University of Alexandria

Faculty of Nursing
Doctorate Program
2005-2006
The Integumentary System
Te s!in is largest organ in te "ody# $t as many functions including %rotection&
containment and tem%erature control#
The two principle parts of the skin:
Dermis
'%idermis (outer layer) as five layers
*tratum corneum+ ardened& flattened dead cells ,ic are constantly "eing sed
*tratum lucidum+ denucleated cells "ut not com%letely ard
*tratum granulosum+ cells ave a distinct nucleus "ut cell mem"ranes are dying
*tratum s%inosum+ cells are living and mem"ranes are intact
*tratum germinativum+ %rimary site of mitosis in te s!in- contains melanin#
The functions of all the structures contained within the dermis
specialized cells : fibroblasts: %roduce areolar tissue& collagen and
elastin- damaged "y U. ligt#
Mast cells: %roduce istamine as an allergic
res%onse and e%arin& an anticoagulant#
Histiocytes+ also %roduce istamine
2
Leucocytes:/ite "lood cells ,ic el% figt
infection and disease#
Nerve endings: Alert te "rain to eat& cold& %ressure and %ain#
Sweat glands : t,o !inds+ - eccrine+ excrete ,atery s,eat and control
"ody tem%erature#
-a%ocrine+ excrete mil!y fluid- found in groin
and axilla#
Hair follicles+ travel troug te dermis and te e%idermis- erector %ili muscles %ull
airs u%rigt to tra% eat and tus control "ody tem%erature#
Sebaceous glands + connected ,it air follicles- %roduce se"um& a fatty acid ,ic
lu"ricates air safts and el% to regulate te %0 of te s!in (%015#6-6#5)
Blood supply+ a system of "lood vessels including microsco%ic ca%illaries ,ic are
one cell tic!#
Lymphatic capillary+ ,or!s in con2unction ,it te "lood su%%ly to collect excess fluid
and lea!ed %lasma %roteins from te cells and return te su"stances to te circulatory
system#
Papilla: *mall& conical %ro2ections at te "ase of te air containing "lood vessels and
nerves ,ic su%%ly te air ,it nutrients#
WO!" H#$LI!%
Te entire ,ound ealing %rocess is a com%lex series of events tat "egins at te
moment of in2ury and can continue for monts to year# $t leads to restoration of tissue
continuity#
&hases of wound healing:
3# $nflammatory %ase#
2# Proliferative %ase#
4# 5aturation and 6emodeling %ase#
'( Inflammatory phase:
$nitial res%onse to tissue in2ury& it ta!es 3-7 or 5 days& it includes+
4
a- Hemostasis:
$t is te %rocess of sto%%ing "leeding "y+
o 'xtravasations
o $nitiation of %latelet activities and "lood coagulation#
o .asoconstriction
o 8eucocytes
b- nflammation:
o 6elease of %rostaglandins and activated com%lement %roteins
o Attraction of neutro%ils and monocytes to te ,ound #
o Activation of neutro%ils
o 5onocytes undergo a %enoty%ic cange to te activated macro%age
)( &roliferati*e phase :
- $t is te gro,t or re%roduction of ne, connective tissue (granulation tissue)#
- $t starts after first stage and lasts a"out 4 ,ee!s (or longer)#
- Formation ne, ty%e of cell called fibroblast "y te macro%ages#
- Fi"ro"last %roduces a net,or! of collagen surrounding te neovasculture of te
,ound#
- 9ranulation tissue formation "eings after several days#
- During %roliferation& t,o oter %rocesses are ta!ing %lace simultaneously&
e%iteli:ation and contraction#
- '%iteli:ation ; resurfaces te ,ound "y regenerating of e%itelium#
- /ound retraction ; decrease te si:e of ,ound
+,Maturation and -emodeling phase:
- $s te final stage of ealing& ,ic "egins rougly 4 ,ee!s after in2ury#
- $s a %rocess of remodeling of te collagen fi"ers laid do,n during te %roliferation
%ase#
- During tis %ase& ty%e $$$ collagen& a soft gelatinous collagen& is gradually
re%laced ,it stronger& more igly organi:ed collagen#
7
Modalities in wound care:
a . /on*entional or standard therapy :
</ound solutions#
De"ridement#
<Dressing %roducts#
$.Wound Solutions(
/ound solutions el% o%timi:e te ealing environment and decrease te %otential for
infection# $t loosens and ,ases a,ay cellular de"ris suc as "acteria& exudates& %urulent
material and residual to%ical agents from %revious dressings#
%oals:,Determine te most effective metod of cleansing#
-5inimi:e cemical irritation#
-5inimi:e mecanical trauma
!ormal Saline:
= *aline is te %referred cleanser for most ,ounds "ecause it is %ysiologic and ,ill
al,ays "e safe#
= $t ,ill not clean ,ell in dirty& necrotic ,ounds#
&o*idone Iodine:
= >ytotoxic to ealty cells and granulating tissues#
= ?road s%ectrum antimicro"ial effective against a variety of %atogens including
*ta%ylococcus aureus#
= Dries and discolors s!in# $t may cause local irritation to te %eri,ound s!in#
Hydrogen &ero0ide:
= >ytotoxic to ealty cells and granulating tissues#
= 'ffervescent cleansing action el%s to lift de"ris from te ,ound surface ,en used at
full strengt# $f used full strengt& irrigation ,it normal saline after use is recommended#
= $neffective at !illing "acteria#
5
= Do not use on ,ounds ,it sinus tracts#
Sodium Hypochlorite 1"akin Solution.:
= >ytotoxic to ealty cells and granulating tissues#
= ?actericidal effect against most organisms commonly found in o%en ,ounds#
= Fre@uently used in %ressure ulcers ,it necrotic tissue to el% control infection#
= Accasionally used over cancerous gro,ts to control "acteria and minimi:e odor#
=*ould not "e used for %eriods longer tan B-30 days#
2. Wound "ebridement
Types: a. $utolytic "ebridement :
"escription: Autolysis uses te "odyCs o,n en:ymes and moisture to re-ydrate& soften
and finally li@uefy ard escar and sloug #
2est ses +
$n stage $$$ or $. ,ounds ,it ligt to moderate exudates
b.#n3ymatic "ebridement:
4 "escription + >emical en:ymes are fast acting %roducts tat %roduce sloug of necrotic
tissue#
2est ses:
An any ,ound ,it a large amount of necrotic de"ris#
'scar formation
c.Mechanical "ebridement:
"escription + Tis tecni@ue as "een used for decades in ,ound care# Allo,ing a
dressing to %roceed from moist to ,et& ten manually removing te dressing causes a form
of non-selective de"ridement#
6
2est ses: /ounds ,it moderate amounts of necrotic de"ris
d.Surgical "ebridement:
"escription +-*ar% surgical de"ridement and laser de"ridement under anestesia are te
fastest metods of de"ridement#
-*urgical de"ridement can "e %erformed in te o%erating room or at "edside& de%ending
on te extent of te necrotic material#
2est ses:
/ounds ,it a large amount of necrotic tissue#
$n con2unction ,it infected tissue#
/."ressing products:
'.$lginates
/haracteristics 5 6unctions:
Alginates are made of soft non-,oven fi"ers derived from sea,eed#
Tey are usually in te forms of %ads& ro%es or ri""ons#
Alginates a"sor" ,ound exudates and form a gel-li!e covering over te ,ound&
maintaining a moist ,ound environment#
2est ses:
-/ounds ,it moderate to eavy exudates#
$d*antages:
's%ecially useful for %ac!ing exudating ,ounds
Tey do not %ysically ini"it ,ound contraction as ,ould gau:e
B
0igly a"sor"ent
"isad*antages:
6e@uires a secondary dressing
>an "e too drying if ,ound as a lo, volume of exudates
).6oam "ressings
/haracteristics 5 6unctions
Foams are igly a"sor"ent dressings generally made from ydro%ilic
%olyuretane foam#
Tere are various a"sor%tion rates of te different foams on te mar!et# *ome ave
adesive ta%es surrounding an CislandC of foam#
0igly a"sor"ent foams may allo, te caregiver to cange dressings less
fre@uently# Foams tat a"sor" exudates and !ee% it off te ,ound ,ill decrease
maceration to te surrounding tissue#
2est ses
For eavily exudating ,ounds - es%ecially during te inflammatory %ase follo,ing
de"ridement and deslouging& ,en drainage is at its %ea!
Dee% cavity ,ounds - as %ac!ing to %revent %remature closure ,ile a"sor"ing
exudates and maintaining a moist environment#
/ee%ing ulcers& suc as venous stasis#
$d*antages
.ery a"sor"ent& can fre@uently "e left undistur"ed for 4 - 7 days#
>omforta"le and conforma"le
D
"isad*antages
>an cause a drying effect on te ,ound if tere is too little drainage
+./ollagen
>ollagen is a natural "iomaterial tat as uni@ue %ro%erties and as "een used for
ealt care since te ancient 'gy%tian civili:ation# $t is te most a"undant %rotein
found in te "ody#
>ollagen %lays an integral %art during eac %ase of ,ound ealing and is an
excellent omeostatic agent# $t a"sor"s 70 - 60 times its ,eigt in fluid#
Te most a"undant and ,ell caracteri:ed collagen is ty%e 3 extracted from "ovine
(co,) ide# Ater sources include %orcine (%ig)& cic!en tendon& "ovine tendon& etc#
/en a%%lied to a ,ound& collagen initially acts as a aemostatic agent# >ontinued
a%%lication seems to aid and asten te "odyCs o,n re%air mecanisms#
Products !vailable "#edifil$ S%in &emp'(
7 .#n3ymatic "ebriding $gents
'n:ymatic de"riding is relatively selective in removing te necrotic tissue#
?y loosening te necrotic de"ris& surgical de"ridement may "e avoided#
'n:ymatic de"riding agents act on any one or all of tese materials+ collagen&
%rotein& fi"rin& elastin and E or nucleo%roteins# >ec! ,it eac %roduct as to its
metod of action#
Tunneling ulcers are %articularly suita"le for tese %roducts as tey remove de"ris
,ic may "e difficult to visuali:e and E or reac#
All re@uire a %rescri%tion
Products !vailable: "!ccuzyme$Panafi'
4
F
8.Hydrocolloid "ressings
/haracteristics 5 6unctions
0ydrocolloids are occlusive and adesive ,afer dressings ,ic com"ine a"sor"ent
colloidal materials ,it adesive elastomers to manage ligt to moderate amounts
of ,ound exudates#
5ost ydrocolloids react ,it ,ound exudates to form a gel-li!e covering ,ic
%rotects te ,ound "ed and maintains a moist ,ound environment#
0ydrocolloid %o,ders and %astes are also availa"le ,it increased a"sor%tive
ca%acity
2est ses
9ranulating and e%iteliali:ing ,ounds tat are draining lo, to moderate amounts
of exudates#
0ydrocolloid seets el% %romote autolytic de"ridement "y !ee%ing ,ound
exudates in contact ,it necrotic tissue (sloug G escar)#
$d*antages
>onforma"le for easy a%%lication and el% reduce %ain at te ,ound site
"isad*antages
5oderate to eavily exudating ,ounds may over,elm te ydrocolloid dressing&
usually ,itin a fe, days
?rea! do,n of te %roduct may %roduce a residue of varying colors and %ossi"le
foul odor# Tis sould not "e confused ,it an infectious %rocess#
Products !vailable: "&egasorb' .
30
9.Hydrogels "ressings
/haracteristics 5 6unctions
/ound gels are excellent for el%ing to create or maintain a moist environment
some ydrogels %rovide a"sor%tion& deslouging and de"riding ca%acities to
necrotic and fi"rotic tissue#
0ydrogel seets are cross-lin!ed %olymer gels in seet form# *ome are availa"le
,it an adesive "order
2est ses
0el%s %rovide and maintain a moist ,ound environment
?y increasing moisture content& ydrogels ave te a"ility to el% cleans and
de"ride necrotic tissue
For ,ounds ,it minimal or no exudates
$d*antages
'ffective in ydrating ,ound surfaces and li@uefying necrotic tissue on te ,ound
surface
Non-aderent and can "e removed ,itout trauma to te ,ound "ed
H*ootingH effect %romotes %atient acce%tance
"isad*antages
Not too a"sor%tive& terefore& ydrogels or ydrogel seets may not "e an
a%%ro%riate coice for moderate to igly exudating ,ounds
6e@uire secondary dressings
Products !vailable "&egagel$ !merigelt &opical )intment'(
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b . $d:unct wound care products 1!ew, Old therapeutic
modalities. :
I.Wound ;($(/(
TM '
1;acuum $ssisted /losure.
/ound care o%tions tat are effective include te /ound .acuum Assisted >losure#
Using su"-atmos%eric %ressure tat can "e constantly a%%lied to ,ounds in a continuous
or intermittent fasion& ,ound ealing is often %romoted and facilitated# A ,ide range of
,ounds may "e treated and tis usually increases %atient comfort and ,ell-"eing&
decreases overall cost and mor"idity of te ,ound and decreases os%itali:ation#
Indications:
Acute ,ounds
Traumatic ,ounds
*u"-acute ,ounds (i#e# deisced incisions)
Pressure ulcers
>ronic o%en ,ounds
5esed s!in grafts
Fla%s
/ontraindications
Fistulas to organs or "ody cavities
Untreated osteomyelitis
>ancer in ,ound margins
Presence of necrotic tissue
32
Aver ex%osed arteries& veins& nerves& visceral or similar organs <
&recautions
Active "leeding
Patients on anticoagulants
Difficult ,ound omeostasis
/en %lacing in %roximity to "lood vessels& ta!e care to ensure tat all vessels are
adequately %rotected ,it overlying fascia& tissue& or oter %rotective "arrier#
9reater care sould "e ta!en ,it res%ect to ,ea!ened& irradiated or sutured "lood
vessels and it as "een our %ractice not to use te .#A#># in tese areas#
UN$.'6*A8 P6'>AUT$AN* A6' U*'D AT D6'**$N9 >0AN9'*#
/are and Safety Tips -$t is recommended tat te .#A#># device not "e turned off
from %atient use for more tan 2 ours %er day# /en te .#A#># suction device is turned
off& te .#A#># dressing sould "e removed from te %atient#
-Al,ays use sterile dressings %ac!aged "y I>$ for .#A#># use# $ns%ect ,ound at eac
dressing cange and ,atc for signs of deterioration and infection# *igns of infection
include "ut are not limited to fever& redness& s,elling& itcing& ras& discarge& ,armt&
odor#
-Dressings may adere to te ,ound and may ave to "e moistened ,it saline first#
Ada%tic
T5
may "e %laced "et,een te ,ound and te s%onge to decrease aderence& but be
careful to remove it at dressing change as it may get "uried in te a"undant granulation
tissue tat forms#
-$f used on infected ,ounds& dressings sould "e canged every 32-27 ours and te
.#A#># use sould "e guided "y a %ysician ,o is o"serving te ,ound at fre@uent
intervals#
34
&roduct Specifications and se
-.#A#># is availa"le in %orta"le& "attery %o,ered& and larger ,all %lug-in versions# Tey
are often& "ut not necessarily& intercangea"le#
-Te "asic set u% consists of a vacuum %um%& collection canister& connecting tu"ing and
dressing sets# Te dressing set consists of one of availa"le s%onges& %lastic seal dressing
and tu"ing to incor%orate in continuity ,it te s%onge#
->urrent foam dressings are "lac! %olyuretane and ,ite %oly vinyl <<alcool soft foam#
Troubleshooting for Lack of -esponse or "eterioration of Wound
a# >ec! %atient com%liance and dressing tecni@ue minimi:ing lea!s& correct#
"# ?e sure foam is not com%ressing ,ound edges and causing iscemia& correct#
c# ?e sure ,ound does not need de"ridement& correct#
d# ?e sure nutrition is ade@uate#
e# ?e sure %ressure is offloaded#
f# >ec! for infection and osteomyelitis#
g# >ec! for institution of ne, medication or routines tat may interfere ,it ,ound
ealing#
# ?e sure excessive sloug and necrosis are not accumulating#
!(2+ Te .#A#># may not ,or! for all ty%es of ,ounds %articularly ,en tere is severe
iscemia& severe infection& severe nutritional com%romise and ongoing trauma# 0o,ever&
it may "e of "enefit in even tese ty%es of ,ounds to %romote ealing under adverse
circumstances#
&rinciples and #0planation of ;($(/( Therapy <-Te si:e of te ,ound ,as 30cm
long x 5cm ,ide x Dcm dee%#
37

1Wound after debridement.(
/ound .#A#># ,as a%%lied in te o%erating room at te end of te surgery# A "lac! large
%ore s%onge ,as trimmed ,it scissors to fit te ,ound ,itout forci"ly com%ressing te
s%onge to get it in# *mit and Ne%e, *!in Pre%J ,as %laced around te s!in edges and
allo,ed to dry#
35
1Wound with sponge inserted and Skin &rep< applied around the edges.(
Te clear adesive dressing from te .#A#># dressing !it ,as trimmed to cover te ,ound
,it am%le (B-32cm) overla% of te s!in to %rovide a lasting seal# Te clear dressing ,as
a%%lied to te s%onge (,it an incor%orated tu"ing connecter in contact ,it te s%onge)
and carried out over te s!in# $t ,as a%%lied as a covering and so as not to com%ress te
s%onge or %lace tension on te s!in#
36
1;($(/( dressing applied.(
Te dressing and s%onge are connected to te vacuum %um% "y tu"ing tat connects
troug te dis%osa"le drainage canister on te %um%#
$n tis case& a %orta"le unit ,as used and te %atient ,as discarged to ome care# After 32
days a"out 60K of te ,ound ad granulated in#
1&ortable= battery powered ;($(/( connected to the wound.(
3B

1!ote that after only se*en days= the abo*e wound by actual measurement
is >?@ filled in by granulation tissue.(
1&ortable ;($(/(( Supplied in a portable case and consisting of a fanny
pack to carry the apparatus around while connected= batteries= canister(
3D
1Larger ;($(/( is shown here( This one reAuires an electric outlet(
"ifferent tubing= canisters and slightly different adhesi*e dressing are
used.(
).Warm B p therapy system
$s a tem%orary tera%y tat increases te tem%erature of te ,ound "ed #
Indications :
- Acute or cronic ,ound
- Full or %artial tic!ness
)ne e*ample of warmth therapy---+#oist Heat Pac%s+
5oist eat %ac!s are te most common metod of eating te tissues#
Tese %ac!s vary in si:e from 6 "y D in# to tose tat ,ill cover a large
%ortion of te "ac!# Tey also come in s%ecific sa%es and si:es to fit
te nec!& soulder& and oter irregularly sa%ed areas#
Indications:
-Decrease %ain& muscle s%asm& cronic edema
-$ncrease soft tissue mo"ility#
-%rior to oter treatment suc as 2oint mo"ili:ation& massage& range of motion exercises#
3F
Its idea: Te %ac!s are filled ,it finely ground sand and are stored in a unit tat eats
tem to a%%roximately 360L F# ?ecause tey are so ot& your caregiver ,ill %lace te %ac!
inside of a terry clot cover andEor cover te %ac! ,it to,eling# /en te moist eat
%ac! is %laced on your s!in& it sould comforta"le ,arm& "ut not so ot to "urn te s!in#
Mour clinician ,ill cec! "ac! ,it you regularly to ma!e sure tat te tem%erature does
not "ecome too great# $f at any time you feel tat you are "eing "urned& remove te ot
%ac! and summons assistance# 5oist eat treatments are usually a%%lied for 20 to 40
minutes#
/ontraindications :
Tird degree "urn -
+. Hydrotherapy:
,arm ,hirlpool
ts idea : -
/irl%ools use a system of air 2ets and ,ater %um%s to
circulate ,ater and %roduce air "u""les to massage and
relax te treated area#
Benefits: -*oftens tissue
- 6emove de"ris
- $m%roves "lood flo,
ndications -8arge surface area
- /ounds ,it toug& "lac! escar #
- Painful ,ounds #
-ontraindication: infection& edema& "o,el or "ladder incontinence
20
-/arm ,irl%ools are normally used ,it a tem%erature range of 300L F to 330L F# $f only
te extremities are "eing treated ,armer tem%eratures are used- if te entire "ody (or
larger %ercentage of te "ody is immersed) a cooler tem%erature is used# *ince te "ody
floats in ,ater& ,irl%ools are an ideal environment to %ractice range of motion exercises#
/arm ,irl%ool treatments last "et,een 35 to 40 minutes#
7 1 Therapeutic light :
. - /ltaviolet"/0'
ndications: - cronic& slo, ealing ,ound
- $nfected ,ound
- Necrotic ,ound
C ontraindications: Pulmonary T#?& cardiac& renal& e%atic diseases #
1 - laser therapy :
ndications :
- *lo, ealing ,ounds
- Nerve regeneration
- Pain relief
- ontraindications: include treatment over :
Te eye& a emorrage& a malignancy& a
% regnant ,omanCs uterus& %otosensitive s!in #
8 1 Lar*al therapy 1Maggot therapy.
-Tera%eutic maggots used most commonly
today are tose of te green"ottle fly (Lucilia
sericata)& a facultative %arasite tat& in umans&
only attac!s necrotic tissue#
23
-Te maggots atc from eggs laid "y mature adult flies# Tese initial maggots (first
instars) gro, from 3-2mm to D-30mm& moulting t,ice to "ecome tird instars some five
days later# Tey ten %u%ate in a dry location and undergo metamor%osis to adult flies
after a furter ,ee!#
-Tey can only "e used in ,ound de"ridement during te maggot stages& ,en tey are
inca%a"le of re%roduction- metamor%osis to adult flies only occurs outside te
recommended time limits for teir clinical a%%lication#
Method of applications +
-A%%lication of to%ical silver sul%adia:ine (Flama:ine) to soften te escar#
-For maggots to function o%timally tey re@uire a moist environment- saline soa!s ,ere
terefore a%%lied for 7D ours to moisten te ,ound and remove excess silver
sul%adia:ine %rior to a%%lication of maggots#
-Tree "atces of 8arvae ' ,ere a%%lied to te ,ound& eac remaining in-situ for tree
days#
# 5aggots constitute a living "iological dressing& ,ic acts in a num"er of ,ays#
2enefits:- 5aggot secretions a%%ear to am%lify te ealing effects of ost e%idermal
gro,t factor and $8-6 in addition to teir aemostatic %ro%erties
-*ecretions include allantoin and urea (antimicro"ial activity)& calcium car"onate
(stimulation of %agocytosis)& and %roteolytic en:ymes (slougEnecrotic tissue
"rea!do,n)# Te resultant en:ymatic degradation %roducts are su"se@uently ingested and
digested "y te maggots#
-$ni"it and destroy a ,ide range of %atogenic "acteria including Staphylococcus aureus&
grou% A and ? stre%tococci& 9ram %ositive& aero"ic and anaero"ic strains
22
-5icromassage of te ,ound "y maggot movement is tougt to stimulate te formation
of granulation tissue and ,ound exudates "y te ost
# Te net effects of maggot tera%y are accelerated de"ridement of sloug and necrosis and
a reduction in te "acterial load of te ,ound& leading to earlier ealing& reduced ,ound
odor and less %ain#
!(2: Ance a%%lied& maggots remain local to te ,ound and ave no systemic adverse
effects# Tey rely on air for res%iration and act in te a"sence of good "lood su%%ly#
Tis ma!es maggots %articularly useful in ,ounds ,ic are oter,ise unsuited for
surgical treatment#
/ontraindications+
active emorrage
excess ,ound exudates
,ounds in "ody cavities or in close %roximity to large vessels#
9 1 Hyperbaric o0ygen
ntroduction :
0y%er"aric medicine is an acce%ted medical %ractice for te treatment of numerous
%ysical and neurological in2uries and dysfunctions #
H 0y%erH is sim%ly an increase& ,ile H"aricH refers to te %ressure# 0y%er"aric is te
increase of atmos%eric %ressure around te "ody #
"efinition: $s a medical treatment tat uses te administration of 300 %ercent oxygen
at a controlled %ressure (greater tan sea level) for a %rescri"ed amount of time-usually 60
to F0 minutes# $t el%s te "ody eal itself "y ma!ing oxygen availa"le to "ody tissues& or
organs& ,ic are not receiving an ade@uate su%%ly "ecause of illness or trauma #
P hysiological Basi s :
24
- /en ,e normally "reate air (,it 23K A2) at sea level %ressure& most tissue needs of
Axygen are met from te Axygen com"ined to 0"& ,ic is F5 K saturated# 300 ml "lood
carries 3F ml A2 com"ined ,it 0" and 0#42 ml dissolved in %lasma# At tis same
%ressure if 300K A2 is ins%ired& A2 com"ined ,it 0" increases to a maximum of 20 ml
and tat dissolved in %lasma to 2#0F ml #
- Te iger %ressure during y%er"aric oxygen treatment %uses more oxygen into
solution #
- Te amount of A2 dissolved in %lasma increases to 7#7 mlEdl at a %ressure of 2 ATA and
to 6#D mlEdl at 4 ATA #

- Tis additional A2 in solution is almost
sufficient to meet tissue needs ,itout
contri"ution from A2 "ound to emoglo"in
and is res%onsi"le for most of te "eneficial
effects of tis tera%y #
#echanisms of action :
- Te air ,e normally "reate contains
a"out 23K oxygen& ,ic is carried
trougout our "odies "y red "lood cells in
"lood #
- During 0?AT& te 300K oxygen ,e "reate& com"ined ,it iger %ressure& delivers
u% to 35 times te oxygen content to all "ody fluids& including %lasma& cere"ros%inal
fluid surrounding te "rain and s%inal cord& lym%& and intracellular fluids #
- Tis allo,s oxygen levels to increase even in areas ,it "loc!ed or com%romised
"lood su%%ly as a result of in2ury or illness& as ,ell as in areas of tissue damage #
$ncreasing tissue oxygen levels %roduces several im%ortant long-term tera%eutic
"enefits including enanced gro,t of ne, "lood vessels &increased a"ility of ,ite
"lood cells to destroy "acteria and remove toxins# $ncreased gro,t of fi"ro"lasts #(
#ethod of !dministration :
#onoplace chamber
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Accommodate one %atient and are %ressuri:ed ,it 300K oxygen tat te %atient
"reates directly #
2ualplace chambers
Accommodate t,o %atients simultaneously #
#ultiplace chambers
Accommodate multi%le %atients simultaneously #
Some systems may accommodate up to 13 patients #
- ?ot te dual%lace and multi%lace cam"ers are %ressuri:ed ,it air and %atients "reate
oxygen using a ood or mas! #
- Te treatment control %anel controls te tera%y
and monitors te %atient during te treatment #
- 5ost tera%y is given at 2 or 4 ATA
and te average duration of tera%y is
60 to F0 minutes #
- During ,ic you can ,atc videos&
or read# For te first fe, minutes& your
ears ,ill ad2ust& te same as in an
air%lane ta!e-off& so you can ce,
gum (or s,allo,) #
- Num"er of tera%ies may vary from 4-5 for
acute conditions to 50-60 for radiation illnesses#
Mou ,ear te oxygen mas! over your nose#
>ildren can ,ear a %lastic elmet tat loo!s li!e an astronaut elmet
&o*ic 4ffects5 -omplications :
/en used in standard %rotocols y%er"aric oxygen tera%y is safe #
>ommonest side effect may "e +
*ligt %ain in te ears (aural "arotraumas) due to a "loc!ed 'ustacian tu"e # -
- Pneumotorax and air em"olism and transient reversi"le myo%ia after %rolonged
0?A tera%y are rare com%lication
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An occasional %atient may "e claustro%o"ic - #
- Fire is a realistic a:ard "ut %reventa"le "y strict safety %rocedures
&herapeutic 4ffects of HB) :
- $mmune stimulation "y restoring /?> function and enancing teir %agocytic
ca%a"ilities
- Neo-vasculari:ation in y%oxic areas "y augmenting fi"ro"lastic activity and
ca%illary gro,t #
0asoconstriction +
6educes edema and tissue s,elling ,ile ensuring ade@uate Axygen delivery and is
tus useful in acute trauma ,ounds and "urns #
Bactericidal:
- For anaero"ic organisms G ini"its gro,t of aero"ic "acteria at %ressures N 3#4 ATA#
$t $ni"its %roduction of al%a-toxin "y > /elcii and is synergistic ,it Amino
glycosides and Ouinolones#Tus it is life saving in gas gangrene and severe necroti:ing
infections #
- 6educes alf-life of >ar"oxyaemoglo"in from 7 to 5 ours to 20 minutes or less and
is te treatment of coice for >ar"on 5onoxide %oisoning in fire victims #
#echanical effects :
Direct "enefit of increased %ressure el%s reduces "u""le si:e in Air 'm"olism and
Decom%ression $llnesses #
6eactivates 7sleeping cells8 in the penumbra region around central dead neuronal
tissue(Tis is te "asis of its use in neurological conditions# $t also reduces aderence
of /?>s to ca%illary ,alls and may"e useful in acute "rain and s%inal cord in2ury #
ndications of HB) :
,ounds :
- Pro"lem& non-ealing ,ounds and ulcers (dia"etic& venous etc) #
- $nfective ,ounds - gas gangrene& refractory osteomyelitis& necroti:ing soft tissue
infections #
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Acute traumatic iscemia& crus in2uries& com%artment syndromes # -
- >om%romised s!in grafts and fla%s #
- Termal "urns #
)ncology :
8ate radiation induced tissue damage and com%lications due to endarteritis # -
- Pro%ylactically ad2unctive to tera%eutic radiation& for %re%aration of surgery or im%lant
%rocedures in %reviously irradiated fields #
Primary Line of &reatment :
- Air or gas em"olism #
Decom%ression *ic!ness # -
- >ar"on 5onoxide %oisoning& smo!e inalation
/ontraindications :
$bsolute: -Untreated tension %neumotorax #
- *ome ty%es of congenital eart disease #
- Astma #
-elati*e: - u%%er res%iratory tract infection
- 'm%ysema
- Pregnancy
- >laustro%o"ia
- *ei:ure disorder #
c.!ew ad*anced wound ther?apy :
'.#L#/T-I/$L STIML$TIO!:
"efinition: Te use of an electrical current to transfer energy to
a ,ound#
Te ty%e of electricity tat is transferred is controlled "y te electrical source)# 'lectrical
stimulation involves te transfer of electric current troug an a%%lied surface electrode
2B
%ad tat is in ,et (electrolytic) contact ( ca%acitatively cou%led) ,it te external s!in
surface and Eor ,ound "ed#
Te %ulse ,idt varies ,it a range from 20-200 microseconds# $t is a very safe current
"ecause itCs very sort %ulse duration %revents significant canges in "ot tissue %0 and
tem%erature#
I!"I/$TIO!S :
Pressure Ulcers *tage $#
Dia"etic ulcers due to %ressure& insensitivity and dysvascularity
.enous Ulcers
Traumatic /ounds
*urgical /ounds
$scemic Ulcers
.asculitic Ulcers
Donor *ites
/ound Fla%s
?urn ,ounds
/O!T-$I!"I/$TIO!S:
3-Presence of a cardiac %acema!er
2-Placement of electrodes along regions of te %renic nerve
4-Presence of malignancy
7-Placement of electrodes over te carotid sinus
5-Placement of electrodes over te laryngeal musculature
6-Placement of electrodes over to%ical su"stances containing metal ions
B-Placement of electrodes over osteomyelitis
TH#O-C $!" S/I#!/# O6 TH# TH#-$&C
2D
$n 3FF7& te Agency for 0ealt >are Policy and 6esearc (A0>P6) %anel issued treatment
of Pressure Ulcers "y using of electrical stimulation as an ad2unctive tera%y for *tage $$$
and $. %ressure ulcers tat ave %roved unres%onsive to conventional tera%y# Te %anel
found tat data from 5 clinical trials involving 37B %atients to su%%ort te effectiveness of
tis tera%y for %ressure ulcers#
2ioelectric System
Te "ody as its o,n "ioelectric system# Tis system influences ,ound ealing "y
attracting te cells of re%air& canging cell mem"rane %ermea"ility &enancing cellular
secretion troug cell mem"ranes and orientating cell structures# A current termed te
Hcurrent of in2uryH is generated "et,een te s!in and inner tissues ,en tere is a "rea! in
te s!in# Te current ,ill continue until te s!in defect is re%aired# 0ealing of te in2ured
tissue is arrested or ,ill "e incom%lete if tese currents no longer flo, ,ile te ,ound is
o%en# A moist ,ound environment is re@uired for te "ioelectric system to function (,it
normal ( 0#FK ) saline & amor%ous ydrogels and occlusive dressings
Inflammation phase
$nitiates te ,ound re%air %rocess $ncreases "lood flo,
Promotes %agocytosis
'nances tissue oxygenation
6educes edema
Attracts and stimulates fi"ro"lasts and e%itelial cells
*timulates DNA syntesis
>ontrols infection
*olu"ili:es "lood %roducts including necrotic tissue
2F
&roliferation phase
*timulates fi"ro"lasts and e%itelial cells
*timulates DNA and %rotein syntesis
$ncreases ATP generation
$m%roves mem"rane trans%ort
Produces "etter collagen matrix organi:ation&
*timulates ,ound contraction
#pitheliali3ation phase
*timulates e%idermal cell re%roduction and migration
Produces a smooter& tinner scar
&-#/$TIO!S:
-*igns of adverse effects ,ere evaluated in te various clinical trials and none ,ere found
exce%t some s!in irritation or tingling under te electrodes in a fe, cases#
-Patients ,it severe %eri%eral vascular occlusive disease (P.D) may ex%erience some
increased %ain& usually descri"ed as tro""ing& in te leg after electrical stimulation#
6igure '( As%ect of te ,ound caused "y an
automo"ile accident& one ,ee! after te
accident#
6igure )( /ound ealing %rogress at
session F in te same %atient#
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6igure +( $nserted needles encircling te ,ound
at session 3D#
6igure 7( Autcome of te treatment after
2B sessions of electrical stimulation#
). ltrasound:
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"efinition: $s a mecanical vi"ration delivered at a fre@uency a"ove te range of uman
earing#
. >linical ultrasound units currently "eing manufactured ty%ically deliver ultrasound at
fre@uencies of 3 and 4 50: ,it duty cycles ranging from 20 to 300 %ercent# Duty cycles
less tan 300K are usually termed %ulsed ultrasound ,ile a 300K duty cycle is referred
to as continuous ultrasound #
2enefit
3# Inflammatory &hase
-Degranulation of mast cells resulting
in te release of istamine#
),&roliferati*e &hase
-'ffect fi"ro"lasts and stimulate tem to secrete collagen I# Tis can accelerate te
%rocess of ,ound contraction and increase tensile strengt of te ealing tissue
- >onnective tissue ,ill elongate "etter if "ot eat and stretc are com"ined#
- >ontinuous ultrasound at iger tera%eutic intensities %rovides and effective means
of eating dee%er tissue %rior to stretc#
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9re:uency: !s the fre:uency of ultrasound is increased$ the penetration of the signal
decreases( 9or most dermal wounds$ it is preferable therefore$ to utilize a fre:uency of ;
#Hz( . #Hz wound be more effective on deeper structures or periwound s%in(
/onsiderations in the use of ultrasound
As ,it oter medical devices& ina%%ro%riate use can result in serious com%lications# &he
basic precautions should be ta%en:
3# Treat at te lo,est intensity tat ,ill %roduce te desired result#
2# Assure tat te a%%licator is !e%t in constant motion trougout treatment and tat
te %ro%er acoustic cou%ling medium is used#
4# 6educe te intensity or terminate treatment if te %atient com%lains of any increase
in %ain#
$pplication of ultrasound to wounds:
- Prior to ultrasound treatment& remove dressings and clean ,ound of foreign de"ris or
dressing residue#
-A ydrogel seet sould "e %laced in direct contact ,it te ,ound "ed and ,ound
margins& %aying s%ecial attention to removing any air "u""les tat migt "e %resent
"eneat te dressing# 6emove any %rotective %lastic covering on te ydrogel seet#
-$n cases ,ere a cavity ty%e of ,ound exists tat %revents com%lete contact "et,een te
ydrogel seet and te ,ound "ase& as sterile a@ueous ydrogel filler sould "e used#
Te cavity is filled ,it te a@ueous gel& and ten covered ,it te ydrogel seet#
6emove all underlying air "u""les "et,een te a@ueous ydrogel and ydrogel seet#
-Ance te ydrogel seet is in %lace& a%%ly an ultrasonic cou%ling gel on to% of te seet#
--*elect te a%%ro%riate si:ed a%%licator# (Te area treated sould "e no larger tan 3#5 to 2
44
times te si:e of te a%%licator)# $f a relatively large ,ound is "eing treated& it ,ould need
to "e divided into sections#
-*et te ultrasound macine to a 20 K duty cycle at a fre@uency of 4 50:#
-A%%lying ligt %ressure& te sound ead is %laced in contact ,it te cou%ling medium on
to% of te ydrogel seet and moved in a slo, and deli"erate manner using eiter a linear
or circular tecni@ue#
-*et te intensity to less tan 0#5 ,atts %er s@uare centimeter (usually 0#4 ,attsEcm 2)#
6educe te intensity if te %atient ex%eriences %ain or eat#
-Treatment duration is suggested to "e a"out 3 to 2 minutes %er :one#
-Acute ,ounds are treated 3 to 2 times %er day until acute sym%toms (inflammation)
su"side# Treatments can ten decrease to 2 to 4 times %er ,ee!
$pplication of ultrasound to periwound tissue
/en it is desired to %rovide mild eating to te %eri,ound tissue in order to stimulate
circulation& iger intensity ultrasound can "e given# 'xtreme are sould "e used&
o,ever& to assure te tissue is ca%a"le of andling te termal levels delivered#
To treat %eri,ound tissue& 3 50:& continuous ultrasound is usually em%loyed# Again& an
ultrasound a%%licator 3#5 to 2 times te si:e of te treatment area sould "e used# /it an
a@ueous cou%ling medium in %lace& te sound ead is %laced ligtly against te s!in
surface and moved in a slo, and deli"erate manner#
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Te intensity is ty%ically set to "et,een 3 and 3#5 ,atts %er s@uare centimeter# Tis
%arameter is extremely varia"le and de%ends on te %atientCs circulatory& sensory and
mental status#
!(2:, Termal ultrasound sould never "e used in situations ,ere im%aired %erce%tion
%revents te %atient from sensing eat or %ain#
-$f at anytime during te treatment te %atient sould ex%erience an increase in %ain&
te intensity sould "e turned do,n or te treatment discontinued#
Treatment duration is sligtly longer tan tat of %ulsed ultrasound since a mild termal
effect is desired# $nitial treatment is a"out 2-4 minutes %er :one and can "e increased "y 40
second increments to a maximum of 5 minutes %er :one and delivered 4 times %er ,ee!#
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