WOUNDMyths & facts of

Care Graphics & Research:;

Mansoor Khan (M.B.B.S)

Plastic & Reconstructive Surgery Hayatabad Medical Complex, Peshawar.

WOUN

D

Discontinuity of the skin, mucous membrane or tissue caused by physical,

chemical or biological insult”“

Changing trends in the classifcation…?

ACUTE Recent wound which has yet to progress through the sequential stages of healing

CHRONIC Wound that has arrested in one of the wound healing stages usually inflammatory phase

Acute vs Chronic Wounds

SIMPLE WOUND those wounds which are readily managed by local wound care /contraction, direct closure, skin grafting, local tissure rearrangment.

COMPLEX WOUND these are large wounds requiring tissue distant from wound site i.e. regional, distal transposition or microvascular composite tissue transfer

PROBLEM WOUND Those wounds which fails to achieve closure with the above methods or recurres due to local or systemic causes.

Clinical History, examination & investigations….?

Mechanism of trauma,

duration, pain, discharge .

Co-morbidities (DM, HTN e.t.c.),

radiotherapy

Location, size, depth, exposed structures, level

of contamination, necrosis, level of

exudation, granulation,

Visitrak Grid

Visitrak Grid

Standardized serial digital photography

Portable Digitizer for Wound Monitoring

Full blood count, serum albumen,

blood glucose level and HbA1c,

CRP and ESR, ABPI,

Transcutaneous oxygen pressure (tcPO2)

Causative factors of problem wounds….?

PROBLEM WOUND

Bacterial

Infection

Ischemia

Age

Accelerated senescence, diminished production of growth factors, collagen, matrix, decreased ability to survive hypoxic stress, Aging is irreversible: optimization of the systemic parameters & supplementation is the solution

AGE

Damage to the small vessels in the wound leads

to hypoxia of the wound relative to the normal tissue (25mmHg vs

40mmHg), this hypoxia becomes chronic due to peri-wound fibrosis in

problem wounds.

ISCHEMIA

Reduction of edema

ISCHEMIA

Offloading: Reduction of pressure reduces ischemia.

ISCHEMIA

Reduction of peripheral vascular resistance

ISCHEMIA

Warmth: Vasodilates the vessels

ISCHEMIA

ISCHEMIA

Hydration: Improves circulation

ISCHEMIA

Bacterial inoculum & virality, presence of foreign bodies, determines the severity of the wound

Bacteria: Set up free radicles environment, secrets toxins & proteases----bystander damage

BACTERIA

Indications for antibiotics: Venous stasis ulcers, lymphangitis, cellulitis, critical colonization of the

wound, infection (straw color oozing, pain),

BACTERIA

Never forget to use topical antibiotics ‘cuase peri-wound fibrosis restricts the the delivery of systemic antibiotics

Management (debridement)….?

Debridement : without debridement wound is exposed to cytotoxic stressors & competes with the bacteria for scarce oxygen & nutrition resources, debridement reduces the bioburden and help ensure healing

Post-debridement

Eschar : should be excised: Many surgeons still consider it as a biological dressing & believes in healing under eschar. Proteinaceous eschar acts as meal for bacteria.

Enzymatic wound debridement

Autolytic debridement: through the action of the leukocytes i.e. hydrocollides

Pressurized water jet machamical debrider (VersaJet)

Adjuvents in management….?

NEGATIVE PRESSURE WOUND THERAPY

Tremendous adjuvent for wound closure Mechanism: relieves edema, removes deletrious enzymes, exudates, bacterial load, cyclical compression & relaxation stimulates mechanotransductive pathway of growth factors.

Precautions: the sponge should not be placed on normal skin, use of optimal negative pressure of 125mmHg

Indications: lymphatic leak, venous stasis ulcers, diabetic wounds, sternal wounds, orthopedic wounds, abdominal wounds

Contraindications: malignancy, ischemic wounds, inadequately debrided & badly infected wounds, exposed vessels, patients on anticoagulants

Hyperbaric oxygen therapy

100% oxygen at 2-3 ATA raises the dissolved oxygen level from 0.3% to 7% in plasma which increases 4-5 times oxygen delivery to the wound

DRESSINGS

Goals: to clean the wound, creat moist healing environment to facilitate cell migration & prevent dessication

Paradigm shift: from moist to dry dressing to moist dressing.

Hydrogel/films/composite dressings: ;used for light exudating wounds

Hydrocollides are used for moderate quantities of exudation.

Alginates/foams/NPWT: usefull for heavy exudation.

CHOICE OF DRESSING IS BASED ON QUANTITY OF EXUDATE

GauzeAdvantages: Traditional first choice used for moist to dry dressing, low material expense, easily availble, excellent as surgical bandage for uncomplicated.

Dis advantages: moist to dry dressings are traumatizing as gauze is non-selective debrider causing significant bystander damage, leaves behind fine microfibers which are irritants and source of infection.

Impregnated gauze with petrolium, iodinated compounds for moist dressing is available having comparable results with the modern dressings.

Semiocclusive DressingsUnpermeable to fluids to keep moist environment, permit of gas molecules.To cover freshly closed incisions, skin graft donor site. Should not be used for contaminated wounds .

Hydrogel dressing: Autolytic debridement by rehydrating the wound and facilitat healing. Used in wound with small amount of eschar and predisposed to dessication, infected wounds, require secondary dressing on top of it.

Foam dressingHighly absorptive and acts like a wick making it useful in highly exudative wounds.

Alginates useful in wounds with significant exudated fluids, they can absorb fluids 20 times their dry weight, not to be used on nonexudative wounds as they will dry up the wound. If used for dry wound they should be hydrated with saline prior to application

Pyodine iodine & Chlorhexadine damages the normal cells,

fibroblasts and growth factors as well, so newer antimicrobial

agents containing dressings are favoured i.e. silver and

cadexomer iodine

Antimicrobial dressingsMost benefical agent is Silver, broad spectrum antimicrobial agent including VRE, MRSA.

Cadexomer iodineSlow release iodine for cosistent bactericidal levels without the wound cell damaging effects seen with pyodine-iodine products

Management of simple & complex wounds….??

Thorough wound wash Debridement of the necrosed

margins, conservatively on the face,Layered closure to obliteration the

dead spaceNo skin stiches untill skin margins

are <2mm apart by applying intradermal sutures

Use of fine monofilament sutures with carefull handling of the skin margins.

Timely removal of the sutures, and application of the scar

modification measurements ensures a fine scare…..

Elective surgery patients are advised to refrain from strenous activity for at least 6 weeks

Management of problem wound…?

Decreases angiogenesis, collagen deposition, cellular proliferation, prone to infectionPatients should receive Vit-A (25000IU/day PO or 200000 IU topically TDS)Goal should be to maintain a clean wound with minimal bacterial colonization

Irradiated woundsProgressive endarteritis obliterans, microvascular damag, fibrotic changes leading to ischemia, prone to infection.Needs very carefull debridement, antimicrobial moist dressing while promoting autolysis are ideal for these wounds. Hyperbaric oxygen therapy and growth factors are also useful adjuvents. Usually needs flap coverage.

Pressure soresPatients are usually malnourished and nutritional uplift is necessory in these patients along with the administration of growth hormones or anabolic steroids (oxandrolone) to counteract the catabolic s state of the patients

Pressure soresThey needs thorough multiple sessions of debridements and ultimately fasciocutaneous or musculocutaneous flape coverage. Frustrating part is its high recurrence rates.

Film drssings are ideal for stage I & II to keep the moist environment. While for stage III & IV more absorptive dressings (hydrogel, hydrocollides, foams and alginates) are required depending on the exudatation level.

Pressure soresThe spasm of the patients should be relieved non-surgically (benzodiazipins, dantrolen e.t.c.) or surgically. Use of pressure relieving devices are helpful in healing and preventing recurrence.

Diabetic woundsCombination of microangiopathic, neuropathic and pressure necrosis ulcers. Thorough serial debridement , glucose control, pressure offloading, revascularization, nerve decompression combination is required.

Venous stasis ulcersCompression therapy is the main stay of theapy i.e. graduated compression stockings (30-40mmHg pressure), contraindicated when ABPI is <0.7 and shloud be used with causion in 0.7-0.9.

Supplementary dressing depending upon the amount of exudate is used. When edema subsides then the wounds are closed & compression therapy contiued post-op for several weeks.

Ulcers resistant to compression therapy should undergo venous insufficiency studies. The superficial/perforators insufficiency is the idication for vascular surgery.