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Wound Management
Wound Management
In the following we would like to give you an understanding of wound management.
 
 
 

Wound Treatment

Wound treatment plays a central role in the case of chronic wounds. In general they can be divided into 7 areas:

 

Wound History

Wound treatment generally begins with a detailed medical history of the wound. It serves to identify the possible factors influencing wound healing in order to be able to treat the wound professionally. Here the following should be tested for or enquired:

  • Age and mobility of the patient
  • Wound classification
  • Severity of the wound
  • Origin
  • Comorbidities
  • Pain
  • Medication
  • Existing vaccination (e.g. vaccination against tetanus or rabies)

Wound Cleansing

Wound cleansing is one of the first and most important steps in wound care. The primary objective is the removal of debris to allow a good assessment of the wound and its surrounding area. At the same time, germ reduction is achieved by the cleansing. Odour and exudate management play an equally important role in cleansing as wound bed preparation.
Depending on the wound situation, different forms of wound cleansing may be required: A fresh superficial abrasion will have to be cleaned differently than a chronically existing pressure ulcer. The wound can also be cleansed mechanically by means of rinsing solutions.

During wound cleansing, “waste products” such as necrotic particles, exudate, cellular debris, plaque and biofilms are removed. There are a number of ready-to-use products. Particularly suitable are conserved wound irrigation solutions, such as octenilin® wound irrigation solution. Use of tap water for wound cleansing is highly controversial among experts due to the possibility of microbial contamination of the wound. Ideally, a sterile product is used for wound cleansing. In order to carry out the wound cleansing as atraumatically as possible, the wound irrigation solution should be – depending on the product – warmed to body temperature before application. Then the wound is not cooled down. At temperatures below 28 °C, wound healing can be delayed.

 

In debridement – wound cleansing –, various methods are discriminated:


In surgical debridement, a scalpel, forceps or ring curette are used to remove necrotic ma-terial and debris from the wound. Depending on the required degree of debridement, general or local anaesthesia may be required.

For biosurgical debridement, maggots are used, often the larvae of the native green blow-fly (Lucilia sericata). These larvae produce a secretion that dissolves necrotic tissue and de-bris in the wound.

In autolytic debridement, hydrogels are applied to the wound in order to soften necroses and debris. The supplied moisture promotes cell growth. After dissolution of necrotic material and debris, they can be easily rinsed from the wound. Conserved hydrogels provide additional protection against a further ingress of bacteria from the outside.

For mechanical debridement, a sterile compress is used to remove dead tissue and debris.

In enzymatic debridement, enzymes in combination with endogenous proteins liquefy existing necroses and debris. The importance of this form of debridement is controversial among experts.

Wound Assessment

Only after the wound has been thoroughly cleansed, it can be assessed properly. This step of wound treatment is decisive for choosing the right therapy. The following factors should be examined after removal of the dressing:

  • Wound size (length, width, depth of the wound)
  • Wound stage (necrosis, fibrin, granulation)
  • Wound bed
  • Exudate (moist, wet, dry)
  • Signs of infection (contamination, colonization, infection)
  • Wound edge (irritation, maceration)
  • Nature of the surrounding skin (irritation, oedema, humidity)
  • Wound odour
  • Pain (intensity, localization, quality of pain)

Wound Swab

A wound swab is a method for germ detection. It can be performed in case of suspicion, risk, or signs of wound infection. The swab should be taken before the cleansing of the wound.
There are several sampling techniques for wound swabs, for example, the method according to Levine or the “Essen Rotary”.

Wound Infection

Signs

The classic signs of inflammation are frequently found also in wound infections:

  • Redness = lat. rubor
  • Overheating = lat. calor
  • Swelling = lat. tumor
  • Pain = lat. dolor
  • limited function = lat. functio laesa

Wound infection can be localized; it will usually lead to impaired wound healing. In addition to local signs of inflammation, general symptoms such as fever, chills, swollen lymph nodes or increased numbers of white blood cells (leucocytosis) may also occur. Spreading of a local wound infection may, in the worst case, result in life-threatening sepsis.
Wound infections can be caused by various microorganisms such as viruses, fungi and bacteria.

The most important problem microbes in wounds include:

  • Staphylococcus aureus / Methicillin-resistant Staphylococcus aureus (MRSA)
  • Pseudomonas aeruginosa
  • Enterococci
  • Escherichia coli
  • Streptococcus pyogenes

Antisepsis and Antiseptics

The terms antisepsis and antiseptics refers to all antimicrobial measures for the elimination of pathogens with the goal of preventing or eliminating an infection. The disinfection of a wound has the same goal.

Many antiseptics act by destroying or denaturing the cell wall of a pathogen and disturbing the pathogen’s metabolism up to cell death. Antiseptics have the advantage, compared to antibiotics, that development of resistance occurs much less frequently and in some antiseptics virtually does not exist. Modern antiseptics have a high therapeutic index and good tolerability, and, in contrast to antibiotics, they are also suitable for preventive use in certain clinical indications. Using these measures, in many cases prolonged treatment can be rendered unnecessary. The indication for antisepsis depends on stage, severity, location and degree of contamination / infection of the wound.

Indications for wound antisepsis:

  • Infected wounds
  • Wound at risk for infection
  • Ischaemic wounds
  • MRSA-colonized wounds
  • Traumatic wounds
  • Poorly healing wounds

In modern wound care, localized infections are as a matter of principle treated locally with antiseptics. Wound infections with beginning spread of the infection through the body up to sepsis are treated with systemic administration of anti-infective agents (e.g. antibiotics), possibly in combination with antiseptics. However, there are clinical situations in which rapid spread of the infection is possible and which are therefore treated early with anti-infective agents. The practitioner will decide individually which therapy is specifically required for the patient.

Requirements for modern wound antiseptics:

  • Broad spectrum of activity
  • Rapid onset of action
  • No disturbance of wound healing
  • Absorption as low as possible
  • Effective even under high blood and protein stress
  • Water-based
  • Active ingredients in the lowest possible concentration
  • Painless application
  • No toxic / allergenic substances
  • No development of resistance
  • Colourless
  • No contraindications in pregnancy / lactation / children

Recognized publications therefore recommend treatment of acutely infected wounds with octenidine or povidone-iodine. The first-line preparations for the treatment of chronic wounds include octenidine or polyhexanide.

Unnecessary substances include:

  • Local antibiotics (limited spectrum of activity, cytotoxicity, allergenic potential, resistance problems)
  • Chlorhexidine (poor effect in Gram-negative bacteria, cytotoxic, mutagenic, neurotoxic, resistances known)
  • Ethacridine lactate (insufficient efficacy, resistance possible, granulation inhibitor, allergenic, mutagenic in vitro)
  • Hydrogen peroxide (insufficient efficacy, cytotoxicity, inactivation by blood)
  • Dyes (insufficiently effective, locally intolerable, partially with systemic risks)
  • Benzalkonium chloride (cytotoxic, absorption, resistances)
  • Silver sulphadiazine (development of resistances, cytotoxic, systemic risks, allergy, increased scab formation)
  • Organic mercury compounds (systemic side effects, environmental pollution)
  • 8-quinolinol (insufficiently active, mutagenic, neurotoxic, allergenic)

Traditional vs Moist Wound Treatment

Traditionally it was thought that wounds heal best when treated dryly. The “exsiccation” of the wound and the formation of scabs were considered positive signs of wound healing. Today the disadvantages of the traditional wound treatment are evident. Firstly, the necessary cell nutrition was interrupted, proliferation reduced and cell migration inhibited. In addition, the dressing changes were often traumatic due to the adhesion of the dressing material to the wound.

Meanwhile, there is a paradigm shift in wound treatment: Optimal wound treatment is carried out under moist conditions. In moist wound treatment, physiological conditions for wound healing are created: New cells can develop, proliferate and migrate more easily. Proper exudate management is also important. The goal is to collect excess wound exudate while promoting an ideally moist wound environment. The dressing should ensure gas exchange and be capable of being replaced as atraumatically as possible.

Wound Dressing

Rational use of wound dressings depends on the individual condition of the wound and should be done, depending on the desired therapeutic goal, in accordance with the specific phase of wound healing.

Wound dressings in the exudation phase
The main objectives in the early phase of wound healing are wound bed preparation and exudate management. Hydrogels can be used in gel form as well as applied to a supporting film. In addition to its cleansing properties (autolytic debridement), by keeping the wound moist they promote formation of granulation tissue. Excessive exudation can be controlled with the aid of absorbent fibre dressings, e.g. alginates and hydrofibres, or absorbent dressings, such as foam dressings and superabsorbers. The fibre dressings are characterized by being able to absorb relatively large amounts of liquid (up to 20 times their own weight) and thereby turn into a gel that ensures sufficient moisture of the wound surface and is also suit-able for packing wound cavities. The fibre dressings are especially suitable for the control of slight to moderate exudation and should be fixated by a secondary dressing. For moderate to heavy exudation, use of polymer foam dressings is recommended. Depending on the amount of exudate, daily dressing changes may be necessary, since the exudate absorbed into the foam dressing may be released again upon pressure. So-called superabsorbers consist of polymers into which a fleece is incorporated. Such polymers are also used, among other things, in baby diapers; they can absorb large quantities of liquid which they do not release again even under pressure. Superabsorbers are particularly suitable for highly exuding wounds.

Wound dressings in the granulation and epithelisation phase
During the granulation phase, the focus is on protection of the nascent granulation tissue and on preparation of the epithelisation of the wound. The soft structure of the polymer foam dressings provides good mechanical protection. In combination with hydrogels, in dry wounds the humid climate optimal for wound healing can be ensured. The changing of the dressings depends on the individual condition of the wound. Use of transparent film dressings allows assessment of the wound without removal of the dressing. Due to its semi-permeability, these dressing ensure adequate gas exchange while at the same time providing protection against contamination from outside.

Compact
Wound Bed Preparation ("TIME")
In 2003, an international group of experts presented a systematic approach to the manage-ment of chronic wounds under the acronym “TIME” (Schultz et al., 2003, Leaper et al., 2012).

Tissue: Assessment and debridement of non-viable tissue and foreign material (e.g. necrotic tissue, old dressings, biofilms, debris) on the wound surface.

Infection/Inflammation: Assessment of infection and inflammation signs and initiation of measures for their control (e.g. topical application of antiseptics, systemic administration of an antibiotic).

Moisture imbalance: Assessment and management of wound exudate; use of appropriate wound dressings.

Edge of wound: Assessment of the wound edges and surrounding skin (with special attention to non-progressive or undermined wound edges).

Summary:
Hydrogels: “All-rounders” for moisturizing / cleansing of wounds
Alginates: optimal for promoting granulation
Foam dressings: Fluid absorption, mechanical protection
Film dressings: Protection against wetting, fixation

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