Wound Management Training Holden 07

Wound management training GMH 2007

1: Types of deep tissue healing • Wounds heal by one of 2 ways: – regeneration, which only occurs in the epidermis – repair, which occurs in any tissue deeper than the epidermis

• Wounds that regenerate tend to require little or no intervention • Deeper wounds that heal by repair can suffer interruptions or complications • Being able to identify healing by first (primary) intention or second intention allows for more realistic assessment and planning T.Ellis – Director, WoundHeal Australia, July - 2007

1: Types of deep tissue healing

TYPES OF DEEP TISSUE HEALING Characteristic

st

1 Intention

nd

2

Intention

rd

3 Intention

Approximated

Not approximated

Initially not approximated

Absent

Frequently present

Frequently present

Small amount

Large amount

Larger amount than in healing by 1st intention; less than healing by 2nd intention

Scar

Small

Large

Larger than healing by 1st intention; smaller than healing by 2nd intention

Healing time

Short

Long/delayed

Longer than healing by 1st intention; less than healing by 2nd intention

Surgical wound

Venous (leg) ulcer

Surgical wound post perforated appendix

Wound Edges

Infection

Granulation

Example

• Healing by first intention: • Healing by first (primary) intention is uncomplicated healing where: – – – – –

wound edges are joined together there is no tissue deficit to fill no infection the scar tissue formed is relatively small union of the wound edges occurs in a timely manner though the actual time taken to heal depends on the person’s condition

• Initial union of wound edges would take place over 7-10 days, though the maturation stage of healing could take up to 2 years.

1: Types of deep tissue healing • Healing by Second intention: • Healing by second intention occurs when there is a tissue deficit • The body must fill and contract the wound area in order to restore tissue integrity • The body produces granulation tissue in order to establish scar tissue • Wounds healing by second intention will always have more granulation tissue in relation to size than a wound healing by first intention • Healing time is longer because of the additional need for tissue growth

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2: Overview of healing four stage model • Healing is a feature of the immune system • When wounding occurs the body devotes an enormous amount of energy to repairing the damage so that normal body defenses are restored • Healing generally occurs in an orderly fashion and features bleeding, inflammation, growth of new tissue and scar maturation • Wounds that don’t heal in an orderly fashion represent a significant burden on the person and may require specific intervention to facilitate tissue growth and repair Healing by second intention over a period of 10 weeks

• In order to determine the correct care you must be able respond to the changes in tissue as wounds heal

2: Overview of healing four stage model • Skin, muscle and other tissue types are highly organized in their original state • When wounding occurs the healing process replaces that highly organized tissue with “filler” tissue or scar • Whilst scar tissue is very important in restoring integrity, it is never as strong, functional or visibly the same as the tissue it replaces • The new tissue is relatively disorganized compared to the tissue it replaces and will require ongoing protection to ensure its maintenance • There are a large number of co-factors that interplay to produce new tissue and any interruption to the supply or function of these factors will result in less than adequate scarring

When damage occurs, organisation and function are lost – repair is required!

Tissue in its original state is organised and functional – like this picket fence!

Tissue integrity (the fence!) is restored using materials that can offer similar function to the original but are not as well organised or capable of performing exactly the same way.

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2: Overview of healing four stage model • Stage 1: Wounding – bleeding (0 hours to day1)

2: Overview of healing four stage model • Stage 1: Wounding – bleeding (0 hours to day1)

Key events: Damage to tissue occurs Decrease in tissue / organ function Haemorrhage Clot forms High risk of bacterial and foreign body contamination Extent of wounding impacts on other stages

Wound occurs due to trauma Note: bleeding indicates wound has penetrated through to (at least) the dermis

Bleeding occurs following trauma: Wound is plugged by clot that forms as bleeding slows

Diagram showing blood clot in wound area: wound is sealed off from further contamination at this point

2: Overview of healing four stage model

2: Overview of healing four stage model

• Stage 2: Inflammation - clearing the wound (days 1 - 3)

• Stage 2: Inflammation - clearing the wound (days 1 - 3)

Key events: Blood vessel constriction (stops bleeding) Release of substances by cells that cause blood vessel dilation - increase in size (largely responsible for the redness surrounding wound and the swelling in tissue) White blood cells enter the wound area and clear debris and microbes White blood cells send chemical signals that attract other specialised cells to the wound area Process most active 12 - 72 hours following injury (acute wounds) Inflammation after injury – essential for healing

2: Overview of healing four stage model

Inflammation extends into deeper tissue

2: Overview of healing four stage model Inflammation: clearing the wound continued…

An infected wound showing inflammation induced by bacteria – same process, different reason

White blood cells enter wound area and begin to clear dead tissue and microbes

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2: Overview of healing four stage model

2: Overview of healing four stage model Stage 3: Proliferative stage – growing new tissue (days 3 – 24)

Inflammation: clearing the wound continued…

Key events: granulation tissue formation (days 3 – 24) Macrophages and neutrophils (white blood cells) are involved in the transition from inflammatory to proliferative stage New cells migrate through wound and begin to divide and produce new tissue Specialised cells called fibroblasts begin to increase the production of collagen which provides the scaffold for new tissue to grow on whilst adding strength to new tissue The inflammatory stage helps the body to clear unnecessary dead tissue as well as microbes from the wound. If dead tissue and high numbers of bacteria remain in a wound, the process of inflammation will continue and sometimes causes wounds to “stall” in the inflammatory stage. The pictures above show how the body clears dead tissue from a wound during the inflammatory stage. These pictures were taken about six weeks apart demonstrating how long the process can sometimes take.

Blood vessels begin to grow from within the wound forming new capillaries and then join to original capillaries outside the wound area allowing blood to flow through the wound area and increasing the amount of oxygen in the wound

2: Overview of healing four stage model •

2: Overview of healing four stage model

Stage 3: Proliferative stage – growing new tissue (days 3 – 24)

Stage 3: Proliferative stage – growing new tissue (days 3 – 24)

Newly formed granulation tissue ready for epithelialisation; granulation tissue is very fragile and bleeds easily if disturbed by trauma, for example during dressing changes

Blood vessels are cleared and new vessels grow into and from the wound; white cells continue to clear debris; oxygen levels in the wound begin to improve; redness and swelling reduces;

2: Overview of healing four stage model •

Stage 3: Proliferative stage – growing new tissue (days 3 – 24)

2: Overview of healing four stage model •

Stage 3: Proliferative stage – growing new tissue (days 3 – 24)

Key events: epithelialisation (days 6 – 24) Tissue matrix provides substrate for migration of epithelial cells Epithelial cells derived from edges of wound, hair follicle remnants, glandular remnants Requires moisture and occurs under scab if one exists Tissue is pink-white in appearance despite the original skin colour This is because there is no melanin in the new tissue at this point New tissue begins to lose its red “see through” appearance Wound surface area and volume begin to decrease significantly due to contraction – up to 80% of closure is due to contraction

Inflammation largely subsided, the wound area is filled with new tissue (granulation) and resurfacing (epithelialisation) begins. Note that the wound is beginning to contract now that new tissue is growing. Contraction is the main process by which wounds close

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2: Overview of healing four stage model •

Stage 4: Maturation stage – tissue remodeling (24 days – 2 years)

2: Overview of healing four stage model •

Stage 4: Maturation stage – tissue remodeling (24 days – 2 years)

Key events: Epithelial (new tissue) lining becomes multi-layered – less “see through” Cell growth balanced by cell death Collagen production balanced by activity of collagenase (an enzyme that breaks down collagen); if this does not occur properly, scars can be “lumpy” rather than flat and smooth Scar continues to form and strengthen, continues contraction Scar will gradually shrink over time and will eventually be quite pale in colour rather than the pink colour of newly formed scar In darker skin, the scar will always remain paler then the skin it replaces

An epithelialised wound that is now maturing. This wound is superficial so “scar” will disappear entirely. In larger, deeper wounds however the scar will remain visible and undergo changes over a 2 year period.

2: Overview of healing four stage model •

Treating laceration

Stage 4: Maturation stage – tissue remodeling (24 days – 2 years)

• The key to correct treatment is ASSESSMENT • Factors to assess: depth, trauma, haemorrhage, wound edges, contamination, pain or loss of sensation, location • Administer first aid – refer after assessment… Maturation phase now complete and only pink, visible surface scar remains

First Aid • Arrest haemorrhage – pressure and elevation • Expectations: bleeding should slow or cease after 2 or 3 minutes • If bleeding continues, especially pulsing, maintain pressure and contact emergency assistance – i.e. ambulance • Where possible – use sterile items in contact with wounds, ensuring hands are clean and gloves are worn (Standard Universal precautions)

First Aid • When bleeding has slowed – assess depth • • • •

Grade 1 – epidermal Grade 2 – dermal Grade 3 – Subcutaneous tissue (fat) Grade 4 – muscle through to bone

• Grade 3 and 4 should be referred for suturing

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First aid

Treatment - dressings

• When bleeding has slowed – cleanse • Aim is to remove debris: running tap water is effective; antiseptics can be used after this but evidence suggests this may not be of any significant benefit • Ensure loose debris is completely removed as foreign bodies delay healing

• Immobilise – up to 3 days ideal: may require splinting/rest – this will allow clot, granulation, adhesion to progress – especially in deeper wounds • Non-stick dressings: foams are ideal as they will absorb and adhere • Film backed non-stick dressings like Opsite surgical or Tegasorb etc can also be used • Use water-proof dressings to facilitate care

Burn Wound management

Observation •

• Further bleeding

1.

• Redness, pain, heat, swelling, loss of sensation or increasing pain (all may indicate infection of deeper nerve damage) • Patients should be referred for medical treatment if any of the above occurs

Superficial burn

Burn wounds fall into 3 categories: Superficial – confined to epidermis; characterised by redness/inflammation; acute pain; hyperaemic area is blanchable; healing in 3-7 days; no scarring

2.

Partial thickness –

Dermal (Superficial partial thickness): confined to epidermis and upper dermis; characterised by redness/inflammation; acute pain; blistering; blanchable hyperaemia; healing in 3 weeks; possible scarring

–

Deep dermal (Partial thickness): destruction of epidermis and almost all dermis; mottled appearance; sluggish capillary return at best; may be non-blanching; pain will vary according to depth of destruction; scarring likely to be hypertrophic; healing > 3 weeks; REFERRAL for excision grafting etc

Partial thickness burn

Partial Thickness

Deep Partial thickness burn

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Burn Wound Management 3. –

•

Burn Wound Management

Full thickness Destruction of epidermis, dermis and may extend to adipose, muscle tendon and bone; wound can vary in colour from deep red to grey to white; leathery to touch; generally insensate; TERTIARY REFERRAL for resuscitation, excision, grafting, scar management

All partial and full thickness burn wounds occurring on hands, feet, face, throat/neck, genitalia, over joint areas or circumferential burns should be referred to tertiary centres for assessment and intensive management where necessary

Burn Wound Management

•

1st aid: For thermal and most chemical burn wounds - cool and protect; cool running water; can be up to 20 minutes; observe for hypothermia

•

Cement or lime burns: do not wet as this actually activates the substances and caused more injury – allow powder to dry, brush off and then use water to flush

•

5% TBSA in children and 10% in adults can be managed at local level if superficial or partial thickness only; greater than this area should be referred on for assessment at tertiary centre

•

Superficial or partial thickness burn wounds that fail to progress in 4 weeks should also be referred to a tertiary centre

Superficial and PT dressings

• Treatment: Superficial and Superficial partial thickness • Assess tissue – if blistered, cool 20 mins’, cover with soft dressing (foam or Aquaclear) bandage and refer – especially over jointed areas • Dressings: • Aquaclear (Hartmann) – cooling formed gel sheet • Film dressings • Hydrocolloids

• Antimicrobial dressings: • • • • •

Acticoat 3 and Acticoat absorbent Aquacel Ag Contreet Ag – hydrocolloid or foam Atrauman Ag SSD cream – use is now diminishing, especially in burns units

Partial Thickness

Partial Thickness - refer

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Pseudo-eschar forming

Common dressing categories

Categories of dressings and their use

?=

Rules… • •

• • • • • • • •

Tal Ellis Lecturer, Nursing, School of Nursing and Midwifery, University of South Australia Director, WoundHeal Australia Pty Ltd

Categories of dressings • Film membranes: – Properties • • • • •

adhering polyurethane film vapor permeable conformable waterproof maintain moist environment • non-absorbent • primary or secondary

Dressings do not heal wounds, people do! Dressing choice relates to assessment outcomes – assessment and accurate diagnosis are the most important aspects of wound management Dressings are tools of the trade ONLY Dressing categories have specific purposes There is no one answer for every person’s wound Dressings carry instructions for use – these should be followed! Dressing regimes should not be constantly changed Dressings should keep wounds: warm, moist, non-toxic Products should have some evidence to support their use: Evidence based practice Eggs, vegemite, most honey, sugar, vinegar etc should be fed to the patient – not put on their wounds

Categories of dressings • Foams: – Properties • • • • • • •

non adherent foam sheets or fillers (some adherent foams on market) vapour permeable maintain moist environment some waterproofed highly absorbent primary or secondary

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Categories of dressings

Categories of dressings

• Hydrogels: – Properties -

• Hydrocolloids: – Properties -

• polyethylene glycol; polymeric; hydrophilic • amorphous or sheet like • absorbent • hydrating - ie provide moisture • amorphous variety fill space • sheets can conform • primary

Categories of dressings

• Carboxymethylcellulose • wide variety of forms - sheets, paste, islands, woven • maintain moist environment • vapor permeable • conformability depends on form • absorbent - forms gel • primary and secondary

Categories of dressings • Combinant

• Alginates – Properties • • • • • •

derived from brown seaweed hydrophilic calcium/sodium ion exchange haemostatic, absorbent gel forming, conforming multiple presentation - sheet, rope, mixed • primary or secondary (if combined with hydrocolloid)

Acticoat

– eg: hydrocolloid + alginate

• • • • • • •

Hypertonic Saline Retention Parrafin gauze Cotton/gauze/non adherent Enzymes Nanocrystalline Silver Growth factor impreganted (future)

Ionic/nanocrystalline silver • Silver has been used for centuries as an antiseptic agent • Lost favour with the advent of antibiotics • Regained favour as bacterial resistance became a problem • Many differing presentations and manufacturers of dressings using silver as the active agent

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Aquacel Ag - ConvaTec

Aquacel Ag

• Hydrofibre dressing impregnated with ionic silver • Has excellent antibacterial properties • Has excellent exudate handling characteristics • Useful on heavily colonised or infected wounds • Best used on moderate to heavy exudating wounds

Acticoat – Smith and Nephew • Nanocrystalline silver • Similar antibacterial properties to Aquacel Ag – possibly better delivery of silver to the wound bed • Presented in both low absorbent and high absorbent forms • Has been used extensively in burns treatment • Useful in deep/exudating wounds – eg PU’s

Acticoat

Acticoat absorbent

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Contreet - Coloplast Contreet’s three-way mode of action: • Antibacterial effect of silver through hydroactivated technology, producing a sustained release of silver in the wound bed and in the dressing.

Acticoat

• Barrier against external bacteria and fluids reducing the risk of cross contamination • Superior exudate management and moist wound healing (Coloplast website)

Atrauman • New product from Hartmann • Contact layer –like Paraffin gauze • Contains silver delivered in ionic form – i.e. active

Can be left in place and only secondary dressing changed

Conclusion • The digital revolution provides us with excellent resources for imaging, assessment and recording

Digital imaging and assessment tools Visitrak (Smith and Nephew)

• Skill and training valuable as technology is useless unless properly used • Images belong to institution – permission required from client and institution for use outside clinical environment • Not an embedded standard for assessment • Fundamentals of assessment will remain the key to good record keeping

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Using Visitrac…

Visitrac • Produced by Smith and Nephew • Manual recording of wound data which can then be entered via Vistrac Capture to maintain a computer based record • Cost $700 plus tracing sheets and depth gauges (both are ongoing costs) • Very useful where computer facilities are hard to access as data can be used to record in non-digital form (i.e. patient record) • Instant/on-the-spot assessment data

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AMWIS and Visitrak - Summary Alfred/Medseed wound imaging system – AMWIS provides detailed assessment and reporting via web – very detailed, can be slow to use Visitrak – manual tracing but can be combined with Visitrak capture to provide assessment and pictorial records – not as detailed, still takes some time, requires additional equipment, on-the-spot measurement

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