choosing modern dressing upon conventional dressing

1. 1
DR WAN ZURAINI BT MAHRAWI
THE OLD ARMY
VS
NEW ARMY

2. 2
UTILIZATION OF
INVENTORY
Maximum utilization of dressing product and
techniques that readily available – THE OLD
ARMY
KNOWLEDGE
Getting appropriate knowledge to ensure and
enhance clinical practice based by current
evidence
MODERN DRESSING
Selection of appropriate modern dressing
– THE NEW ARMY
WOUND MEDICINE PRACTICE

3. 3
01
02
03
04
Introduction
The Old Army –What's
Common In Our Setting?
Mechanism Of
Action
Effectiveness &
Cytotoxicity To Wound
Healing
05. THE NEW ARMY
OUTLINE

4. 4
The Old Army (Conventional
Dressing)
A 45 minutes learning session on conventional dressing
readily available within Ministry of Health Malaysia –
namely – Chlorhexidine, Povidone Iodine (PVP-I),
KMNO4 solution, Hydrogen Peroxide (H2O2), Silver
preparation, Spirit, Alcohol and Flavin Solution
“But time growing old teaches all things…” – Aeschylus

5. 5
CHLORHEXIDINE
01 HYDROGEN
PEROXIDE02 KMNO4
03
PVP - IODINE
04 ACETIC ACID
05 SILVER
SULFADIAZINE06
THE OLD ARMY – What’s Common in Our
Setting?
4%, 5% 3% 1 : 1000/5000
1%0.25%, 0.5%7 - 10%
ALCOHOL
07 METHYLATED
SPIRIT08 ACRIFLAVINE
SOLUTION09 0.1%96%70%

6. 6

7. 7
01
CHLORHEXIDINE
T H E O L D A R M Y
• BIGUANIDES group, C22H30Cl2N10 ,
• BACTERICIDAL (against Gram-positive and Gram-negative
organisms, facultative anaerobes, aerobes, and yeasts).
Ineffective for polio and adenovirus
• Used in dentistry, urology, gynecology, wound healing
• Time of onset: 30 seconds

8. 8
• Unsure prolonged exposure for
carcinogenesis, recommended stop use
after 6 months
• Anaphylactic reaction
Side Effect
Positive charge cation CHX binds with
negative charge bacteria cell wall to
induce lysis
Mechanism of Action

9. 9
Efficacy
• Safe for wound irrigation in low concentration
• Not severely effect healing time (no effect on
collagen production or tensile strength of
wound)
Cytotoxicity
• Increased resistant to microbes and
cytotoxicity compared to OCT & PHMB
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( C H L O R H E X I D I N E 4 , 5 % )

10. 10
02
HYDROGEN
PEROXIDE
T H E O L D A R M Y
• PEROXYGENS group, H2O2
• Bacteriostatic (sporicidal at 0.88 mol/L, poor bactericidal),
broad spectrum > g+ve
• Dental mouthwash, acute wound minor cuts, cosmetic
• Reaction time: immediate

11. 11
H202 Mode of Action
The production of free hydroxyl radicals in the
Fenton reaction is thought to be the basis of
biocidal actions of hydrogen peroxide. Free radicals
eventually lead to oxidative damage proteins and
membrane lipids in vivo. The oxidizing radical as
the ferryl radical induces DNA oxidation
T H E O L D A R M Y

12. 12
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( H 2 O 2 3 % )
Efficacy
• No negative effect on wound healing but not
reduce bacterial effect
• Effervescence of hydrogen peroxide provide
some mechanical benefit in loosening debris
and necrotic tissue of the wound
Cytotoxicity
• No retardation of re-
epithelialization

13. 13
03
KMnO4
T H E O L D A R M Y
• Dye, manganese oxidizing effect – purple crystals with sweet taste
• Low Bactericidal effect – broad spectrum
• Initially used to suppress vesicular stage of eczema- dermatitis
• Reaction time: required 1hr for bactericidal effect

14. 14
Mechanism of Action
As an astringent that suppress inflammation process
POTASSIUM PERMANGANATE
T H E O L D A R M Y

15. 15
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( K M N O 4 1 : 5 0 0 0 , 1 : 1 0 0 0 0 )
Efficacy
• Effective bactericidal in 1:10000
Cytotoxicity
• Fatal over 4oz consumed
• Burns and stain the skin
• Combustible – mixture with acetic acid might
explode
• Tablet should be dissolved completely –
might cause cutaneous necrosis
• Most centre has obsolete this prep d.t
manganese toxicity – nephrotoxin,
hepatotoxin – should be used only on
superficial wound

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04
PVP - IODINE
T H E O L D A R M Y
• HALOGEN RELEASING group, polyvinylpyrrolidone iodine,
C6H9NO
• Bacteria do not develop resistance to PVP-I
• Bactericidal – broad spectrum
• Usage: antiseptic for prevention and treatment wound infection

17. 17
Iodine is highly reactive with surrounding and has strong oxidizing effect on functional groups of amino acids (-NH 2, -SH etc.), Nucleotides, and fatty acids (double
bond of unsaturated fatty acids). Interaction of Iodine with these groups in a cell results in disintegration of the cytoplasm, enzyme denaturation, loss of integrity in the
bacterial cell membrane and fungal cell wall

18. 18
Efficacy
• Effective in reducing bacterial load in
wound – effect not persist - lasted for
4 days
Cytotoxicity
• No inhibition in wound re-
epithelialization
• Concentration dependent – not
suitable for burns
• Systemic toxicity
Contraindication
• 1. Hypersensitivity to Povidone iodine and other preparations
containing iodine
• 2. Thyroid disorders - goiter, hypothyroidism
• 3. Application to large areas of skin
• 4. Patient on Lithium therapy
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( P V P - I 7 , 1 0 % )

19. 19
05
ACETIC ACID
T H E O L D A R M Y
• PEROXYGENS group, C2H4O2
• Bactericidal , broad spectrum esp. pseudomonas
• Dental formulation, wound antisepsis
• Reaction time: N/A, short duration of action about 1hr, require
repeated dosing

20. 20
Undissociated acetic acid may enhance lipid solubility allowing increased fatty acid accumulation on the cell membrane or in other cell wall
structures. As a weak acid it will inhibit carbohydrate metabolism resulting in subsequent cell death.
Acetic Acid MOA

21. 21
Efficacy
• Efficacious against
pseudomonas, but not
significantly
Cytotoxicity
• Beware of phenylketonuria due to ketone
intermediates
• No delay in reepithelialization
• Does not shown to influence tensile
strength
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( AC E T I C AC I D 0 . 2 5 , 0 . 5 % )

22. 22
06
SILVER
SULFADIAZINE
T H E O L D A R M Y
• Topical antimicrobial – partial to full thickness burns
• Bactericidal – broad spectrum
• Evidence showed that antibiotic are more potent therefore no
more generally recommended
• C10H9AgN4O2S
• Oligodynamic effect to bacteria, fungi and algae

23. 23
MECHANISM OF ACTION
Interact with sodium chloride containing body fluid,
silver ions released – ionized Ag+ catalyze the
formation of disulfide bonds lead to protein structural
changes of bacterial wall
SILVER
SULFADIAZINE
THEOLDARMY

24. 24
Efficacy
• Insufficient evidence whether silver-containing dressing or
topical agents promote wound healing or prevent infection
(Cochrane R)
Cytotoxicity
• Delay wound healing by sloughing mechanism
• no more recommended to burns wound due to altered
appearance and frequent re-application
• Not to be used along with proteases (inhibited by silver
ions)
Precaution
• Itching and pain
• Low WBC count, allergic reaction, red blood cell breakdown,
liver inflammation
• Allergic to sulfonamides
• Not to be used less than two months children
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( S I LV E R S U L FAD I AZ I N E 1 % )

25. 25
07
ALCOHOL
T H E O L D A R M Y
• Ethyl, Isopropanol, C3H8O
• Bactericidal and fungicidal, broad spectrum
• Most commonly used as rubbing
• Reaction onset: immediate

26. 26
Alcohol dehydrates cells, disrupt membranes and cause
coagulation of protein
Mechanism of Action

27. 27
EFFICACY
• No information available for open wound –
burns effect
• Hand rubbing better than hand wash
CYTOTOXICITY
• Depends on the type of alcohol methyl >
isopropyl > ethyl
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( AL C O H O L , 7 0 % )

28. 28
08
METHYLATED
SPIRIT
T H E O L D A R M Y
Ethanol, denatured spirit with addition of 10% methanol,
CH3CH2OH

29. 29
METHYLATED
SPIRIT
T H E O L D A R M Y
For topical umbilical cord care

30. 30
09
ACRIFLAVINE
SOLUTION
T H E O L D A R M Y
• DYE group, acriflavinium chloride, C14H14ClN3
• Commercial preparations are often mixtures with proflavine
• Bacteriostatic to g+ve
• Undergo testing as antimalarial drugs, used in biochemistry for
fluorescently labeling high molecular weight RNA, fungal infection
treatment for fish aquarium

31. 31
ACRIFLAVINE
T H E O L D A R M Y
Proflavine acts by interchelating DNA (intercalation), thereby
disrupting DNA synthesis and leading to high levels of mutation in
the copied DNA strands. This prevents bacterial reproduction

32. 32
Efficacy
• In an animal model, acriflavine has been
shown to inhibit HIF-1, which prevents blood
vessels growing to supply tumors with blood
and interferes with glucose uptake and use
Cytotoxicity
• Proflavine is toxic and carcinogenic in
mammals and so it is used only as a surface
disinfectant or for treating superficial wounds
E F F I C AC Y & C Y TO TO X I C I T Y TO W O U N D
H E AL I N G ( AC R I F L AV I N E 0 . 1 % )

33. 33
WOUND AT RISK (WAR)
SCORE
T H E O L D A R M Y
If the WAR Score reaches or exceeds 3 points, an antiseptic
treatment is justified.

34. 34
THE NEW ARMY
(Modern Dressing
Materials)
Over XXX products on the market

35. 35
( A ) A gauze dressing adhering to the wound. ( B ) A foam dressing, one of the interactive dressing
products. In comparison with a gauze dressing, a foam dressing has many advantages
MOISTURE ENVIRONMENT

36. 36
Dressing
Architecture
PRIMARY
DRESSING
SECONDARY
DRESSING
PERIWOUND
CARE

37. 37
CLEANSE
Octenidine
dihydrochloride
Octenisept
CLEANSE
Superoxidised
solution
Dermacyn
CLEANSE
Polyhexanide
biguanide
Prontosan
CLEANSE
Silver solution
Silversept
PRIMARY
Hydrogel
Intrasite
PRIMARY
Hydrocolloid
Duoderm
PRIMARY
Hydrofiber
Aquacel
PRIMARY
Honey
Medihoney
PRIMARY
Calcium
alginate
Kaltostat
PRIMARY
Silver paste
Calgitrol
PRIMARY
Growth factor
gel
Regranex
PRIMARY
Human
epidermal GF
Regen-D
PRIMARY
Skin substitute
Integra
PRIMARY
Oxygen
transporter
Granulox
PRIMARY
Modified
collagen
Stimulen
PRIMARY
Film
Duoderm
CGF
SECONDARY
Foam
Allevyn
SECONDARY
Superabsorbent
Vilvsorb
SECONDARY
Film
Algoplaque
Periwound
Barrier cream
Critic
Adjunctive
Neg pressure
PICO
Adjunctive
Hyperbaric O2
HBOT
Adjunctive
Ultrasound
MIST
Adjunctive
PRP / Tissue
engineering
THE NEW ARMY

38. 38Dressing protocol Old Army New Army (Category)
Cleansing solution 9 antiseptics Octenidine, super-oxidized, polyhexanide-
biguanide, silver
Primary dressing Antibiotic
Charcoal
SSD
Hydrogel, hydrocolloid, hydrofibre, honey,
alginate, silver paste, modified collagen, growth
factor gel, human epidermal, skin substitutes,
oxygen transporter
Secondary dressing Gauze
Gamgee
Tulle dressing
Foam
Superabsorbent
Film
Periwound dressing Zinc oxide
Glycerin
Petroleum jelly
Opsite spray
Barrier cream
Adjunctive Negative pressure wound therapy, HBOT, PRP, US
Primary +
Secondary =
Composite
dressing + extra
characteristics =
Smart dressing
DRESSINGEQUIVALENCYTABLE

39. 39
CONCLUSION
01
02
03
KNOWLEDGE
Adequate knowledge of conventional and
modern dressing material is compulsory
UTILIZATION OF
INVENTORY
Having fully utilized current existed dressing
material is vital especially for poor resources
clinic
APPROPRIATE SELECTION
OF WOUND DRESSING
PRODUCTBased on net knowledge and inventory

40. 40
THIS PRESENTATION IS
ACCESSIBLE FREELY
THROUGH:
www.slideshare.ne
t
Key term: wan Zuraini, the old army, antiseptic,

41. www.companyname.com
41
THANK YOU
KUALA LANGAT MENERAJUI TRANSFORMASI
PERUBATAN LUKA
drwanzuraini@woundmedicine.co.uk

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