Wound care

Wound Care
Prepared & presented by: Dr :WADIE MADI
‫د‬:‫مادي‬ ‫وديع‬
General Surgery Department.
Abosleem Trauma Hospital.
 UNIT C.
THURSDAY
24th/June/2014

Skin: structure and function:
General Functions:
Each skin layer has its own unique function:
Epidermis = protection
Dermis = nourishment of epidermis
Hypodermis = Composed mostly of adipose tissue insulation.

Skin: structure and function
Skin: structure and function:
Protects deeper tissues from:
Mechanical damage ( bumps & cuts).
Chemical damage (acids & bases).
Bacterial damage.
Thermal damage (heat & cold).
Ultraviolet radiation (sunlight).

Background:
A wound can be defined as:
“A cut or break in the continuity of any tissue, caused by injury
or operation”

Classification of Wounds:
Acute Wounds
Cuts,Abrasion
,Lacerations
Contusions
Pucnture
Skin flaps and
Bites
benbow ( 2005)
They passes
through the
normal
healing
process
readily
Chronic Wound
Wounds
Fail to pass
through
normal
healing
process
Any wound
>3 months
considered
chronic
wound

Wound Types and Characteristics
CLOSED
• Contusion ( Bruise) – Tissue
injury without breaking of skin.
Purple contusion 5x7 cm on left
face(see figure)
•Hematoma – Tissue injury that
disrupts a blood vessels; pooling
of blood under the unbroken skin
hematoma on left face (see
figure)
•Sprain –twisting of a joint with
partial rupture of its ligaments;
causes swelling.

OPEND
•Incision (Surgically) made
separation of tissues with clean,
smooth edges.
(Approx.3-inch incision on R
lower quadrant of abdomen well
approximated clean and dry with
sutures intact(see figure).
•Laceration – Traumatic
separation of tissues with clean,
smooth edges 2 in jagged (pointy,
uneven) laceration app 4 cm deep
on Lt sole foot.(see figure)

.
OPEND
•Abrasion- Traumatic scraping
away of surface layers of skin.
(raw appearing abraded area
diameter on lateral aspect of lower
leg).(see figure)
•Puncture – Wound made by
sharp, pointed object through skin
or mucous membranes and
underlying tissue, (Small circular
entry wound on Rt palm from sharp
pointing nail see figure)

OPEND:
Penetrating- Variable -size open
wound through skin and
underlying tissues made by a
bullet , metal or wood fragment
may extend deeply into body
Jagged Deep wound 10cm in
posterior on L leg(see figure).
•Avulsion – Tearing away of a
structure or a part, such as a
fingertip, accidentally or
surgically.(Avulsion of L leg from
Vent Aspect. Attach only by skin.)

OPEND:
•Ulceration – Excavation of skin and/or underlying tissue from injury
or necrosis.
(Ulceration on L sole foot 4 cm x 5 x 2 cm deep. Yellow drainage
present. Wound edges reddened) see figure below:

 Wounds according to the depth:
-Superficial
Involves only the epidermis Injury is usually
result from fiction, shearing (cut) or burn.
-Partial Thickness
Involves the epidermis and the dermis, Wounds heal more quickly.
-Full Thickness
Involves the epidermis, dermis, fat, fascia and exposes bone In
order to heal, all dead tissue must be removed so that
granulation tissue can gradually fill in the defect.

1-serous -clean, watery.
2-Purulent - thick, yellow, green, tan or brown.
3-Sanguineous - bright red, indicative of active bleeding.
4-Serosanguineous -pale, red, watery mixture of serous
and sanguineous.
Types of wound drainage:

Wound Healing:
-All wounds heal following a a specific sequence of phases
which may overlap.
-The process of wound healing depends on the type of tissue
which has been damaged and the nature of tissue
disruption.
-The phases are:
1-Inflammatory phase
2-Proliferative phase
3-Remodeling or maturation phase

injury
Exposure of plasma to
injured site Release of Histamine
Capillary Permeability
Edema
Rubor
(Redness)
Tumor
( Swelling)
Prostaglandin
Dolor
( Pain)
Vasodilatation
Calor
( Heat)
Inc bld Flow
Activation of Hageman Factor

Phases of wound Healing:
1-INFLAMMATORY PHASE:
Starts immediately after injury and lasts 3-6 days or 4-6 days.
(2 major processes occur during this phase:
A-Hemostatic and B-phagocytosis
A- Haemostatic
Tissue and capillaries are destroyed, plasma and blood leaks. Area blood vessels
constrict, platelets aggregates and bleeding stops, scabs ( rough protective
crust) forms, preventing entry of infectious organisms.
B- Inflammation & Phagocytosis
Characterized by oedema, erythema, pain, temperature increase blood flow, to
wound resulting localized redness and edema, attracts WBC and wound
growth factors. ( Wbc arrive-clear debris from wound).

2- PROLIFERATIVE PHASE
-extends from day 3 to about day 21 post injury.
-Macrophages continue to clear the wound debris, Stimulates Fibroblast to
synthesize collagen 9 main ingredient For tissue scaring)
-(New capillary networks are formed).
3- REMODELLING OR MATURATION PHASE
-final healing stage may continue for I year or more.
-Remodelling of scar tissue to provide wound strength.
Cont..Phases of wound Healing:

Natural wound healing process
A B C

Acute Wounds
Haemostasis &
Inflammatory
Phase
Proliferative
Phase
Proliferation,
Granulation
Remodelling
Phase
Healed Wound

Types of wound healing:
1-first intention healing: partial thickness wounds.
- a clean incision is made with primary closure, minimal scarring.
-expected when the edges of clean surgical incisions are sutured together,
tissue loss is minimal or absent if the wound is not contaminated with
microorganism. e.g.-abrasion or skin tear.
2-second intention healing:
-granulation.
-accompanies traumatic open wounds with tissues loss or wounds with a
high microorganisms count.
-go through a process involving scar tissue formation a heal slowly because
of the volume of tissue needed to fill the defect.
e.g.-contaminated surgical wound, pressure ulcer.

Note also there is:
(Delayed primary healing If there is high infection risk – patient
is given antibiotics and closure is delayed for a few days
e.g. Bites)
1-Immune status.
2-Blood glucose levels (impaired white cell function).
3-Hydration (slows metabolism).
4-Age.
5-Lifestyle- enhances bld circulation.
6-Nutrition .
7-Blood albumin levels (‘building blocks’ for repair, colloid
osmotic pressure - oedema).
8-Oxygen and vascular supply.
9-Medication- Corticosteroids (depress immune function).
Factors affecting wound healing:

-heal very easily.
-It passes phases of wound healing.
-Inflammatory phase.
-Collagen building phase.
-Remodelling Phase.
 Aim of management:
-Healing without complications such as infection and disfiguring.
-(Wound care) includes:
1-Remove FB
2-Dry or wet to dry dressing to cover the wounds
3-Suturing if acute.
4-Bites -give Prophylaxis.
A- Acute Wounds:

> Uses of ABO in Acute wounds
Only indicated if contaminated or evidence of infection is
demonstrated.
>Evidence of infection (local)
-Redness
-Warmth
-Swelling
-Tenderness
-Local Lymphadenopathy.
Note: (Acute wounds with abscesses if they are large need to be
drained, Smaller once – can manage with antibiotics).
 Betadine*, Hydrogen Peroxide*, Saline, Spirit can be used to
cleanse the wound .
Acute Wounds

 Healing of acute wound :
-Wounds with minimal gaping – heals readily with scarring.
-Wounds with gaping or skin loss – heals with Scar tissue formation
and retraction.
Q1- if there is no improvement ???
Q2-When Does a Wound Become Chronic?
(healthy individuals with no underlying factors an acute
wound→ heal within three weeks remodelling → over the
next year or so...)
NOTE: When wound does not follow the normal trajectory it may
become stuck in one of the stages and the wound becomes
chronic.
Acute Wounds

Chronic wounds
Working Definition: wound lasting >3 months
Chronic wound – Fail to heal due to various local and systemic
causes.
-Healing process arrests at different levels of healing.
-Wound may appear at different colours.
-Remains at same stage without progressing to wound healing.
-Often an underlying cause remains undetected.

Chronic wounds
The wound healing cascade impairs and arrests at different stages
Hemostasis
Platelet Aggregation
Neutrophil Immigration
Monocyte Immigration
Granulation
Re-epithelialization
Wound Closure
Scar Formation
Minutes Hours Days Weeks Months Years Time
CHRONIC WOUND

Local and systemic factors that impede wound
healing
• Local factors
• Inadequate blood supply **
• Increased skin tension
• Poor surgical apposition
• Wound dehiscence
• Poor venous drainage **
• Presence of foreign body and foreign body
reactions
• Continued presence of micro-organisms &
Infection **
• Excess local mobility, such as over a joint
• Systemic factors
• Advancing age and general immobility **
• Obesity ***
• Smoking
• Malnutrition ***
• Deficiency of vitamins and trace elements ***
• Systemic malignancy and terminal illness Shock of
any cause
• Chemotherapy and radiotherapy
• Immunosuppressant drugs, corticosteroids,
anticoagulants
• Diabetes and CRF***

Chronic Wounds Appearance
approach has been criticised for being too simplistic as wound healing is a
continuum and wounds often contain a mixture of tissue types.

Wound healing continuum
Wound Healing Continuum (Gray et al. 2005) have
been developed. This tool incorporates intermediate colour
combinations
between the four key colours

Common Chronic Wounds
Pressure
Diabetic / Neuropathic
Arterial
Venous
Surgical

Pressure Wounds
This staging system was developed by the NPUAP (National
Pressure Ulcer Advisory Panel) and classifies only pressure
ulcers based on anatomical depth of soft tissue damage.

Stage 1
Appears as defined area of persistent
redness in lightly pigmented skin,
whereas in darker skin tones, this ulcer
may appear with persistent red, blue or
purple hues.
If it doesn’t become pale with pressure
aka blanch, this is considered a Stage I
pressure ulcer.

Pressure on anterior tibialis tendon
from compression wrap applied
incorrectly
Stage 1

Stage 2-Partial thickness skin loss involving
epidermis, dermis, or both. The ulcer is
superficial and presents clinically as an
abrasion, blister or shallow crater.
Pink
Partial
Painful
No slough, eschar or undermining
Stage 2

Stage 3- Full thickness skin loss involving
damage to, or necrosis of, subcutaneous tissue
that may extend down to but not through,
underlying fascia.
The ulcer presents clinically as deep crater with
or without undermining of adjacent tissue.
Stage 3

Stage 4
 Stage IV—Full thickness skin loss with extensive
destruction, tissue necrosis, or damage to muscle, bone or
supporting structures (ie. Tendon, joint capsule)
Undermining and sinus tracts may be associated w/
stage IV ulcers
Can differentiate from stage III ulcers because it will
go PAST the Fascia.

Stage 4
Plantar heel:
past subcutaneous level and goes
to the calcaneous bone
Sacrum, eschar, past sub-
cutaneos tendon exposed

Deep Tissue Injury
Purple or very dark areas that are surrounded
by profound redness, edema, or induration
suggest that deep tissue damage has already
occurred and additional deep tissue loss may
occur.

Unstageable
• The deepest level of tissue must be
visible in order to stage a pressure
wound.

Management of Pressure Ulcers
Offload Dress Protect
Nutrition Debride

Group 1 Pressure Relief
Group 1 mattress overlays preventative (Qualifications):
1. Completely Immobile Or
2. Limited mobility
3. Any stage pressure ulcer on the trunk or pelvis.
(plus 1 of the below)
4. Impaired nutritional status.
5. Fecal or urinary incontinence.
6. Altered sensory perception.
7. Compromised circulatory status.

Low Air Loss/Alternating Pressure Mattress
(Aggressive pressure ulcer treatment)
Qualifications:
(1 large or multiple stage 3 or 4 pressure ulcer(s) on trunk or pelvis)
Or
(Recent flap or skin graft for pressure ulcer).
Group 2 Pressure Relief

Etiology:
Diabetic Facts:
Diabetic foot ulcer:
7th leading cause of
death in the USA
16 million (6% of
population) people in
the USA have diabetes
Each year: 798,000
new cases of DM
diagnosed
15% of all diabetics will
develop diabetic foot
ulcers
14-20% patients with DFU
require amputation

Wagner Staging
Grade
0
Grade
1
Grade
2Pre-ulcerative
callus, no
open lesion
Superficial
diabetic
Foot ulcer
Penetrates to
ligament tendon,
bone, joint,
fascia
NO Abscess,
NO Osteo

Wagner Staging
Grade 3 Grade 4 Grade 5
Deep Ulcer
With
Abscess/Oste
oarthritis
Gangrene
portion of
Midfoot
Extensive
Gangrene of
whole
Foot. ONLY
treatable with
amputation

Etiology:
Corns and Calluses
Nails: Thickened or Atrophic, Ingrown ,Color of nail bed,
Discharge, Fungal infections
Edema: poor fitting shoes, impedes healing
Pulses
Color & temperature of feet
HgbA1c
Goal for HgbA1c of <7
Assessment

Etiology:Treatment of DFU
Blood
sugar
CTRL
Offload Dress
Manage
Bacteria HBOT
(if criteria met)
Debride
Re-
Vascularize

Etiology:
Intermittent claudication to sharp, unrelenting pain.
Diminished or absent pulses.
Pallor and coolness.
Loss of hair.
Tight shiny skin.
Thickened nails.
Characteristics of Arterial
Insufficiency

Characteristics of Arterial
ULCER
Located in areas of pressure, tips of toes
Very painful.
Deep, may involve joint.
Usually circular in appearance.
Wound base pale to black.
Little, if any, edema

Pain
Intermittent claudication – crampy pain associated
with activity.
Rest Pain.
Pulses.
Skin appearance.
Skin temperature.
Edema.
Hair Growth on Toes.
ABI’s, Waveforms.
Assessment

 ABI 0.9-1.30 Normal Study
 ABI 0.8 - 0.9 moderate PVD
 ABI 0.5 - 0.8 claudication
 ABI < 0.5 critical ischemia
 Always check ABI with LE ulcers
Ankle—Brachial Index
(ABI)

Etiology:Treating Arterial ulcer
Eliminate
Cause
Pain
ControlMoist Wound
Care
Debridement

Medical treatment
ACE Inhibitors—(Lisinopril, Captopril, etc).
(Vasodilators & Decrease Plaque Formation)
Pletal (Cilostazol).
(Relaxes smooth muscle & vasodilators.).

Achy, cramping pain
Pulses present
Hyperpigmentation of skin
Lots of edema
Inverted Champagne Leg
Lipodermatosclerosis—
tissues become ´woody´
in texture and the leg
narrows near the ankle
Venous Insufficiency Characteristic

Irregular Wound Edges.
Skin scaling.
Moderate to heavy exudate.
Partial to full thickness.
Malleolus region.
Venous Ulcer Characteristics

Elimination of Edema
-Compression
-Elevation.
 Debridement.
 Moist Wound Care.
Skin Care—dermatitis.
Management of Venous Disease

Non-Healing Surgical
Wounds

Surgical Wound Complication
Infection Dehiscence

Treatment of Surgical Wound
Heal
Debride
Moist
Wound
Care
Specialist
Eliminate
Cause sutures
mesh
infection

First…Listen to Your Patient…..

Aetiology
Wound bed
,necrosis
granulation
Wound
edges
Surrounding skin:
colour, moisture,
Labs
investigation
Signs of
infection
Odour or
exudate
Size, depth
Location
WOUND
ASSESSMENT
Assessment

Lab Work – CBC, HgbA1C, Albumin.
Vascular Testing - Doppler, Angiography, measures,
Arteriogram.
Infection Assessment - X-ray, Bone Scan, Tissue Biopsy,
MRI.
 Physical Assessment – Vital Signs, Pain, Weight,
Psychological, Community Resources.
In Addition to Wound
Measurements…

Basic Wound Care
Assessment.
Cleaning &Covering.
Dressings.
Debridement.
ABO ?

Holistic Care
Treating the Whole patient versus treating the Hole in
the patient

DRESSINGS - material applied to wound with or without
medication, to give protection and assist in healing.
(-what are the purposes?)
Protect from contamination.
Prevent trauma.
Absorbs drainage.
Debrides.
Provides medication, moist healing environment, etc.
When picking out your dressings, remember the Cardinal
Rule:
(Keep Moist tissue Moist and Dry tissue
Dry!)
Wound Dressing:

1-DRY TO DRY DRESSINGS
-used primarily for wounds closing by primary intention.
-offers good protection, absorption & provide pressure
-they adhere to the wound surface when drainage dries.
- when remove can cause pain and disruption of
granulation tissue.
-What are the types of dressings?

2-WET TO DRY DRESSINGS
-used for untidy or infected wounds that must be
debrided and closed by secondary intention.
 how can it be done?
- gauze saturated with sterile saline or antimicrobial sol's.
is packed into the wound, the wet dressing are then
covered by dry dressings
(Q-when to changed?) (As-when it becomes dry.)

3-WET TO WET DRESSINGS
-used on clean open wounds or on granulating surfaces.
-provide a more physiologic environment (warmth
moisture) which can enhance the local healing
processes and assure greater patient comfort.
-surrounding tissues can become ulcerated.
(high risk for infection).

Examples of methods used in
dressing
Hydrocolloid.
Hydrogel.
Calcium alginate.
Foam.
Collagenase.
Antimicrobials.

Hydrogels are indicated for
management of pressure ulcers,
skin tears, surgical wounds, and
burns, including radiation
therapy burns. Because they
contain up to 95% water,
hydrogels cannot absorb much
exudate and should be reserved
for dry wounds or wounds with
minimal to moderate drainage.
1-Hydrogel Dressings:

-Because they are occlusive, hydrocolloid dressings do not allow
water, oxygen, or bacteria into the wound. This may help facilitate
angiogenesis and granulation. Hydrocolloids also cause the pH
of the wound surface to drop; the acidic environment can inhibit
bacteria growth.
Like hydrogels, hydrocolloids can help a clean wound to
granulate or epithelialize and encourage autolytic ( distruction of
cells by own enzymes) debridement in wounds with necrotic
tissue. However, because of their occlusive nature, hydrocolloids
cannot be used if the wound or surrounding skin is infected.
2-Hydrocolloid Dressings:

3-Alginate Dressings :
Used in wounds with moderate to heavy drainage, the
alginate forms a gel when it comes in contact with wound
fluid. Capable of absorbing up to 20 times its weight in
fluid, an alginate can be used in infected and noninfected
wounds. Because an alginate is highly absorbent, it
should not be used with dry wounds or wounds with
minimal drainage; it could dehydrate the wound, delaying
healing.

Indications: Highly exudative wound requiring a
non-stick surface (e.g. venous stasis)
Highly absorbent (20 times weight)
Non-adherent wound contact layer, hydrocellular
foam, waterproof outer layer.
Allows for autolytic debridement and gaseous
exchange.
Can be left in place for 72 to 96 hours.
4-Foam:

 Explain the procedure to the patient.
 Hand washing before and after the procedure.
 Clean from least contaminated to the most
contaminated area.
 Use separate cotton for each stroke.
 Start from the center going outward.
 Observe aseptic technique.
Wound dressing:
A-Principles

 Sterile gloves
 Picking forcep
 Dressing forcep
 Bandage scissor
 Adhesive tapes
 Dry cotton balls
 Waste receptacle
 sterile gauze
B-Equipment:
 Cotton balls with
cleanser
 Cotton balls with
antiseptic
 Normal Saline Solution
(NSS)
Wound dressing:

C-Procedures: include(14 steps)
1-Check physician's order for specific wound care and
medication instructions.
 Helps to plan for proper type and amount of supplies
needed.
Wounds dressing:

2-Secure equipment and wash hands thoroughly.
To save time and effort. Reduces transmission of
pathogen

3- Assess the existing dressing
 Indicates types of dressing or applications to use.

4-Explain the procedure to the patient and instruct Pt not
to touch wound area or sterile supplies.
 Decreases anxiety and to gain cooperation.
Sudden unexpected movement on Pt‘s part could
result in contamination of wound and supplies.

5-Loosen and remove the dressing with the use of the
dressing forcep.( If the dressing adheres to the wound,
loosen it by moistening with sterile NSS).
Microorganism can be transferred by direct contact
from dressing to hands. An intact scab is a body
defense and can be damage if not handled gently.

6-Observe the dressing for the amount type, color and
odor of the drainage.
 Provides estimate of drainage amount and assessment
of wound's condition.

7. Discard the soiled dressing in the waste receptacle.
 Reduces the transmission of microorganism.

8-Clean the wound aseptically using the dressing forcep
from the center going outward in
circular motion with:
A. Betadine cleanser
B. Dry gauze
C. Betadine antiseptic solution
(use each gauze for only one stroke)

9-Apply a new dressing by gently placing the gauze
sponges at the wound center and moving progressively
outward to the edges of the wound site.
 Promotes proper absorption of drainage and protects
wound from entrance of microorganism.

10. Secure the edges of the dressing to the patient’s skin
with strips of adhesive tapes.
 Ensures that dressing remains intact and covers
wound.

11-Make the patient feel comfortable and tidy the unint.
 Promotes Pt's sense of well-being. Enhances comfort.

12-Do the aftercare of the equipment.
Soak the dressing forceps in 5% lysol solution for 30
minutes, then wash them with soap and water, Rinse
them then dry ,Send them for sterilization..

13. Wash hands(Prevent
spread of microorganism).
14-Chart: site of wound, character of wound/ discharges,
treatment given if any(e.g. ointment used) and reaction
of patient.
 For proper documentation and legal purposes.

Growth Factors
Bioengineered Tissue.
Curative Surgery.
Cellular Tissue
Products.
Hyperbaric Medicine.
Advanced Wound Care

Growth Factors
Indication: Diabetic foot ulcer
Activates endothelial cells and fibroblasts
Stimulates vascular proliferation, migration, new
blood vessel formation
People who use 3 or more tubes of
REGRANEX® Gel may have an increased risk from
cancer.
Can be very effective
Have a new “360” program to help patients obtain
medication and monitor progress.

Oxidized Regenerated
Cellulose (ORC)
Indicated in Stalled Wounds
ORC inactivates MMPs and Elastace
Damaged
tissue
Cytokines
Excess
proteases

Day 1
-Prisma (O.R.C)
-Silver Foam.
-3 layer
Compression.
4 Week
Has decreased
more than half in
wound surface area
with
Continue same care
7 Week
Resurfaced
Measured for
Compression
Stockings
(ORC)
VSU

Cellular Tissue Products
(CTP)
So many, so little time
Apligraf
Dermagraf
Oasis
Graft Jacket
Primatrix
Integra
And so many more….

Day of
application
2 Days post
Application
4 weeks post
initial App
2 wks s/p 2nd Oasis
Application
Cellular Tissue Products
(CTP)
VSU

(HBOT) :
Hyperbaric Oxygen Therapy (HBOT) is breathing 100%
oxygen while the entire body is pressurized to a point greater
than sea level
What Is It?
This is usually
2to 2.4 absolute
atmospheres
(the equivalent of
the pressure
exerted by a33-45
foot dive into
sea water)

Multiplace Hyperbaric Chamber

UHMS Indications for HBOT
1-Air or Gas Embolism.
2-Carbon Monoxide Poisoning(Co Poisoning Complicated
By Cyanide Poisoning).
3-Clostridial Myositis and Myonecrosis (Gas Gangrene).
4-Crush Injury, Compartment Syndrome and Other Acute Traumatic
Ischemia.
5-Decompression Sickness.
6-Arterial Insufficiencies:
Central Retinal Artery Occlusion.
Enhancement of Healing In Selected Problem Wounds.
7-Severe Anemia.
8-Intracranial Abscess.
9-Necrotizing Soft Tissue Infections.
10 -Osteomyelitis (Refractory).
11 -Delayed Radiation Injury (Soft Tissue and Bony Necrosis).
12 -Compromised Grafts and Flaps.
13 -Acute Thermal Burn Injury .

Adjunctive HBOT and Problem Wounds
HBOT is only one component of a comprehensive
wound healing program.
Non-healing wounds are evaluated to determine
underlying conditions which might interfere with
healing.
More conservative measures should be tried first.

What We Will Cover Today?
Radionecrosis.
Failing Graft/Flap.
Gas Gangrene.
Diabetic Foot Ulcer.
Arterial Insufficiency.

Radionecrosis:
 Vascular Changes from Radiation:
 Edema .
 Medial thickening (progressively depletes the blood supply to
the irradiated tissue).
 Collagen deposition may also cause severe scarring and
further blood vessel obliteration, resulting in tissue hypoxia
and necrosis.
 Effects of Ionizing Radiation on the Cell:
 Rapid cell death with heavy doses.
 DNA Synthesis impaired, mitosis delayed.

Soft Tissue Radionecrosis
Radionecrosis from
treatment for Cancer of
Larynx 05/02/02
Same neck, 07/09/02
after 40 hyperbaric
treatments

Failing Flap
Long-term survival of skin grafts and flaps depend
on angiogenesis.
When the wound bed does not have enough oxygen
supplied the graft may partially fail.
HBO2 can help by assisting in the preparation and
salvage of skin grafts and compromised flaps.

Gas gangrene infection
Clostridium bacteria.
High amounts of oxygen can inhibit the replication,
migration, and production of endotoxin.
Advantages of using HBOT as adjunct to for gas
gangrene:
life-saving because exotoxin production is rapidly halted.
limb and tissue-saving.
preventing limb amputation that might otherwise be
necessary.

Diabetic Foot Ulcer:
Wagner Grade 3.
Used in conjunction with standard wound care,
offloading.
Improved results compared to routine wound care.

Tissue
Hypoperfusion
Hypoxia Infection
Arterial Insufficiency

Arterial Insufficiency
Left Lower Extremity Ulcer, before and after 40 treatments of HBOT

http://www.npuap.org/resources/educational-
and-clinical-resources/pressure-ulcer-
categorystaging-illustrations/
http://www.as.miami.edu/chemistry/20081MDC/2
085/Chap4_New/chap4.htm
http://www.webmd.com/diabetes/guide/glycated-
hemoglobin-test-hba1c
http://sydney.edu.au/medicine/diabetes/foot/Pvd
x1.html
http://www.webmd.com/dvt/d-dimer-test-for-
deep-vein-thrombosis
http://rarediseases.info.nih.gov/gard/9671/lipoder
matosclerosis/resources/1
References:

http://membership.uhms.org/default.asp?
page=indications
http://aawconline.org/
http://www.wocn.org/
http://www.nawccb.org/default.asp
http://mkt.medline.com/clinical-
blog/channels/clinical-
solutions/understanding-the-role-of-
outpatient-wound-centers/
http://www.medscape.com/viewarticle/56
6133_8
References continued :

http://www.bayareahyperbarics.com/files/UHMS-lay-
language.pdf
http://www.surgerysupplements.com/hydrocolloid-
wound-dressings-reduce-incision-healing-time/
https://woundcare-today.com/categories-
pyramid/hydrogel-dressings
References continued :

Wound care

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