected larvae Allergic reaction Tickling sensation Ethical issues Aesthetic issues

VAC Therapy
Provides a moist environment Prevents bacterial activity Evacuates excess exudate Kills anaerobic bacteria in the wound bed Controls odour

 Negative pressure suction drainage  Not a new idea as surgeons have employed drainage

methods for years  The difference: the application of topical negative subatmospheric pressure across the surface of the wound

Indications
Chronic non-healing wounds:
  

Pressure ulcers Venous/arterial ulcers Diabetic ulcers

Sub-acute non-healing wounds

   

Dehisced surgical wounds Acute and traumatic wounds Meshed flaps and grafts Graft and flap donor sites

Others
 

Burns Snake and spider bites

Contraindications Fistula of unknown source Opening into a body cavity Vulnerable body organs (protect) Malignancy Necrotic tissue with eschar Untreated osteomyelitis

Recommended regime Negative pressure 50-75mmHg split-skin graft, leg ulcer 125mmHg all other wounds Cycle continuous for 48 hours then intermittent pressure wound assessment determines cycle Dressing changes 4-5 days (every 48 hours if infected)

Success will depend on:

   

Wound selection Type of foam dressing The degree of negative pressure The duration of treatment

Possible complications of VAC

 Allergic reaction to the drape  Skin trauma  Pressure necrosis from the tubing  High pressures may cause pain  In-growth of granulation tissue  Fistula formation  Neoplasms

increase in blood flow

Laser therapy
Little evidence of faster healing Needs expert handling May increase tensile strength Costly Time-consuming

Hydrofibre dressing
Aquacel hydrofibre, non-woven hydrocolloid dressing Forms a non-sticky gel Very absorbent Moist environment Needs secondary dressing

Long-term use dressings

Mepitel, Omniderm, Tegapore Non-adherent Allow passage of exudate into a secondary dressing

Urgotul hydrocolloid and petroleum jelly Promogran collagen and cellulose it interferes with substances (proteases) in the wound that prevent it healing

Natural skin

Vivoderm, Dermagraft, Apligraf Expensive but cost-effective Reduce need for skin grafts Useful for diabetic ulcers

Growth hormones Proteins that direct biological processes Chronic wound deficiency Messengers Under research

Hyaluronic acid Hyalofil promotes rapid healing Optimum environment Expensive Requires secondary dressing

Xelma
What is Xelma extracellular matrix protein? Xelma consists of amelogenin proteins, a thickening agent propylene glycol alginate (PGA) and water. Xelma has been proven to improve healing in hard to heal ulcers. What is Xelma for? Xelma is a medical device for treatment of hard-toheal ulcers, primarily venous leg ulcers. It is indicated for use with standard compression therapy of noninfected wounds.

Xelma
How is Xelma different from other therapies? Xelma is the first product containing extracellular matrix protein, amelogenin, which temporarily replaces the damaged extracellular matrix proteins in the hard-to-heal wounds in order to restore wound healing. How does Xelma work? When applied to the wound bed Xelma provides a temporary extracellular matrix protein for cell attachment. This creates favourable conditions for wound healing by restoring vital cell functions including proliferation, migration and production of growth factors and essential extracellular matrix proteins. Restoration of the cellular and biochemical balance is facilitated in the hard-to-heal wound, which will promote granulation tissue formation and normal wound healing.

MySkin
Myskin
is a cultured autologous epidermal substitute for the treatment of burns, ulcers and other non-healing wounds. Myskin contains living cells expanded from the tissue of individual patients. Each patient treated with Myskin receives only their own cells in a viable state designed to initiate wound closure. Myskin comprises a layer of keratinocytes (epidermal cells) on an advanced polymer-like coating which facilitates the transfer of cells into the wound where they can initiate healing. Myskin uses a medical grade silicone substrate layer to support cell delivery, wound coverage and allow exudate management.

Myskin

Myskin case studies Patient Profile Mrs B 68 years old Medical Condition Two chronic non-healing pressure ulcers. The Patient After receiving a burn to her leg Mrs B was left with scar tissue causing her foot to become deformed. Pressure ulcers developed from her corrective footwear and despite conventional treatment they remained unhealed for three years. Mrs B was also awaiting surgery to correct her foot which was not possible until the ulcers had healed.

Myskin
Evaluation Mrs B has undergone three skin grafts along with conventional treatment all of which have failed to heal the ulcers. Mrs B was then referred for treatment with Myskin. For Myskin treatment, a thin biopsy (approximately 0.6mm thick, 2cmx2cm) of skin is taken from the thigh area and transported to the laboratory in sterile saline solution. The biopsy is treated with a digestive enzyme overnight. The following day the keratinocytes are isolated from the dermal/epidermal junction, multiplied in cell culture and stored in liquid nitrogen until they are needed. Three days before dressings are required, keratinocytes are thawed and cultured on a 5cm silicone disc. These discs have a patented surface layer that encourages keratinocytes, to transfer from the dressing to the wound bed and promote re-epithelialization. This cell transfer process takes about four days after which the Myskin dressing can be removed and a standard dressing applied.

Myskin
Mrs B attended the clinic for the once weekly dressing applications which, after four days, were removed and replaced with a standard dressing. Twenty two weeks after the first Myskin dressing was applied one ulcer had healed completely and the second healed after forty five weeks. Both Ulcers Healed

Outcome After two applications Mrs B experienced a significant reduction in pain and once the ulcers had completely healed Mrs B was referred back to the orthopaedic team. She has since had her foot deformity corrected with no complications post operatively. Mrs B has now resumed activities which she previously enjoyed such as swimming and has been on holiday. Due to the severity, location and age of the ulcers it was necessary for Mrs B to have several more applications of myskin than usually required. It has been found that up to twelve applications are usually needed to heal a chronic wound although the number of applications may vary between patients.

ANTIBIOTICS

Indications

1.Contaminated wound 2.Areas of marginal viability 3.Wounds involving joints, open fractures 4.All human bite wounds 5.Most animal bite wounds 6.Generally, wounds > 12hr. old

SPECIAL WOUNDS

Bite Wounds High risk of infection with involvement of bones, joints, tendons, vessels, nerves Puncture wounds (difficult to irrigate and decontaminate)

Dog Bites 75% involve the extremities Most dog bites in children involve an extremity Severe facial lacerations involve the cheeks and lips as they try to "kiss the doggie

Closure
Dog bites scalp, face, trunk, proximal extremities may be closed if superficial never close primarily Human bites (delay 48 72hr.)

Puncture Wounds
Never close Irrigate drain, if necessary Foot shoe on or barefoot? Increased infection risk if shoe on

Abscesses Incise, drain, irrigate, loosely pack with Iodoform gauze Return at 24 hrs. for irrigation fresh pack Return at 48 hrs. for pack removal and healing by granulation

New onset DM may present with abscess Antibiotics may be indicated in addition to I&D

Nail / Nail Bed Injury Subungual hematoma, < 40 % nail area, nail bed injury unlikely, but distal phalanx fx. Might be present Treatment: Battery cautery to make drainage hole in nail, irrigate with 25ga. needle and 1% lidocaine Nail Bed - requires surgical repair

Foreign Bodies
Inert (glass, metal), may leave unremoved if necessary Organic (wood), must be removed

Vamana
Eix qx vT i MT e uvwi : | xYs vrq kU uh mcNSl Wiq || x c 1/31 Wound with hypergranulation,shotha having predominance of kapha, blackish or reddish wounds vamana is beneficial.

VIRECHANA

Wounds afflicted by Vata & predominance of Pitta Dosha Situated in Madhyama & Adhoshaka of the body Non healing wounds, chronic wounds

BASTI

Nirooha & Anuvasana - Vata dustha, Rooksha, Ati vedana. - Adha kayagata Vrana - Prepared with Tikta Rasa drugs

SIRAVYDHANA
Vrana which is predominant of Pitta and Rakta In Margavarana conditions,raktamokshana is advised Indicated in shothayuktha, kathina, shyama, aruna rakta and vedanayukta vrana with vishalamoola.

In pitta pradhana condition raktha mokshana can be done with jalauka

LEKHANA

Should be done in Kathina(hard), thick & rolled margins of vrana and in hard & raised granulated surface

KASHAYA

Kashaya should be used for shodhana, in wound having foul smell, Kledayukta, Picchila, Shodhana kashaya drugs are Shankhini, Ankhotha, Karaveera, Sumana, Suvarchala & Aragvadhadhi gana

VARTI

Varti should be used for shodhana, in wound where there is a foreign body, with narrow opening & deep seated.

KALKA

Kalka should be used for Shodhana in highly infected wound, foul smell, & when all the Doshas are involved (vata & kapha) Drugs are Haratala, Pippali, Maricha, Shunthi, Sphatika.

SARPI

In Pittaja Vrana symptoms are Daha & paka, the drug are used Karpasa Phala Siddha Ghrita

TAILA

In Kaphaja Vrana if wound is Utsanna Mamsa, Ruksha, Alpasravayukta the drugs to be used Sarshapa + Tila Taila

RASAKRIYA

An indurated ulcer, not responding to Taila should be purified with a dually prepared Rasakriya. Shodhana Rasakriya Brihati,Kantakari, Haritala, Manashila

The drugs are Salasaraadi Gana, Patola, Triphala.

AVACHOORNA

Medhayuktha, superficial wound, foul smell conditions choorna is used for Shodhana Drugs are Kaseesa, Saindava, Vacha, Rajanidwaya

UTSADANA Utsanna mridu mamsa & Madhu

Kasisa

DARUNIKARANA Mridu mamsa Dhava,Priyangu, Ashoka etc Avachoornana.

PATRADANA Sthira, Alpamamsa, Roukshya, Anuparohatam. Pittaja & Raktaja vrana for Shaitya karanat Vataja & Kaphaja vrana for Oushnyam karanat KRIMIGHNA Surasadi gana, Karanja, Arka, Nimba etc for Dhavana & Poorana

Conclusion
Wound care is complex There are no easy solutions Evidence is needed of efficacy and cost-effectiveness Correction of the underlying causative factors is essential Key principles must be adhered to with regard to basic patient and wound assessment