Wound Breakdown, Fungating
Lesions, Pressure Sores, Fistulae
Rebecca Owen
Objectives
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Stages of Wound Healing
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Fungating Lesions overview
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Types of wound + dressing suggestions
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Pressure Sores – common areas and treatment
pathway
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Fistulae overview
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Summary
Stages of Wound Healing
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Haemostasis
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Inflammatory
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Bacteria and debris phagocytosed and removed
Release of factors causing migration + proliferation
Proliferative
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Clotting cascade
Angiogenesis, collagen deposition, granulation tissue
formation, epithelialisation, wound contraction
Remodelling
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Collagen remodelled and realigned along tension lines
and unneeded cells removed by apoptosis
Wound Healing Phases
Wound Healing – Primary
Intention
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“Involves epidermis and dermis without
total penetration of dermis healing by
process of epithelialization”
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When wound edges are brought together so that
they are adjacent to each other (re-approximated)
Minimizes scarring
Most surgical wounds
Wound closure is performed with sutures (stitches),
staples, or adhesive tape
Examples: well-repaired lacerations,well reduced
bone fractures,healing after flap surgery
Wound Healing – Secondary
Intention
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The wound is allowed to granulate
Granulation results in a broader scar
Healing process can be slow due to
presence of drainage from infection
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Wound care must be performed daily to encourage
wound debris removal to allow for granulation tissue
formation
Surgeon may pack the wound with a gauze or use a
drainage system
examples:gingivectomy,gingivoplasty,tooth extraction
sockets, poorly reduced fractures.
Wound Healing – Tertiary
Intention
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(Delayed primary closure or secondary
suture):
The wound is initially cleaned, debrided
and observed, typically 4 or 5 days
before closure.
The wound is purposely left open
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examples:healing of wounds by use of tissue grafts.
Fungating Lesions
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Can be associated with
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Pain
Pruritis
Exudate
Malodour
Bleeding
Infection
Consider topical morphine, NSAIDs (pruritis),
abx,
Treat exudate + infection with appropriate
dressing
Fungating Lesions
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Malodour
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Clense and debride surface
Topical/systemic metronidazole
Live Yoghurt (topically)
Manuka Honey (Activon) (topically)
Mask odour with camphor, herbs,incense
Psychological Support
Skin Tear
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Occurs when friction + shearing forces
cause tissue layers to slide across each
other breaking blood vessels
Caused by sliding patients in
bed,agitated patients moving in bed,
removal of adhesive dressings
Skin Tear Management
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Remove dressings using “lateral pull”
technique
Mepitel dressing + dry gauze
Change Mepitel every 5-7 days
Change gauze when saturated
Wet Wound with Granulating
Tissue
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Aims
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Minimise dressing changes
Relieve the pressure that caused the ulcer
If increasing exudate then consider infection
Maximise nutrition and hydration
Suggested dressing – Aquacel
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Place sheets in wound bed and cover with dry dressing
Cover dressing depends on wetness
 Daily – Gauze; 2-3/7 – Alldress, 3-5/7 –
Allevyn/Mepilex
Multiple layers of aquacel can minimise dressing changes
Change Aquacel when it has turned into a gel
Cellulitis
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Local infection of dermis and subcutaneous
tissue characterised by spreading redness,
pain and swelling.
Monitor demarcation by marking and dating
the skin
Consider systemic/topical antibiotics
Use Mepitel on wound bed to reduce surface
pain
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Change every 7/7 or PRN
Sacral Ulcer
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Remove/prevent pressure on area
Observe for infection
If problems with incontinence –
consider barrier cream i.e. Cavilon
Sacral Shaped Tegasorb – dressing of
choice
Applying a Sacral dressing
Fold sacral dressing in half
Insert "bookmark" into the patient's
fold, above the rectum and secure
the dressing up the middle
Pinch the fold to form a crease
"Bookmarking"
Secure the dressing out the sides
using the heat of your hand and slight
pressure to help it adhere
Peel off the entire backing
Slowly peel away the border while
securing the tegaderm with your fingers
Clean Wound with Granulating
Tissue
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Remove/prevent pressure on affected
area
Maximise nutrition and hydration
Sugessted foam dressing such as
Mepilex
Dressings can remain on wound for 7/7
Wound with Yellow Slough
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Stage X as wound bed cannot be visualised
Pain management with dressing changes
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2 options of treatment:
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Option 1 - cut silver dressing, such as Acticoat to fit into the wound
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Option 2 - Spread a thin layer of Iodosorb on a gauze and place in
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bed and moisten with sterile water. Cover with a light dressing (gauze
and tape or “island dressing” such as Alldress). Ensure daily that
Acticoat dressing is moist. Change Acticoat 3/7.
wound bed.Cover with island dressing (such as Alldress) or foam.
Change dressing q 3 days, when Iodasorb changes to a creamy colour.
(NB) make sure patient doesn’t have thryroid issues—Iodosorb has
iodine & contraindicated if thyroid condition or breast-feeding mother).
Diabetic/Neuropathic Ulcer
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Most common on plantar aspect of foot,heels
and over metatarsal heads
Dry,warm, cracked, fissured skin, thickened
nails
Usually no oedema/exudate
Causes – peripheral neuropathy,arterial
insufficiency, poor microvascular circulation,
inadequate blood glucose control
Treatment – debridement plus
mepilex/Allevyn + Intrasite gel
Pressure Sores
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Several factors that increase risk of
developing a pressure sore:
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Mobility problems
Poor nutrition
Underlying health condition
Age >70 yrs
Urinary &/or bowel incontinence
Serious mental health conditions
Treatment of Pressure Sores
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Changing position
Mattresses and cushions
Dressings
Creams and ointments
Antibiotics
Nutrition
Debridement
Maggot therapy
Surgery
Fistulae
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Abnormal communication between 2 hollow
organs or between a hollow organ and the
skin
Aetiology
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Anastomotic leaks
Trauma - often iatrogenic post surgery
Inflammatory bowel disease
Malignancy
Radiotherapy
Fistulae Types
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Rectovaginal/Rectovesical fistulas
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Conservative/Surgical
Enterocutaneous fistulas
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Simple
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Single orifice with intact abdominal wall
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Multiple orifices in abdominal wall
Multiple
Disrupted
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Fistula caused by dehiscence or surgical wound/scar
Imaging
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Important to determine anatomy of fistula
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Fistulography will define tract
Small bowel or barium enema will define
state of intestine or distal obstruction
US and CT will define abscess cavities
Management of Fistulae
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Usually conservative management - at least initially consisting of:
Skin protection
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Correction of fluid and electrolyte loss
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Upper GI contents are very corrosive
Require careful fluid balance & restoration of blood volume
Correction of acid-base imbalance
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H2 Antagonist, proton pump inhibitor to reduce gastric
secretions
Somatostatin analogues (e.g. Octreotide) to reduce GI and
pancreatic secretions
Management of Fistulae
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Tissue viability review
Nutritional support
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Restrict oral intake and possibly an nasogastric tube
Malnutrition corrected with either parenteral or enteral
nutrition
Total parenteral nutrition given via Dacron-cuffed tunneled
feeding line
Radiological screening to ensure tube in correct site
Enteral nutrition can be given distal to fistula
Control of sepsis
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Abscess cavities should be drained
Antibiotics
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Enterocutaneous fistulas will not close
if:
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There is total discontinuity of bowel ends
There is distal obstruction
Chronic abscess cavity exists around the
site of the leak
Mucocutaneous continuity has occurred
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Fistulas are less likely to close if:
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They arise from disease intestine (e.g.
Crohn's Disease)
They are end fistulae
The patient is malnourished
They are internal fistulas
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60% will close in one month once
sepsis has been controlled with
conservative treatment
Mortality associated with fistula is still at
least 10%
Surgery should be considered if fistula
does not close by 30-40 days
Summary
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Fully assess area and cleanse thoroughly
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Use appropriate dressing – if in doubt ask
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Treat malodour
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Be aware need of ongoing psychological
support
Any Questions?
References
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Symptom Management in Advanced Cancer; (2009) Twycross, Wilcock,
Toller.
http://www.google.co.uk/imgres?imgurl=http://www.lhsc.on.ca/Health
_Professionals/Wound_Care/
Blowers A L Irving M. Enterocutaneous fistulas. Surgery 1992; 10.2:
27 – 31
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Dubrick S J, Maharaj A R, McKelvey A A. Artificial nutritional support
in patients with gastrointestinal fistulas. World J Surg 1999; 23: 570-
576.
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Mcintyre P B. Management of enterocutaneous fistulas: a review of
132 cases. Br J Surg 1984; 71: 293 -296.