Wound management

The evaluation of the patient with a non-healing wound consists of the following three
components: subjective history, medical history, and wound assessment. The histories will
usually allow the clinician to make a diagnosis of wound etiology, and if not, at least know what
needs to be ruled out. Thorough histories will also give indications as to why a wound is not
healing. The wound assessment provides data for objective, measurable outcomes and progress,
as well as information on how to treat the wound initially. The most important aspects of treating
any wound are to treat all underlying co-morbidities and to address any issues that may be
impeding wound healing. Finally, the initial treatment will consist of appropriate debridement of
necrotic tissue and application of a dressing that will ensure adequate moisture for wound healing
to advance.

Classification after morphology:

 Healing wounds
o Epithelial resurfacing (Epithelialization wounds):
 migration of epithelial cells across the skin edges,
 defining parameter for wound healing,
 affected by wound environment: dry – epithelialization is inhibited by scab or
crusts; moisture – enhances epithelial resurfacing.
o Granulation tissues (Granular wounds):
 migration of fibroblasts accompanied by angiogenesis (formation of capillaries
from existing vessels)
 => friable reddish moist “granules” of tiny capillary buds;
 it is indicative of deep tissue healing.
 Infected wounds:
o purulent discharge from the wound,
o painful,
o discoloured tissue,
o wound breakdown (friable tissue),
o delayed healing (=>sepsis),
o inflamed,
o abnormal smell

 Slough wounds:
 o dead tissue (usually cream or yellow in colour) that needs to be removed from the wound
for healing to take place,
o common feature of chronic wounds,
 Necrotic wounds: non-viable tissue due to reduced blood supply, it is important to treat the cause
of necrosis before excising the dead tissue (+eschar)

Classification after etiology:

 Surgical wounds
 Traumatic wounds:
o Friction
o Stab
o Cut
o Shear
o Bite
o Gunshot
o Pressure

It is important in the case of traumatic wounds to ensure proper cardio-respiratory function and
hemostasis before managing the wound.

 Burns:
o Thermal
o Chemical(acid/base)
 Frostbite
 Eschars
 Ulcers (varicose, arterial/ischemic, pressure and neurophatic/diabetic)

Location Tissue Pain Skin Exudate

Arterial Distal digits Dry, necrotic or YES!!! May Dry, hairless, shiny, None unless
slough. Little or no have dependent thin, positive rubor of infected
granulation leg syndrome dependency
or rest pain

Venous Lower 1/3 of the Red or pink, yellow Generally not Hemosiderous Varies, may
leg slough, poor painful unless have copious
Atrophie blanche
granulation vasculitic or serous drainage
infected Thick and dry

Pressure Over bony Varies from non- Varies Discolored from Varies
prominences blanchable erythema depending on erythema to hypoxic,
to dark red to eschar the structures may be macerated, may
or slough, depending involved have “peau d’orange”
on the depth appearance
Neuropathi Weight-bearing Callus, blister, NONE!!! Until Dry, thick, scaly, Varies,
c surface of the slough, may probe to infected, then hyperkeratotic depending on
foot or distal bone, necrotic if deep throbbing location and
digits PAD is present pain presence of
infection

Atypical wounds:

Treating a chronic wound:

 Diabetes – Keep glucose levels <150 mg/dL or hemoglobin A1c <7

 Infection – differentiate between colonization and periwound tissue infection
 Protein energy malnutrition – 2-2.5 g/kg/day depending on size of the wound
 Arterial insufficiency – ABI < 0.5, use no compression; <0.3, healing will not occur
 Edema – base compression on vascular status
 Smoking and alcohol abuse – counseling for cessation
 Obesity – diet counseling and exercise program
 Cardiac disease – ensure cardiac output is sufficient for wound healing to occur

From chronic to acute:

 Removal of barriers to healing
 Transition to the next phase of wound healing
 Formation of a healthy wound bed that is granulated and free of bioburden
 Healthy wound/periwound tissue that will support re-epithelialization

DIME/TIME:
 • D/T debride necrotic tissue
• I address inflammation/infection
• M maintain moist wound environment
• E facilitate epithelial migration at the edges

Steps of addressing a chronic wound:

The initial treatment of almost all wounds involves (1) debridement of necrotic or infected tissue,
(2) treatment of microbes that may be interfering with the wound healing process, and (3)
application of a dressing that will maintain adequate moisture balance. Wounds that should not
be debrided include the following:
 Wounds suspected of being pyoderma grangrenosum
 Wounds with inadequate perfusion for healing
 0 or 1+ pulses
 Ankle brachial index < 0.5
 Trancutaneous oxygen tension (TcPO2) <30 mmgHg
 Wounds with non-fluctuant dry eschar on the heels of non-ambulatory patients
 Eschar that is adhered to underlying tendons, muscle fibers, or bone

While a complete discussion of sharp debridement techniques is beyond the scope of this
chapter, the goal is to remove as much of the non-viable tissue as possible given the patient’s
pain tolerance, with care to protect viable tissues under the eschar and to minimize bleeding.

In cases where pain levels do not allow sharp debridement, autolytic or enzymatic debridement
are alternatives; however, the time to convert a chronic wound to an acute wound and thereby
facilitate the healing process is much longer with these techniques. At present the only approved
enzymatic debridement agent is collagenase
(marketed under the trade name Santyl, Smith & Nephew, Fort Worth, TX) which is
best applied daily, but can be applied two to three times a week if dressings do not need to be
replaced daily.

If signs of local critical colonization of bacteria are visible, topical antimicrobial dressings
[silver, cadexomer iodine, medicinal honey, or polyhexamethylene biguanide (PHMB)] are
recommended. Systemic antibiotics should be reserved for patients who have signs and
symptoms of infection. Table 1-6 lists signs of infection in a wound for which systemic
antibiotics are indicated. In addition, patient conditions that need to be considered when deciding
on the use of systemic antibiotics include acquired immunosuppressive disease (e.g. diabetes),
severe acquired or innate immunodeficiency (e.g. HIV infection, AIDs, post stem cell
transplant), use of immunosuppressant medications, age, or wounds that contain foreign material
(e.g. joint replacements).
After appropriate debridement, a dressing is applied that will maintain adequate moisture balance
for wound healing to progress (i.e. a moist dressing to a dry wound, an absorbent dressing to a
draining wound). Note that wet-to-dry dressings are no longer considered standard care and
should only be applied when no other options are available.
Any patient whose wound fails to show progress in 2 weeks is advised to be referred to a wound
specialist.

Step 1: washing the peri-wound area

- The peri-wound area can be washed with alcohol or hydrogen peroxide

Step 2: Debridment
- Some debridment can be done ambulatory and some other deep or complex debridment should be
done in the OR to avoid excess bleeding, or excess pain.
- Hyperkeratozic tissue should always be debrided should be done at every check-up of the patient
- For more information on this topic please consult a wound management book.

Step 3: Moist wound care:

- Provides a moist wound environment
- Manages exudate while protecting periwound skin
- Facilitates autolytic debridement of non-viable tissue
- Minimizes pain, especially upon removal
- Protects from environmental contaminants
- Delivers appropriate antimicrobial agents

AVOID CYTOTOXIC AGENTS!

• Iodine
• Hydrogen peroxide
• Alcohol
• Acetic acid
• Sodium hypochlorite
• Dyes (scarlet red, proflavine)

Step 4: use proper bandages:

- Do not use rigid gauze role or cotton wool, unless indicated for compression.
- Use semi-elastic and/or semi-adhesive gauze rolls
- use proper gauze pads
- use good quality adhezive wound dressings (pansamente)
- use adhezive non-woven elastic dressings

Conclusion: use good quality dressings and bandages. This can make the difference in treating your
patient!
References:
 Snyder RJ, Jensen J, Applewhite AJ, Couch K, et al. A standardized approach to evaluating lower extremity chronic wounds
using a checklist. Wounds. 2019;31(5):S29-S44.
 Weir D, Scarborough P. Wound debridement. In: Hamm R, ed. Text and Atlas of Wound Diagnosis and Treatment. 2nd ed.
New York: McGraw Hill Education; 2019;349-371.
 Weir D, Brindle T. Wound dressings. In: Hamm R, ed. Text and Atlas of Wound Diagnosis and Treatment. 2nd ed. New
York: McGraw Hill Education; 2019;373-417.
 Care Partners. Signs, Symptoms and Actions for Superficial and Spreading Wound Infection (All Etiology’s). October 2014.
Available at wwwoundcare.ca/Uploads/ContentDocuments/Signs%2C%20Symptoms%20and%20Actions%20for
%20Superficial%20and%20Spreading%20Wound%20Infection%20%28All%20Etiology%27s%29%2C%20Care
%20Partners%2C%20Oct%2020%2C%202014.pdf. Accessed on May 27, 2019.
 Reitan RL, McBroom RM, Gilder RE. The risk of infection and indication of systemic antibiotics in chronic wounds.
Wounds: A Compendium of Clinical Research and Practice. 2020;32(7):186-194.