WOUND:

“A type of physical trauma whereby the integrity of the skin

or of any tissue is compromised.”

 A wound is a breakdown in the protective function of the skin.

 It is the loss of continuity of epithelium, with or without loss of
underlying connective tissue (i.e. muscle, bone, nerves) following
injury to the skin or underlying tissues/organs caused by
surgery, a blow, a cut, chemicals, heat/cold, friction/shear
force, pressure or as a result of disease, such as leg ulcers or
carcinomas.

COMPLEX WOUNDS:
“Tissue is lost or destructed by means of a crush, burn, or
foreign body in the wound.”

A complex wound may present as any of the following:

 An open sore or injury that isn't healing within the expected

time-frame.
 An ulcer that exposes muscle or bone.
 Sores on the lower legs.
These complex wounds identified in medical terms would be known
as:

 Diabetic ulcer.
 Pressure ulcer.
 Venous stasis ulcers.

RISK FACTORS:
One or more of the following factors usually leads to a complex
wound:

1. Loss of a large amount of skin.

2. Infection.
3. Compromised blood flow.
4. Poor overall health.
5. Side effects of medications.

1.LOSS OF A LARGE AMOUNT OF SKIN:

 When a large area of skin is damaged, the wound becomes more

difficult to fix.
 If the wound is small, then a surgeon can sew the two sides
back together.
 However, if a large portion of skin is damaged, then sewing it
shut becomes impossible.
2.INFECTION:
 If infection occurs in a wound, then healthcare providers must
first tackle the infection.
 Only once the infection is eradicated the skin will be able to
regenerate.

3.COMPROMISED BLOOD FLOW:

 In order for the skin to regenerate, blood must bring needed
nutrients to the wound.
 If blood is prohibited from reaching the wound, then healing
will be delayed.
 If a patient has decreased mobility, the likelihood of developing
a complex wound increases greatly.
4.POOR OVERALL HEALTH:
 Patients with other medical conditions have poorer wound
healing.
 For example, patients with diabetes or peripheral arterial
disease are not able to heal as quickly as those patients without
these conditions.
 Similarly, patients who smoke, drink excessively or are obese
also have delayed wound healing.

5.SIDE EFFECTS OF MEDICATIONS:

 Certain medications slow the wound healing process.
 For example, corticosteroids and immunosuppressant decrease
the skin's ability to fight off infection while regenerating.

TREATMENT:
 The first issue when addressing complex wounds is to treat any
underlying conditions.
 The aim of these treatments is to manage exudate, remove
necrotic tissue, encourage granulation tissue formation and
prevent infection.
 In order to tackle these complex wounds, healthcare providers
must decrease risk factors, address underlying health
conditions and utilize several treatments.
Common treatments for complex wounds include:

1. Advanced Dressings.
2. Debridement.
3. Negative pressure wound treatment.
4. Hyperbaric oxygen therapy.
5. Surgical repair.

1. ADVANCED DRESSINGS:
 Dressings used for complex wounds are highly specialized,
containing growth factors, hyaluronic acid or collagens.
 The aim of these dressings is to control the exudate, or
discharge from a wound.
 If excessive exudate is allowed to sit within the wound, then
infection is more likely to occur.

2. DEBRIDEMENT:
 Debridement is getting the wound cleared of any damaged or
dead cells.
 These dead or damaged cells are referred to as necrotic tissue.
 In order for new healthy skin cells to form, the old dead tissue
must first be removed.

3. NEGATIVE PRESSURE WOUND TREATMENT (NPWT):

 NPWT uses a vacuum sealed wound to encourage the wound to
produce granulation tissue, or freshly-formed skin tissue within
the base and edges of a wound.
 In NPWT, the wound is filled with a sponge-like material and
covered with a dressing that attaches to a vacuum.
 The vacuum gently pulls on the wound which increasing blood
flow to the area; thereby bringing needed nutrients to help the
wound heal faster.

4. HYPERBARIC OXYGEN THERAPY (HBOT):

 HBOT involves putting the patient in a chamber filled with high
levels of oxygen.
 Oxygen is critical in the formation of new, healthy tissue, so
providing a patient with lots of it speeds up the wound healing
process.

5. SURGICAL REPAIR:
 Frequently complex wounds require surgical repair.
 The wounded area can be too large for the skin to span without
help, so a skin graft is needed.
 It often takes several treatments when healing a complex
wound.

High Risk Factors Treatments

Loss of a large amount of

Advanced dressings
skin
Infection Debridement

Negative Pressure Wound Treatment

Compromised blood flow
(NPWT)
Poor overall health Hyperbaric Oxygen Therapy (HBOT)

Side effects of
Surgical Repair
medications

ATYPICAL WOUNDS:
“Wounds resulting from uncommon etiologies called atypical
wounds.”

Any wound that is not healing after 3 to 6 months of appropriate

treatment should raise the consideration of an atypical wounds.

TYPES:
 Pressure ulcers due to prolonged pressure.
 Venous leg ulcers due to venous insufficiency.
 Diabetic foot ulcers due to complications of longstanding
diabetes mellitus.
  Arterial ulcers due to poor vascular supply.

EPIDEMIOLOGY:
 They are less frequently encountered and less well
understood.
 Their prevalence has not been studied extensively.
 But it is estimated that at least 10% of the more than
500,000 leg ulcers in the United States may be due to
unusual causes.
 It is present in a location different from that of a common
chronic wound.
 Its appearance varies from that of a common chronic wound.
 It does not respond to conventional therapy.

ETIOLOGY:
1. Inflammatory causes.
2. Infections.
3. Vasculopathies.
4. Metabolic and genetic causes.
5. Malignancies.
6. External causes.
7. Drug-induced causes.

1. INFLAMMATORY CAUSES:
 Vasculitis.
 Pyoderma gangrenosum (diagnostic test to confirm & Curative
treatment does not exist)
 POTENTIAL ETIOLOGIES OF VASCULITIS:

 TREATMENT:
MILD:
 Leg elevation.
 Compression dressings.
EXTENSIVE OR SYSTEMIC:
 Systemic steroids.
 Plasmapheresis

2. INFECTIONS:
 Atypical mycobacteria.
 Buruli ulcer.
 Deep fungal infections.

 PATIENTS AT RISK FOR NECROTIZING FASCIITIS:

 Age 50 and older.
 Alcoholism.
 Malignancy.
  Malnutrition.
 Obesity.
 Renal failure.
 Smoking.
 Diabetes mellitus.
 Hypertension.
 Surgery.

3. VASCULOPATHIES:
 Cryoglobulinemia.
 Cryofibrinogenemia.
 Antiphospholipid antibody syndrome.
4. METABOLIC AND GENETIC CAUSES:
 Calciphylaxis.
 Sickle cell anemia

 CALCIPHYLAXIS TREATMENT:

MEDICAL TREATMENT:
 Decreased calcium in dialysate.
 Antibiotics.
 Low phosphate diet.
 Bisphosphonates.
 Sodium thiosulfate.
 Avoidance of challenging agents.
 Avoidance of systemic steroids.
 Anticoagulation
SURGICAL TREATMENT:

 Parathyroidectomy.
 Wound care and debridement.
 Amputation.
 Renal transplantation.
 Skin grafting using either autologous or tissue engineered
skin

5. MALIGNANCIES:
 Squamous cell carcinoma.
 Basal cell carcinoma.
 Lymphoma.
 Kaposi’s sarcoma
6. EXTERNAL CAUSES:
 Burns.
 Bites.
 Stings.
 Radiation.
 Factitial dermatitis.

7. DRUG-INDUCED CAUSES:
 Coumadin necrosis.
 Extravasation
TREATMENT:
 Treat underlying disease.
 Corticosteroid.
 Immunosuppressant (Cyclosporine).
 Systemic antibiotics.
 Anesthetic.

WOUND MANAGEMENT:
 Control pain.
 Necrotic tissue.
 Surgical debridement is contraindicated as it may
result in even worse ulceration.
 Avoidance of trauma at dressing removal.
 Disturbance can generate an even greater
inflammatory response and stimulate deterioration.
 Negative pressure therapy.
 May be used to assist debridement when the disease
is stable.
 Debridement and skin grafting.
 Can be considered when condition is under controlled.
 Surgery may reactive the disease