CURRENT CONCEPTS IN
WOUND CARE
Tim Brandys MD FRCSC
OUTLINE:
•
•
•
•
•
•
•
Moist Wound Healing
Acute vs. Chronic Wound
Wound Bed Prep
Pressure Ulcers
Leg Ulcers
Dressing Selection
Cases
Moist Wound Healing:
• George Winter 1960’s
Advantages:
-inc.rate reepithelialization
-inc. production collagen
-inc. angiogenesis
-allows autolytic debridement
-Decrease pain
-Dry dressings peel off healing layers
-accelerates healing 50% vs.air dry
Acute vs. Chronic wound
Healing:
Acute Wound Healing:
• Orderly sequence Repair
• 4 Phases:
Hemostasis,Inflammation,Proliferation,
Maturation.
• Each Phase=Cell Type dominate
• Hemostasis=Plt.,Inflamm.=Neutrophil,
Prolif.=Fibroblast,Maturation
• All regulated by growth
factors,cytokines,&chemokines
Chronic Wound:
• Stuck in the Inflammatory Phase,defective
remodeling of ECM,fail to reepithelialize.
CHRONIC WOUND
• Usual Molecular & Cellular processes
disrupted
• Neutrophils dominate: release MMP’s in
excess-digest extracellular matrix
• Leaky capillaries- release excess
Fibronectin binds & inactivates growth
factors
Chronic Wound:
• Fibroblasts become senescent fail to
respond to normal wound healing signals
• Neutrophils continue to stimulated (by
systemic or local factors) and wound is left
in a viscous circle of inflammation.
• Other Chronic wounds are stuck in the
proliferative phase again due to
unresponsive cells
Wound Bed Prep
Wound Bed Prep.:
Goal: Convert the Chronic wound into an
Acute wound and allow normal healing to
take place.
Wound Bed Prep.:
Three Pronged Attack
1. Debridement
2. Decrease Bacterial Burden
3. Manage wound Exudate
Debridement:
Purpose: 1. To remove “Necrotic Burden”and
restore acute wound healing.
2. To allow proper wound
assessment.
Surgical Debridement:
Advantages:
• Remove large amounts
necrotic tissue fast.
• Allows bone, tissue cultures
• Leaves healthy vasc. Bed
Disadvantages:
• Painful
• Can remove too much
Enzymatic Debridement:
Collagenase selectively
digests collagen types
1 & 3 in necrotic
tissue
Advantages: Easy,Not
painful
Disadvantage: Slow
Decrease Bacterial Load:
• All Chronic wounds sit somewhere along a
bacterial continuum.
Contaminated
Colonized
Increased
bacterial burden
Infected
Infection:
Risk
Infection
= Bacterial x Virulence
Burden
Microorganism
Host Resistance
Infection Concepts:
• Host Resistance : Immunocompromised,
Malnutrition
• Bacterial Burden: >10 5th microbes/g
• Biofilm: Microcolonies of Bacteria secrete
protective glycocalyx
Manage Wound Exudate:
Chronic Wound Exudate :
Inhibits: Proliferation
Fibroblasts,Keratinocytes,Endothelial cells
Contains MMP’s,Serine Proteases
Fibrinogen &Fibrin bind and inactivate
growth factors
Hospital Wounds:
Pressure Ulcers:
Leg Ulcers:
Dressing Selection:
THERE IS NO UNIVERSAL WOUND
DRESSING
THE DRESSING MUST FIT THE WOUND
DRESSINGS MUST BE REASSESED FOR
EACH PHASE OF WOUND HEALING
Dressing Selection:
INFECTED
Antimicrobial:
ACTICOAT:
Ionized silver
Broad spec. MRSA/VRE
IODOSORB:
Cadexomer Iodine
Broad spec.
Decr. Foul odour
Absorbent
Dressing Selection:
LOW EXUDATE
HYROGEL:
Moist env.
Autolysis
Decrease pain
Dressing Selection:
ESCHAR,SLOUGH
ENZYMATIC
DEBRIDEMENT:
Collagenase-selective
Digestion types 1 and 3
collagen in necrotic
tissue
Dressing Selection:
LIGHT EXUDATE
HYDROCOLLOID:
Duoderm
Wound granulating
Dessing Selection:
Moderate to heavy
exudate
FOAM:
Allevyn
Hydrophillic
polyurethane foam
Absorbs up to 4 days
Dressing Selection:
Moderate to Heavy
Exudate
ALGINATES
-Seaweed
-Turns to gel
-Moist Wound
Environment
-Hemostatic
-Can be drying
Dressing Selection:
Moderate to Heavy
Exudate
HYDROFIBER
AQUACEL
-Turns into gel
-Moist wound
Environment
Dressing Selection:
VENOUS ULCER
COMPRESSION
BANDAGE
Profore-4 layer
compression
ABI >.8
Dressing Selection:
LARGE WOUND
CAVITY
1.Allevyn Cavity
2.THE VAC
Sponge with suction unit
-stimulates
angiogenesis,causes
wound contraction
CASES
CASE 1:
70 yo smoker admitted
with pancreatitis to the
ICU.Required
prolonged stay on the
ventilator.Physical
exam reveals absent
pedal pulses and a
painful necrotic left
heel ulcer.
What do you do now?
CASE 2:
40 yo male paraplegic
admitted to medicine with
UTI .Develops a large
ischial ulcer while in
hospital.Surgery is
consulted.
WHAT DO YOU DO NOW?
Case 3 :
Otherwise healthy 35 yo
female suffers lacerations
to right leg during accident
with farming
equipment.Transferred to
plastic surgery after failure
to heal wounds in
peripheral hospital.
WHAT DO YOU DO KNOW?
CASE 4:
50 yo diabetic male is
referred to the
orthopedic surgeon
with a non healing
ulcer over the plantar
surface 1st metatarsal
head left foot.
WHAT DO YOU DO
NOW?
CASE 5:
65 yo female comes to
the Vasc.Surg clinic
with a large left ankle
ulcer.It is painless and
has a lot of
exudate.The ulcer has
failed to heal despite
wet to dry saline
dressings.
What Do You Do Now ?