Wound Care Interventions
Kate McKenney PT CWS
June 4, 2013
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Contact Ultrasound – Slide 97
• Full thickness wounds
– Ultrasound transmission gel to intact periwound
and hydrogel to wound bed, then hydrogel sheet
• Partial thickness wounds
– Hydrogel sheet directly over the wound including
4-6 cm onto the periwound
• Cleanse applicator with antibacterial agent
• Ultrasound get on top of hydrogel sheet
(Suspected) Deep Tissue Injury
• DTI
– Purple or maroon
localized area of
discoloration
– Blood filled blister
– May evolve rapidly
into a very bad
pressure ulcer, or
may not evolve at all
(Suspected) Deep Tissue Injury
What we’ve covered
• Cleansing the wound
• Debridement
– PLWS, Syringe Lavage, Whirlpool
– Mechanical, Selective vs Non-Selective
•
•
•
•
Topicals
Dressings
Contact Ultrasound
Electrical Stimulation
Contact Low Frequency Ultrasound
• Ultrasound assisted wound therapy,
ultrasound assisted debridement, Arobella,
Qoustic Wound Therapy System
• Low frequency 20-40 kHz (vs 1-3 MHz)
• Non-thermal
• Creates cavitation
• Acoustic streaming
Contact Low Frequency Ultrasound
• Cavitation
– Creation of miniscule gas bubbles in the tissue
fluid and coupling medium
– Bubbles expand/contract with variation in
ultrasound field pressure levels
– Bubbles implode; tiny shock waves
– Necrotic tissue tensile strength < viable tissue
– Shock waves liquefy necrotic tissue, biofilm
Contact Low Frequency Ultrasound
• Acoustic Streaming
– Movement of fluids along the acoustic boundaries
• Bubbles or cell membrane
– Increases cell membrane permeability
– Increases vascular wall permeability
– Increase protein synthesis
Cavitation and Acoustic Streaming
• Believed to be responsible for stimulatory
effects of cells.
• Believed to modulate cell activity
– Increase cellular proliferation
– Increase collagen deposition*
– Increase growth factor activity
• Bottom line:
– Good for healthy cells*
– Bad for bacterial, senescent and devitalized cells
Contact Low Frequency Ultrasound
• http://www.youtube.com/watch?v=xl0tCZ5kD
TY
Contact Low Frequency Ultrasound
• Indications:
– All wounds that require debridement
Contact Low Frequency Ultrasound
• Benefits:
– Immediate results- removal of slough
– Selective
– Less painful that sharp debridement???
• Considerations:
– $$$$, no “extra” reimbursement
– Can be painful
– Be careful, used for “excisional” debridement
• Debridement of living tissue
• Physician only! (not in scope of practice of PT)
• When performing this technique over living tissue, move the contact
head more quickly so it doesn’t result in excisional debridement.
– Aerosolization and PPE
Contact Low Frequency Ultrasound
• Contraindications:
– All ultrasound contraindications
• Malignancy, cardiac area in CHF, etc.
– Untreated, advancing cellulitis
– Signs of systemic infection
– Metal components
– Electrical device within treatment area
– Uncontrolled pain: know what’s causing this!
– DVT, emboli (can break up clot and cause a stroke)
Non-Contact Low Frequency
Ultrasound
• MIST Therapy
• Same principles as Contact Low Frequency Ultrasound
• No contact = no pain
– Reduces pain???
• Can be used for maintenance debridement
– No harm to healthy tissue
• Disposable; 3-5 minutes total
• No aerosolization: mist does not come out at high
enough PSI to create aerosolization
– MUST wear PPE
Non-Contact Low Frequency
Ultrasound
• http://www.youtube.com/watch?v=dhfGMW
mBhhc
• http://www.youtube.com/watch?v=Yi1hj7QC
Oeo
Non-Contact Low Frequency
Ultrasound
• Indications:
– Suspected DTI (deep tissue injury that hasn’t
opened up)
– Plus any wound
• Considerations:
– $$$$ (18-25K)
– CPT code coming January 1, 2014!
(reimbursement to be determined still)
Non-Contact Low Frequency
Ultrasound
• Contraindications
– Same as Contact Low Frequency Ultrasound
Debridement
• Removal of tissue or foreign material
– Conservative – removal of senescent, dead or
devitalized tissue
– Aggressive or excisional – removal of living tissue
• Done by surgeon/physician in OR
• Indications:
– Any time there is something that needs to be
removed!
Debridement
Benefits
•Decrease bacterial load
•Stimulates growth factors
•Exposes cell receptors for growth factor
interface
•Remove senescent cells
•Facilitate angiogenesis
•Allow full determination of depth and character
of wound bed (which will help with setting a
prognosis)
Debridement
• Considerations
– Pain
– Anticoagulants/Bleeding disorder
– Know your anatomy!
• If you don’t know, don’t remove!
– ABI?
• Some texts say not to do on anyone with ABI less than 0.5 because
there may not be enough blood flow to support debridement
• Have to use good clinical judgment to determine whether to do
this
• Think about what you are doing to increase circulation IF choosing
to do this on someone with a low ABI
• If less than 0.7 send to see a vascular surgeon to see if they can
get a stent, meds etc.
Debridement
• No – leave it alone!
– Granulation tissue
– Viable or potentially
viable tissue
– Stable eschar (see picture)
– Dry gangrene
– Pyoderma Gangrenosum
– Muscle, tendon,
ligament, capsule, fascia,
nerves, blood vessels
(things you need!)
– Intact blisters
Pyoderma Gangrenosum
• Poorly understood skin condition
• 1 in 100,000 (rare, but you will see in wound
clinic)
• Wound that will Rapidly enlarge with trauma and
debridement of wound bed (ie: removing a dressing that is
stuck to the wound bed, etc)
• Unknown etiology
– Associated with inflammatory conditions
• (bowel disease, RA, immune disorders)
– 50% of cases are idiopathic
• Reoccurrence rate 30%
Pyoderma Gangrenosum
• Typically lower legs
• Edges elevated with undermining
• Violaceous borders
– Looks similar to hemosiderin staining
• Cribiform scarring
– Criss cross scarring pattern
• Diagnosis by exclusion
– There is NOT test for this
Pyoderma Gangrenosum
• Treatment
– If suspect, stop debridement and get to dermatologist
ASAP!
• Wound will appear worse after first treatment
• Elevated edges will be worse
– Oral steroids
– Topical steroids, antibiotic and sometimes
immunosuppressant
• Months to years to heal
– Because you cannot do debridement
– Steroids=delayed healing
Debridement
• We’ve already covered some:
– PLWS
– Syringe lavage
– Whirlpool
– Irrigation
– Selective vs Non-selective
Debridement
• Additional means:
– Enzymatic Debridement
– Autolytic Debridement
– Biological Debridement
– Sharp Debridement
Debridement
What are we trying to do?
•Necrotic tissue
•Eschar (firm, thick)
•Slough (yellow,
white, tan. Can be easy
or hard to remove)
•Debris (dressing
residue)
•Residual topicals
•Foreign material
•Callus DEFINITELY get rid
of!
•Biofilm/Bioburden?
•Can’t see this but
needs to be removed
because it can cause
Debridement
Callus (yes)
Blister (no)
Debridement
Granulation
tissue (no)
Debridement
Slough
(yes)
Debridement
Slough (yes)
Debridement
Stable eschar
(no)
Unstable
eschar (yes)
Debridement
Tendon
(no)
Debridement
Dry Gangrene
(No)