wound care for medical practitioner is important

Bio-chemistry

1. Wound Care Overview for Practitioners
Brenda LaVigne, PA -C, Faculty Instructor
Wound and Hyperbaric Medicine, OHSU School of Medicine -Dept. of Vascular Surgery
Urgent Care/ Family Practice, ZoomCare
Complex Home Medical Care, Landmark/Optum

2. Objectives:
1. Review Phases of Normal Wound Healing
2. Review Principles and Management of Wound Healing
3. Discuss Wound Development/Advanced Treatment Options
*WARNING: Graphic Images*

3. •Any brand names used in this presentation are for
example only, there is no preference for specific
products
•This presentation is not comprehensive of all available
brands/products available
•Any product with comparable properties should be
considered depending on patient tolerance and cost
No Disclosures or Conflicts of Interest

4. •Trauma/Surgical Complications
•Edema/Vascular compromise
•Infection
•Diabetes/Neuropathy/Pressure
•Atypical (CA, Autoimmune, Allergies/Rash)
How
Wounds
Occur:

5. 5
Normal Wound Healing Process:

6. 6
Normal Wound Healing Process:
Phase 1 -A
Substrate Phase
Hemostasis/Coagulation
Seconds to Hours

7. 7
Normal Wound Healing Process:
Phase 1 -B
Substrate Phase
Inflammatory/Lag/Exudative
Hours to Days

8. 8
Normal Wound Healing Process:
Phase 2 -C
Proliferative Phase
Fibroplasia + Matrix Deposition, Angiogenesis,
Epithelialization
Days to Weeks

9. 9
Normal Wound Healing Process:
Phase 3 -D
Remodeling/Maturation Phase
Collagen Fiber Maturation, Lysis + Contraction,
Completion of Healing, Scar Maturation
Weeks to Years

10. 10
Primary Intention = First Intention = Primary Union:
Tissue surfaces are approximated (typically within 6
hours via: sutures, glue, staples, steristrip / t a pe ,
closure devices)
E x: Surgical incisions, lacerations, superficial injuries
Secondary Intention:
Tissue damage is extensive and wound edges cannot be approximated (wound must heal from bottom up)
E x: Pressure ulcers, abscesses, avulsions
Tertiary Intention = Delayed Primary Closure =
S e c o nd a r y C lo s u re :
Wound edges could be approximated, but there is reason to delay closure after
debridement/ granulation
(concern of retained foreign body, infection, poor
circulation, unhealthy wound base)
E x: D o g bites/ infected wounds/ Road rash, pending
flap, graft, or revascularization.
Intentional Wound Healing

11. Assessing Patients with Wounds:
Physical Exam:
•Overall appearance
•Circulation
•Edema
•Infec tion
•S ens a tion
•Pressure
Imaging/Diagnostics:
•X-ray
•MRI
•CT
•US/ Vascular studies
•Pathology
History:
•Onset (cause/duration)
•Current care plan
•Improving/Worse
•Prior history, what helped
•ADL’s? Offloading? Diet?
Smoking/ Substance Use?
•Relevant co-morbidities?
Labs:
•Wound culture
•Protein: Albumin, pre-
albumin
•HgbA1c
•CBC
•ESR/CRP

12. Measure:
L x W x D i n c m
(longest/ widest/ deepest)
Pro be & measure tunnels and
undermining (*with instrument)
Box/ Clock me tho d –Patient’s
head @ 12 o’clock.
Images:
Consistent angle/ distance at each
encounter fo r comparison
Assessing Wounds:
W o u n d Edges:
Adhered/ Undermined, epibole, s c a r , ma c e ra te d ,
e xud a te , c a llus , fir m,
W o u n d Bed:
E xpo s e d structures, necrotic tissue, granulation
tis s ue , fibr in, s lo ugh, e xud a te , o d o r , d ra ina ge , tenderness
Periwound skin:
Color, Moisture, Induration, Erythema

13. Describing Wounds:

14. Wagner Diabetic Foot Ulcer Grades:
Grade 0 –No ulcer, but there is
deformity, neuropathy, skin color
changes, hyperkarytosis/callus
Grade 1 –Superficial ulcer to fat layer
Grade 2 –Deep ulcer to muscle, tendon,
ligaments, but no bone or deep space
infection
Grade 3 –Deep ulcer to bone, or with
infected muscle, tendon, bone, joint
Grade 4 –Localized Gangrene due to
infection or PAD
Grade 5 –Extensive gangrene of > 50%
of the foot
Pressure Injury Stages (Braden Scale):
Stage 1 –Red/non-blanchableerythema
over bony prominence Stage 2 –Partial Thickness/Shallow
Dermis/Epidermis, includes blisters Stage 3 –Full Thickness to subcutaneous
tissue without exposed muscle, tendon or bone Stage 4 –Full Thickness to Muscle, tendon
or bone DTI–Discoloration of tissues over bony
prominence without tissue death/necrosis/eschar Unstagable–Necrosis/Eschar/Tissue death
that impedes visualization of wound bed
Describing Wounds:
Partial Thickness
:Loss of Epidermis and Dermis
Full Thickness:Fat/Subcutaneous layer, Muscle, Tendon, Bone, Joint
Unable to Assess:Eschar, blister, abscess, cannot visualize wound base.

15. 15
Why Won’t This Wound Heal?
•Chronic inflammation
•Poor blood supply
•Inadequate edema control
•Pressure/Inadequate offloading
•Infection/Colonization/Poor
bioburden control
•Cancer
•Immune deficiency
•Comorbidities poorly managed
Healthy populations:
Wound size decreases > 50% in 4 weeks
Typically does not re- occur

16. 16
Wound Care
Assess Perfusion
–Arterial Disease:
Hxof PAD/CAD/CVA
Claudication/rest pain/pain > normal
Pulses
Cap refill
Temp of toes
Color (dusky/violet/pale, pallor on elevation or
dependent rubor)
–ABI
–Arterial Ultrasound/Duplex
*Consult Vascular
16

17. 17
Wound Care
Removal of Non-viable tissue
–Debridement
–May refer to OP wound clinic
–Consider Surgical consult (plastics, vascular, podiatry/foot
and ankle, ortho if osteomyelitis)
17

18. DEBRIDEMENT:
▪Removes the necrotic tissue that provides an ideal environment for bacterial
growth, decreasing infection risk.
▪Encourages angiogenesis via minor trauma to exposed blood vessels.
▪Helps override stalled healing in inflammatory phase by triggering release of the
same chemicals as an acute wound, essentially starting the healing process over
again.
▪Multiple types (Surgical, Sharp excisional, Biologic, Autolytic, Mechanical,
Chemical/ enzymatic).

19. 19
Wound Care
Infection Control
–Wound culture
–Obtain after cleaning/debriding
–Consider biopsy/tissue culture (more accurate than swab)
–Imaging/labs(Osteomyelitis/deep
abscess/cellulitis/Necrotizing/Gas Gangrene)
–CBC, ESR, CRP
–X-Ray, MRI, CT
–Antibiotics
–Topical (erythema local to wound bed)
–PO (infection distal to wound)
–IV (resistant/long-term/allergy/culture)
19

20. Bioburden/Infection Control
oCutimedSorbact
(DACC coated microbe binding hydrophobic acetate fabric that holds
bacteria and fungi in dressing as drainage flows through mesh)
oHydroferaBlue
(Gentian Violet/Methalene Bluefoam, non- cytotoxic)
oXeroform
(Bizmuthis bacteriostatic)
oOTC
(Antibacterial -Neosporin/Poly/triple antibiotic, Antifungal –
Terbinafine,Micon/Clotrim-azole)
oRx
(Antibacterial- Mupirocin/Gentamicin/Clindamycin)
Antifungal-Nystatin/Ciclopirox/Miconazole/Clotrimazole/Ketoconazole)

21. Bioburden/Infection Control
oDakins
(Effective against bacteria MRSA/VRE, virus, mold, fungi, yeast)
oAcetic Acid
(Effective against abxresistant pseudomonas, common skin colonizers)
oIodine
(Effective on most infections, drying)
oSilver (Ag)
(ImpregnantedDressings, Silvasorb–3 days/Silvadene –12 hrstopicals)
oMedical/Manuka Honey
(Gel, impregnated dressings, bacteria/fungus)

22. 22
Wound Care
Edema Control
–Venous HTN/Insufficiency: Graduated Compression, Vascular
referral
–Lymphedema: Compression, Pumps, Lymphedema clinic
referral
22
Venous Disease:
-Pitting edema
-Hemosiderin staining
-Varicosities
-Weeping/ blistering
-Often bilateral
Lymphedema:
-Lymphorrhea
( ty pic a lly no n-pitting
later)
-Hyperkeratosis
-Hyperplasia
-Papillomatosis
-Woody appearance
-Stemmers sign
-Unilateral
DO NOT MISS A DVT:
-U n i l a t e r a l c a l f
swelling
-Erythema
-Tenderness w/ calf
s que e z e a nd
dorsiflexion of foot

23. 23
Wound Care
Optimal Wound Environment
–Control Moisture
–Too Dry: physical barrier to wound contraction and
keratinocyte proliferation.
–Too Moist:maceration of periwound tissue, breeding
ground for fungi/bacteria.
–Dressing Adheres to wound/Pain with dressing
changes
–If dressings cause trauma consider:
–Vaseline impregnated/oil immersion contact layer
(adaptic/curity/xeroform)
–Can apply absorptive/cover layers over PRN
–Rx for topical lidocaine
–2% mucosal jelly or 5% ointment
23

24. Moisture Balance
Dry Wounds
oWound dressings should retain or addmoisture to thewound bed
oTypically require less frequent dressing changes(up to 1 week in non- infected ulcers)

25. Moisture Balance
oOil Emulsion
(Adaptic, Curad, Curity, Vaseline
gauze, Xeroform)
oMoistened Collagen
(Promogran/Prisma, Puracol,
Dermacol)
oOcclusives/hydrocolloids
(Tegaderm, Opsite, Duoderm)
oNon-Adherent
(Telfa, Curad)
Dry Wounds
oWound hydrating gel/sheet
(Hydrogel, Plurogel, Bio-Gel)
oOintments
(A&D, Vaseline/Petrolatum, Triad
hydrophilic)
oMedical/Manuka honey
(Medihoney, Therahoney, MaukaMed)
oContact Layers
(UrgoTul, Mepitel, Profore, Versatel,
Smith & Nephew)

26. Moisture Balance
Mild-Moderate Drainage
oWound dressings should maintain current moisture levels
oDressings typically changed every other day to several times per week

27. Moisture Balance
oMedical/Manuka Honey
Dressings
(Medical Honey impregnated
foam,hydrocolloid or alginate)
oCollagen
(Promogran/Prisma, Puracol,
Dermacol, Stimulin)
oCollagen/Alginate Combo
(FibrocolPlus)
Mild-Moderate Drainage
oHydrocolloids
(Duoderm, Procol, Nu-
Derm, DermaFilm)
oHydrofiber
(Aquacel, Aquaderm)
oFoam Dressings
(Mepilex, Alleven, Tielle,
HydroferaBlue)

28. Moisture Balance
Heavy Drainage
oWound dressings should absorb excess moisture and prevent maceration
oDressing changes often require at least daily, to multiple times/day

29. Moisture Balance
oIodine Dressings
(Iodasorb, Iodoflex,
Iodofoam, Iodosorb, Iodine,
Betadine)
oMoistened Gauze
(Saline, Dakins, Acetic Acid)
oFoam Dressings
(Mepilex, Alleven, Tielle,
HydroferaBlue)
oHydrofibers
(Aquacel, Convatec)
oHydroconductive
(Drawtex, HealQU)
oAlginates
(Calcium Alginate, Maxxorb,
MedVance, Silvercel)
oAbsorbent Cover Dressings
(ABD, Exudry)
oSuper Absorbers
(KerraMax, Optilock, Equate)
Heavy Drainage

30. 30
Wound Care
Optimize tissue growth
–Large surface area
–Graft/flap (Allograft/Autograft)
–Advanced cellular tissue based products CTBP (Scaffolding/ECM,
Growth Factors)
–Deep ulcer
–NPWT (Wound VAC)
–“Packing” = Fill gently (plain/Iodoform)
–“Wet to Dry” = Moist (+/-Daikensif infection)
–Medihoney/Iodasorb(tunnel/undermining)
*Always protect exposed bone/tendons
(adaptic/curitynon-adherent/xeroform)
30

31. Negative Pressure Wound Therapy (NPWT)
Indications:
oDeep ulcers (protect exposed
tendon/bone)
oPartial Thickness Burns
oFlaps/Grafts
oHeavy drainage
Contraindications:
oMalignancy
oNon-enteric/Unexplored
Fistulas
oUncontrolled Bleeding
oUntreated Osteomyelitis,Necrotictissue/
Eschar (can beplaced post
debridement)c
Wound VAC

32. Tough Treatments
Tunnels/Undermining/Tight spaces:
oPacking Gauze
oInjecting topicals
oMedical Honey
oCadexomerIodine
oCollagen
oRolled
oPowder
oRope dressings
oHydroferablue
oCutimed
oAlginate
Slough without sharp debridement:
Autolytic
oMedical honey
oCadexomerIodine
oOcclusive dressings
Enzymatic
oCollagenase/Santyl
Biologic
oMaggot Therapy
Delicate Skin/tears:
oSilicone sheets
oSilicone bordered dressings
oNon-adherent dressings
oOil Emulsion
Autoimmune/Malignant:
Realistic expectations/Management
oDrainage
oOdor
oPain
oInfection Risk

33. Periwound Skin Complications
Rash:
Fungal (Tinea):
–Topical antifungals (Nystatin, Miconazole, Terbinafine, powder/cream
Inflammation:
–Topical steroid creams (Trimacinolone, Hydrocortisone, Betamethasone)
Maceration:
–Barrier creams (Zinc based/Diaper Rash cream, Calazime)
–Topical talcum powder, cornstarch, baby powder
–Periwound Stoma Paste/Eakins ring
Dry flaking/hyperkarytoticskin:
Emmolients
–Vaseline, A&D, Oil immersion gauze
Lotion
–Unscented, no dye lotion (Cerave, Eucerin, Lubriderm)
Urea Cream
–40% or in a lotion

34. 34
Wound Care
Offloading
–Avoid pressure on the wound bed
–Limit ambulation
–Walking Boot/Shoe, Orthotics
–Felt/Foam cutout
–TCC (Total contact cast) or Soft cast
–Knee scooter/crutches/wheelchair
–NWB status
–Float heels/ulcer sites
–Foam/wedge
–Pillows/rolled blankets/towels
–Rookeboots
34

35. 35
Wound Care
Pain Control
–Topical Lidocaine, injected Lidocaine/ Bupivocaine
–2-5% viscous lidocaine or ointment used topically
–Typically effective for most patients for debridement
and dressing changes (check insurance coverage)
–OTC NSAIDs
–Rx PRN
–PO or IV analgesics
–Consider referral to pain clinic
–severe/refractory/long-term chronic pain
35

36. 36
Wound Care
Host Factors Optimized
–Comorbidities/Management
–Nutrition -Increase Protein/well balanced diet (adjust for
comorbidities)
–Diabetes–Blood sugar control, assess neuropathy and kidney
function
–HLD/CAD/PAD/CVA –Increased risk of arterial compromise
–HTN/CHF/Arrhythmia–Adequate heart rate, BP and fluid/edema
control
–Cancer–Discussion about palliative vs. healing expectations
–Sleep–Discuss good sleep hygiene, treat sleep apnea
–Inflammation/Autoimmune –Immune modulation regulation
(up/down depending on healing/overall health)
36

37. 37
Chronic Ulcer/Comorbidity Types
37
E. S urgic a l Complication F. Aty pic a l Ulcer G. S kin Te a r

38. 38
What is HBO T?
H o w does it work?
Patients are placed in an enclosed metal and
acrylic chamber, which is filled with 100%
oxygen, and pressurized (typically 2.5
atmospheres below sea level).
Nearly 17 x increase in the amount of oxygen
dissolved in plasma and available to tissues
38

39. 39
Hyperbaric Oxygen Consideration
•Indications:
–Diabetic foot ulcers > 30 days with deep space/bone infection not
reduced by 50% in 30 days despite advanced wound care.
–Chronic Refractory Osteomyelitis > 60 days despite long term
antibiotics/surgical debridement.
–Radiation injury non- healing > 6 months post completion of RT
–Severe Infections –Gas Gangrene, Nec. Fasc., Intracranial Abscess
–Crush Injury/Compartment Syndrome/Amputation w/reattachment
–Acute critical limb ischemia
–Compromised Flap/Graft w/history of previous failure
•Contraindications:
–Absolute = untreated pneumothorax
–Relative = recent (< 6 half lives)/current treatment with bleomycin/cisplatin/disulfiram/doxorubicin/sulfamylon(active CA?),
unstable seizures, recent/current URI/sinus/ear infection, implanted device not rated for chamber pressure, high fever, uncontrolled
COPD/Asthma, congenital spherocytosis, or untreated
claustrophobia/severe anxiety
39

40. Case Study Wagner III DFU
5 8 y / o M w/PmHxof DM w/ chronic non- healing
Wagner III DFU, tendon exposed.
•Treatment # 7:
–Healthy granulation tissue in wo u n d b a s e
(Fig 2).
•Treatment # 20:
–Contracture of wound edges
–Peripheral Epithelialization (Fig 3).
Post HBO Follow-ups:
Week 2 (F i g 4 )
Week 6 ( F i g 5 )
*Patient d i s c h a rge d healed.
v

41. Outpatient Wound Clinic Referrals:
-Any patient w/wound > 30 days not responding as expected or with
complications that is not under a 90 day global for surgery
Outpatient Hyperbaric Referrals:
-Any patient with an insurance covered diagnosis for hbot.

42. Questions?
lavigne@ ohsu.edu

43. 43
1. Pandian G, Hamid F, Hammond M. Rehabilitation of the Patient with Peripheral Vascular Disease and Diabetic Foot Problems. In:
DeLisaJA, Gans BM, editors. Philadelphia: Lippincott‐Raven; 1998.
2. International Diabetes Association. (2001, October). Diabetes Voice . Retrieved from www.idf.com
3. Blough DK, Hubbard S, McFarland LV, Reiber GE, Smith DG, Gambel JM. Prosthetic Cost Projections for Service members with Major
Limb Loss From Vietnam and OIF/OEF. J. Rehabil. Res. Dev. Journal of Rehabilitation Research and Development. 2010;47(4):387- 402.
4. Dept of Veterans Affairs. (2012, May). diabetes-taking-steps-to-prevent-amputation.Retrieved from Lower Extremity Review:
lermagazine.com/article/diabetes-taking-steps-to-prevent-amputation
5. Margolis D, Malay DS, HoffstadOJ, et al. Prevalence of diabetes, diabetic foot ulcer, and lower extremity amputation among Medicare
beneficiaries, 2006 to 2008. Diabetic Foot Ulcers. Data Points #1 (prepared by the University of Pennsylvania DEcIDECenter, under
Contract No. HHSA29020050041I). Rockville, MD: Agency for Healthcare Research and Quality. February 2011. AHRQ Publication No.
10(11)-EHC009- EF.
6. Shishir Shah, DO . Clinical and Economic Benefits of Healing Diabetic Foot Ulcers With a Rigid Total Contact Cast.
Wounds.2012;24(6):152- 159.
7. Kalani et al. Hyperbaric Oxygen Therapy in treatment of diabetic foot ulcers long-tern follow up. J Diabetes and Its
Complications2002;16:153- 158.
8. Abida et al. Hyperbaric Oxygen Therapy for diabetic leg ulcers-a double blind randomized controlled Trial. Undersea Hyperbaric
Med . 2001; 28: 64
9. Fife et al. Factors influencing the outcome of lower extremity diabetic ulcers with hyperbaric oxygen therapy. Wound Rep Reg 2007;
15:322- 331
10. Vyas K, Vasconez H. Wound Healing: Biologics, Skin Substitutes, Biomembranesand Scaffolds. Healthcare(Basel). 2014 Sep; 2(3):
356-400 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934597/
11. Wound Care Solutions (2020, Oct) Scab vs. Eschar. Accessed Aug 2021.https://www.sharedhealthservices.com/post/scab-versus-
eschar
12. Karen Evans, MDPaul J Kim, DPM, MS. Overview of Treatment of Chronic Wounds. In: Post TW, ed. UpToDate. UpToDate; 2022.
Accessed May 17, 2022. https:// www.uptodate.com/contents/overview-of-treatment- of-chronic-wounds
13. David G Armstrong, DPM, MD, PhDAndrew J Meyr, DPM. Basic Principles of Wound Management. . In: Post TW, ed. UpToDate.
UpToDate; 2022. Accessed May 17, 2022. https://www.uptodate.com/contents/basic-principles-of-wound-management
14. Sun BK, SiprashviliZ, Khavari PA. Advances in skin grafting and treatment of cutaneous wounds. Science 2014; 346:941
43
References