2018 UF ED/Trauma Symposium

1. Interdisciplinary Approach to Wound
Management
Providing Quality Care With Positive Patient
Outcomes
Donna Geiger MSN, FNP-BC, CWON

2. Disclosures
 Nothing to Disclose financially relevant to this
presentation

3. Todays Clinical Challenges….
 Patients are very complex
 There's scrutiny: Financial, Regulatory and Quality
 Evidence is required
 Cost effectiveness is mandatory
 The patient is the focus.

4. Learning Objectives
 Physiology of Wound Healing
 Identify Key barriers to wound healing
 Wound Assessment and Documentation
 Pressure Injuries/Differential Diagnosis
 Wound management Guidelines/Treatment
 LEAD/VI/DFU
 Discuss methods of debridement and what not to debride
 Determine when to refer patients for further evaluation

5. Physiology of Wound Healing
 Two types of healing: Regeneration: Heals by epidermis/dermis loss
Scar formation: Deep dermal/subcu/muscle loss
Acute: Partial thickness: Epidermis, partial dermal loss. Area Superficial
Predictable and durable closure:
Topical Care
Chronic: Full thickness: Total loss of skin layers: Scar tissue formation
Delayed healing and repeat breakdown common
3 Phases: Hemostasis/Inflammatory: 1-4 days. Clot formation
Proliferative: Post-op
Epitheial:1-3 days
Granulation: 5-9
Maturation: Same: Remodeling of collagen fiber to
provide tensile strength

6. Key barriers to wound healing
 Level of growth factors/cytokines
 MMP (matrix metalloproteases) and TIMP (tissue inhibitors of matrix
metalloproteases) levels: Proteins
 Hormone levels
 Senescent cells: Sluggish, slow
 Status wound bed
 Systemic factors and comorbidities

7. Wound Bed Assessment
 Etiologic factors
 Systemic factors
 Wound status
 Impact on quality of life
 Follow up assessment:
 Change in wound bed status, depth, volume, exudate
 Evaluate weekly

8. Documentation
 Location
 Parameters: L x W x D
 Tunneling and undermining
 Consistency matters: Head to toe, Clock

9. Tunneling/Undermining
 A narrow passage way created by separation or destruction of facial planes
 Occurs when the tissues of the edges become eroded

10. Wound Bed
 Is it healing?
 Open or closed edges
 Parameters: >2cm of Erythema = Cellulitis
 Yeast rash, denuded, macerations edema, callus
Exudate
 Volume, type, color, viscosity, clarity, odor

11. Look at the Wound
 Wet
 Deep
 Shallow
 Dry

12. Things to Remember When
Assessing….
 Bruising may indicate a DTI or even blood thinners can cause bruising
 Difficulty in assessing highly pigmented skin: Get another set of eyes
 Gold standard for wounds is biopsy not a swab culture & with viable
tissue
 No reverse staging, back staging, or down staging: Document what you
see!
 2-4 weeks healing: Is noted by……
 Reduction in size
 Reduction in infection
 Reduction of necrotic tissue
 Reduction in pain
 Reassess every week

13. Pressure Injuries (Ulcers)
 Stage 1: Non-blanchable erythema intact skin.
 Stage 2: Partial thickness skin loss with exposed dermis
 Stage 3: Full thickness skin loss
 Stage 4: Full thickness and tissue loss
 Unstageable: Obscured full thickness and tissue loss
 Deep tissue injury: Persistent deep red, marron or purple discoloration

17. Prevention is the Key
 Braden scale < 15
 Turn every two hours
 Elevate heels
 Barrier creams
 High intense support surfaces

18. Differential Diagnosis
 Moisture Associated Skin Damage (MASD) Incontinence Associated
Dermatitis (IAD), Intertriginous dermatitis (ITD), Skin Tears, Trauma

19. Wound Management Guidelines
 D= Debride necrotic tissue
 I = Identify and treat infection
 W = Wick away fluid from tunneled/undermined area
 A = Absorb excess exudate
 M = Maintain moist wound surface
 O = Open wound edges
 P = Protect healing wound and peri-wound skin
 I = Insulate healing wound

20. Methods of Debridement
 Clean wounds require gentle flushing
 Dirty wounds require irrigation 8-15 psi force, pulse lavage
 Avoid H202…….Use wound cleansers
 Wound debridement:
 Surgical: Wounds involving bone joint infected with large amounts
of necrotic tissue. Not always feasible
 Conservative Sharp Wound debridement (CSWD): loose necrotic
tissue
 Enzymatic: Selective, non-invasive, cost effective
 Autolytic: Uses bodies own WBC to debride
 Chemical: When wound has odor and highly infected. (Dakin's
Solution)

21. Warning

22. Last but not least on guidelines
Wet To Dry is… No longer standard of care
It is non-selective and painful
It’s a band aid

23. Hydrogel Dermal Wound Dressing may be
used in the management of pressure ulcers,
stasis ulcers, first- and second-degree burns,
cuts, abrasions and skin tears. Alginate
impregnated
HYDROFIBER
MediHoney
Pressure injuries, DM foot ulcers, leg ulcers,
1-2nd degree burns
Mepitel One
Treatment

24. Skin Tear
•Replace skin flap if possible
• Cover with non adherent
dressing; Allevyn gentle, or
Xeroform gauze/Kerlix

25. Road Rash

26. Since this is a trauma Conference

27. Burn Severity
Partial thickness burns if >10% TBSA 3rd
degree burns any age
referred to Burn Center

28. Takeaway for Wound Care
 Determine depth, presence of tunneled or undermined areas, volume of
exudate and need for bacterial barrier.
 Clarify wound as deep/wet, deep/dry, shallow/wet/, shallow/dry.
 Use grid and clinical judgment to determine best dressing for wound care
Deep Wet Wounds >0.5 cm’s depth Deep Dry Wounds >0.5 cm’s depth
Need: Absorptive filler + Cover dressing
Filler Dressing Options:
-Hydrofiber (Aquacell)
-Gauze & Specialty Gauze
Cover Dressing Options:
-Gauze/tape
-Gauze or ABD/Tegaderm
-Waterproof adhesive foam dressing
Need: Hydrating filler + Cover dressing
Filler Dressing Options:
-Liquid gel to wound bed + lightly fluffed damp
normal saline gauze
-Gel-soaked gauze fluffed into wound bed
Cover Dressing Options:
-Gauze + Tegaderm
-Waterproof adhesive foam dressing
Shallow Wet Wounds <0.5 cm’s depth Shallow Dry Wounds <0.5 cm’s depth
Options:
-Foam dressing with adhesive border
-Aquacel + foam dressing
-Aquacel + gauze/wrap gauze
-PolyMem pink + wrap gauze
-Nonadherent contact layer
Adaptic or Mepitel + gauze cover or foam drsg
Options:
-Hydrogel + foam dressing
-Hydrocolloids
-Nonadherent contact layer + cover dressing
Xeroform, Vaseline gauzed
Debridement Topical Tests
-Santyl - moist saline gauze over ointment to activate it
-Dakins solution ¼ strength
-Santyl & Dakins ¼ strength
-Medihoney products
Segmental Doppler of lower extremities- arterial
US for DVT
CT for tunneling wound
Fistulagram

29. The Epidemic
 Lower extremity arterial disease (LEAD): 8-12 million: Damage to arterial vessels
resulting in diminished blood flow to tissues and varying levels of ischemia also
known as peripheral arterial disease (PAD)
 Venous Insufficiency (VI): Acute-300-600k: Causes back pressure on capillaries with
leakage of fluid, WBCs & proteins into the tissues resulting in
 Progressive fibrosis
 Inflammatory changes
 Edema (< perfusion)
 Dermatitis
 Diabetic foot ulcers (DFU): Occurs in approximately 15 percent of patients with
diabetes> Red sores that can occur most often on the pad (ball) of the foot or the
bottom of the big toe.
 Neuropathy:
 Hypo/Hyper sensation
 Numbness
 Tingling
 Burning

30. Facts
 Hospitalizations
 In 2014, a total of 7.2 million hospital discharges were reported with diabetes as any
listed diagnosis among U.S. adults aged 18 years or older
 Discharges included the following:
 1.5 million for major cardiovascular diseases
 (70.4 per 1,000 persons with diabetes)
 400,000 for ischemic heart disease
 (18.3 per 1,000 persons with diabetes)
 251,000 for stroke
 (11.5 per 1,000 persons with diabetes)
 108,000 for a lower-extremity amputation
 (5.0 per 1,000 persons with diabetes)
 168,000 for diabetic ketoacidosis
 (7.7 per 1,000 persons with diabetes)

31. Imagine this…

32. LEAD
Poor circulation
Neuropathy
Diabetes
Smoking

33. Venous Ulcers
Edema (ankle to knee):
Hallmark sign
Hemosiderosis: greyish,
brown hyperpigmentation of
skin from leakage of fluid &
breakdown hemoglobin in
tissues)
Varicosities/Ankle flare

34. Diabetic Foot Ulcers
Calluses
Skin Changes
Ulcers on the sides of the foot are
usually due to poorly fitting shoes.
Gangrene

35. Referrals
 Podiatry
 ABI
 Venous Duplex Scan
 Segmental Doppler
 Interventional Cardiology/Vascular
 Procedures such as Stents etc….
 Venous and Arterial studies
 ID
 Tissue culture and biopsy

36. Management
 Management: First priority is to improve venous return
 Options:
 Surgical obliteration of damaged perforators
 Leg elevation-above level of heart*
 Compression therapy*
 Walk; ankle pumps for 1-2 min q 30 min
 Meds (pentoxifylline). Second-line treatment
 Compression + elevation remain cornerstones of venous ulcer
management
 Therapeutic level (ABI > 0.8): 30 – 40 mm Hg @ ankle

37. Contraindications to static therapy
(wraps & stockings)
 Uncompensated heart failure
 Coexisting arterial disease
 (ABI < 0.8) If ABI > 0.5 to < 0.8: Use a modified, reduced level of compression (23-
30 mm Hg)
 If ABI < 0.5, Do not compress- Refer
 Compression wraps usually best option for initial therapy (till edema
 & exudate controlled)
 Applied by professional; replaced 1- 2 x/week depending on exudate
 Elastic: Multilayer wraps provide sustained compression (sub bandage pressure)
whether active walking or at rest
 Inelastic (short stretch): Require ambulation for therapeutic compression--low
resting pressure

38. Takeaways
 Peripheral arterial and venous disease are associated with significant
morbidity and mortality.
 The NIH estimates peripheral arterial disease currently affects between 8-12
million Americans
 Venous disease including deep vein thrombosis, pulmonary embolism,
pulmonary hypertension and chronic venous insufficiency is estimated at
300,000-600,000 events each year in the US.
 We must identify patients early due to increased risk of MI, Stroke, CV death,
impaired QOL and the potential to develop critical limb ischemia
 Due to the complex nature of PAD an EB team approach is essential to early
assessment proper diagnosis and optimal treatment
 Minimally invasive endovascular techniques now enable us to treat
significantly higher numbers of patient with less morbidity and mortality
 Appropriate referrals to specialists must be emphasized if we are to continue
to improve the lives of patient with these disease.
 Consult the Inpatient Wound Care Team

39. Do forget Wound Care Conference
 Surf’s Up Ride the Wound Care Wave March 15th 2018
Registration in HealthStream
5 Nursing CE’s
CME’s applied for

40. References
 Bryant, R. & Nix, D. 2016. Acute & Chronic Wounds. Current Management
Concepts. 4th e.
 Centers for Disease Control and Prevention. National Diabetes Statistics
Report, 2017. Atlanta, GA: Centers for Disease Control and Prevention, U.S.
Dept of Health and Human Services; 2017.9
 Gornik, Heather L.; Sharma, Aditya M. 2014.Duplex Ultrasound in the
Diagnosis of Lower-Extremity Deep Venous Thrombosis. Circulation.129:917-
921
 HAPU Video: Bert Duviosin
 National Pressure Ulcer Advisory Panel. 2016. Retrieved on 02/05/2018 from
www.NPUAP.org
 Prevention and Treatment of Pressure Ulcers: Clinical Practice Guideline. 2014
 Weiss, R. 2017. Venous Insufficiency. The Heart Org. Retrieved from Medscape
on 02/05/2018