Wound Management in General Practice

December 2017

Jan Rice Director, Jan Rice WoundCareServices Pty Ltd

At the end of this webinar it is anticipated that the attendee will be able to: • • • • • • • • • •

Name 4 of the most common types of wound classification Name the 3 most common wound classification seen in aged care Name the tissue types described in wound management Discuss to management aims for the various tissue types Name the most common generic listings of dressings Name 4 topical antimicrobials Discuss the best practice management of venous leg ulcers Discuss the management principles of arterial leg ulcers List the 6 stages of pressure injury List 4 factors influencing healing

Topics to be discussed • Common wound types • Common dressings available • Typical presentations of the most common of these wounds • Cleaning wounds/wound management • Signs for review and perhaps referral on

Categorising of wounds • Acute • Chronic • Surgical • Non surgical • Skin tears • Pressure injuries • Venous leg ulcers • Arterial leg ulcers • Inflammatory ulcers

Acute wounds • Generally surgical or non surgical and healing in a normal time frame • Generally less than 4-6 weeks old

Chronic wounds • Again can be surgical or non surgical but have not progressed along the normal healing trajectory and so are older than 6 weeks and no end is in sight-possibly even getting worse

Skin tears • Category 1—A & B • Category 2 – A & B • Category 3

www.silverchain.org.au

Pressure injuries • Stage i • Stage ii • Stage iii • Stage iv • Unstageable • Suspected deep tissue injury www.woundsaustralia.com.au

Venous leg ulceration • Classifies according to the CEAP system although only generally amongst medical staff

CEAP classificati on of Clinical classification chronic venous disease C0

No visible or palpable signs of venous disease

C1

Telangiectasies or reticular veins

C2

Varicose veins

C3

Edema

C4a

Pigmentation or eczema

C4b

Lipodermatosclerosis or athrophie blanche

C5

Healed venous ulcer

C6

Active venous ulcer

Arterial leg ulcers • Arterial disease can be seen in those who have diabetes, past history of smoking, hyperlipidaemia, hypercholesterolaemia and hypertension

So how do these systems of classification help us?

Once you have a name for the wound types you can almost “Google” it and you will find a management pathway Certainly looking there are text books on all of these wounds and injuries

Principle of management of acute wounds • Stop the bleeding • Apply a protective dressing • Ensure there is no oedema • Inspect in 2-3 days, watch for S & S of infection • Ensure good nutrition and hydration

Principles of chronic wound management • Ensure underlying pathology is being addressed • Generally antimicrobials and good wound cleansing are required • Reduce oedema • Ensure excellent skin care • Provide good nutrition and hydration • Seek help if wound is stagnant

Skin tears • If you classify the skin tear according to the STAR tool then there is no need to keep inspecting the wound and protocols of care can be set reducing confusion in care management and promoting best practice • Standardisation of common wound types care also means better utilisation of wound care dressings etc

Pressure injuries • Again if classified we know what to expect and can minimise confusion as to what products to use and how to manage and what to expect

Leg ulceration • Venous leg ulcers require –elevation and compression • Arterial leg ulcers require restoration of the arterial flow , prevention of infection and management of pain-may be considered palliative if none of the above can be achieved • www.woundsaustralia.com.au

Ideally staff can identify all of these things I have mentioned so far

Generic names for dressings • Impregnated mesh dressings • Low adherent lightly absorbent pads • Super absorber pads • Protective film wipes • Film sheets • Foam and foam like absorbent dressings • Hydrocolloid wafers and paste • Hydrogel sheets and amorphous with or without additives

Generic names for dressings • • • • • • • • • •

Calcium alginates HydroFibre Hypertonic salt dressings Cadexomer iodine Silver Tea Tree Oil dressings Antimicrobial Binding dressings Medicated honey Zinc paste bandages Biofilm inhibitors and surfactants

Decision making process of dressing selection • What is your aim? • Where is the wound located? • What type of tissue do you have ? • How much exudate and what type of exudate? • How much pain and what type of pain? • What products do you have available or access to?

Wound tissue descriptor and possible aim • Necrotic tissue—eschar or slough---maintain or remove?? • Granulation tissue--protect • Hypergranulation tissue--reduce • Epithelium--protect • Macerated tissue—manage exudate • Infected tissue-use antimicrobials • Foul smelling tissue-antimicrobials/debride

Matching tissue type & colour & product • Black necrotic---****if aiming to heal--cleansing dressing, but if dry and ischaemic keep dry • Green Infected----antimicrobial dressing • Wet yellow necrotic ---antimicrobial dressing • Dry yellow necrotic ---rehydrating dressing • Red granulation---protect • Hypergranulation---antimicrobial dressing • Pink epithelium---protect This is not a prescription but a guide to where to start—it is imperative that the underlying pathophysiology be addressed where possible World of Wounds

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Dry hard black-almost no erythema, nil odour, ‘quiet’ DO NOT HYDRATE!!! Keep dry

Soft, boggy, offensive black often with peri wound maceration—have someone debride but usually after a few days of antibiotics-if you debride without antibiotic coverage there is often uncontrolled bleeding

Infected wounds These wounds have thick purulent exudate often brown/red in colour or green • requires systemic antibiotic therapy, exudate control and safe topical therapy

Yellow (sloughy) wounds The drier yellow/brown tissue if not able to be debrided requires rehydration to assist autolytic debridement

The moist creamy yellow wet tissue requires an antimicrobial that will help to manage exudate

Clinicians must however be able to identify other yellow tissue….. • Tendon • Bone-creamy / white • Fat / Subcutaneous tissue

Healthy red (granulating) This tissue should be almost level with the perimeter of the wound and not bleed easily when cleansed This tissue requires some moisture but not too much and it requires a dressing that will protect

Poor quality granulation tissue • Can present as pale tissue with irregular tissue and copious exudate and non healing edges • This tissue often requires an antimicrobial, very good cleansing and exudate management and peri wound protection

Hypergranulation tissue • Bleeds easily and raised above side edges of wound • May also present as loose ‘bubbles’ of tissue within deeper wounds • Sometimes described as ‘Jelly like’ tissue • Flattens when pressed for short length of time • The aim here is to control exudate, apply direct pressure and consider antimicrobials

Pink (epithelialising) tissue • This represents the wound in the final stages of healing, it may be transparent and pearly pink • Young epithelium wrinkles when pressed and has a matt finish appearance with minimal exudate -requires some hydration and protection, particularly against friction and shear

In planning the treatment the clinician must also consider the depth of wound • For pressure injuries use the pressure injury classification tools, other will be described according to the burn classifications of superficial, partial, thickness, deep partial and full thickness • Determining depth will influence product choice

Wound exudate assessment is perhaps the final side of the triangle in product selection Exudate is often described as , nil, minimal, moderate and heavy, but in reality these are very subjective and determined by product selection. Naturally the type of exudate needs also to be considered • www.woundsinternational.com for an excellent document on wound exudate

Assessing if progress is being made is often done by...... • Calculating size change • Tissue type progresses from necrotic to healthy granulation or epithelium • Exudate volume decreases • Pain settles/ subsides • Peri-wound condition appears normal • Malodour disappears

45%
 granulation
 tissue 25%
 epithelium 15% fibrinous
 tissue/slough 15% nectrotic
 tissue

Principles • Treat the underlying cause if possible • Control all known factors that may influence healing • Select product or device to manage wound based on tissue assessment, volume and type of exudate, depth or wound, condition of peri wound and ability to purchase • Plan to review regularly, adjust as tissue changes and maintain integrity once healed

The skin is a very important part of the immune system

The body’s natural defence system

Consider this brick wall…..

Wound healing is similar to the brick wall

Even when we patch up this wall-it will still have a weak point

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Factors influencing healing

Consider… • Where the wound is located? • What is the condition of the periwound? • How great a risk is there of further contamination by other body fluids? • How deep is the wound? • Is there tunnelling and tracking?

Factor

Effect on healing

Level of evidence

Inadequate pefusion

Increased risk of infection

Level I

Presence of non viable Increased risk of infection tissue

Level I

Presence of haematomas or seromas

Causes wound ischaemia, Level I increases dead space, supplies nutrients for bacteria, increases risk of infection

Wound Infection

Prolongs inflammatory phase

Level I

Excess proteases Systemic immune deficiency

Degrades extracellular matrix Inhibition of cellular proliferation and function, nutritional deficiency

Level I Level II

Systemic conditions, e.g. diabetes

Hyperglycaemia, increased risk of infection, wound ischaemia

Level II

Increased age

Impaired immune response

Level II

Obesity

Increased risk of infection, wound dehiscence and pressure injury

Level II

Malnutrition

Protein loss, increased risk of pressure injury

Level II

Cigarette smoking

Higher incidence of complications

Level II

Corticosteroids

Detrimental effect on growth factors and collagen deposition

Level II

Without a doubt........Infection

Also ranking very high on the list is the tissue within the wound......

Other important factors to be considered • Nutritional factors • Mechanical factors • Wound temperature • Desiccation and maceration • Chemical stressors • Patient factors

Normal RDI’s

25-30 cal / kg 8-10Cal/ kg Energy

100-200 mg

1.2-2g/ kg 50g/kg Protein

10-30m

15-25mg 40 mg Vitamin C

12-15mg

12-16mg

Zinc

Iron

Nutrition • Mini-nutritional assessment scale-available from
 www.mna-elderly.com For your free copy contact 1800 671 628 and also ask for the recipes using Arginaid extra and ask for the new patient guide- Support wound healing from the inside out.

Mechanical factors

Temperature • Extremes of body temperature will cause tissue damage • Optimum temperature of wound is 370C • Sub-optimal temperatures occur if dressings are changed frequently • Wherever possible warm wound cleaning solutions

Wound debris • Necrotic tissue, dry scabs and excess slough will impair epithelial migration and impair the supply of nutrients to the wound. • Wound debris prevents the formation of granulation tissue and prolongs the inflammatory phase of healing. • Foreign material in the wound will do the same, e.g. cotton wool fibres, dog & cat hair.

Maceration • ‘Softening and breakdown of skin resulting from longed exposure to moisture’(Anderson 1998) • Difference between acute & chronic wound exudate, the chronic can be quite harmful to surrounding tissue • Excessive moisture may predispose the wound to infection, skin sensitivities and irritations • Apart from wound exudate other sources of excess moisture are urinary and faecal incontinence, and wet dressings from the shower!

Topical antiseptics-yes, no, sometimes? • Bacteria cause local inflammation and are leucocytotoxic. 
 
 They also damage epithelium, retard wound contraction, reduce wound tensile strength and trigger microthrombi. 
 
 Therefore, the cytotoxicity of bacteria must be weighed against any possible antiseptic cytotoxicity • More and more new research is demonstrating that there is a place for skin cleansing with antiseptics and in some cases cleansing wounds with antiseptics and then rinsing off with sterile saline

These wounds require more than soap or soap alternative

Smoking and wound healing
 ONE CIGARETTE WILL REDUCE THE PERIPHERAL BLOOD FLOW BY 50% FOR ONE HOUR

Pain

www.ewma.org

Further reading... www.ewma.org • Wound complexity and healing
 P Vowden, J Apelqvist, C Moffatt • Psychosocial factors and delayed healing
 C Moffatt, K Vowden, P Price, P Vowden • Economic burden of hard-to-heal wounds
 M Romanelli, JC Vuerstaek, LC Rogers, DG Armstrong, J Apelqvist

We need to look at the ‘whole’ person not the ‘hole’ in the person

Resources • www.awma.com.au • www.woundpedia.com • www.worldwidewounds.com • www.globalwoundacademy.com • www.ewma.org • www.woundinfection-institute.com • www.woundsinternational.com • Facebook- Regional Wounds Group

Thank you for participating!

Got a question? Email: [email protected]