Week 12: Wound Care Modalities

Why is irrigation helpful to facilitate wound healing?

Irrigation involves using fluid to remove debris, bacteria, exudate, and residues from wounds. Benefits include: debridement, maintaining moist environment, and enhancing healing!! Esp. healing granular wounds!!

What are the most common types of irrigation?

Solutions: normal saline, sterile water, tap water, wound cleansers (Shur-Clens, Vashe), antiseptics (Acetic Acid, Dakin's, Hydrogen Peroxide)

Methods: gentle irrigation and rinsing, low pressure capsule, low pressure lavage, whirlpool, pulsed lavage w/ suction (PLWS), ultrasonic mist

When is immersion or soaking an area contraindicated? When should we avoid irrigation as it is contraindicated?

Immersion or soaking is CONTRAindicated:

- recent grafts

- recent surgical incision sites

- w/ caution = diabetic feet/ immunocompromised

Irrigation is CONTRAindicated:

- active profuse bleeding

- dry gangrene (leave it be!!)

What is the safe and effective PSI for wound irrigation? Why is this important?

GENTLE irrigation and rinsing (ex: saline bullets, syringe) = PSI 4-15.

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Positives. vs. negatives: whirlpool

Positives: cleanses, agitation, additives, temperature range, treatment for large areas

Negatives: risk of infection, sterility, aerosolization, risk of tissue injury, PSI?, maceration, additives, expense, cleaning + space + water

Why is whirlpool use not recommended within wound care?

Risks outweigh the benefits. High risk of cross-contamination & infection, can break down healing tissue or macerate surrounding tissue, and it is labor-intensive.

When is a whirlpool absolutely contraindicated?

1. Clean & granulating wounds

2. Edematous, draining, macerated ulcers

3. Active bleeding

4. Venous Insufficiency (VI)

5. Multi-wounds same area

6. Uncontrolled seizures

7. B&B issue

Positives vs. negatives: pulsed lavage w/ suction (PLWS)

Positives: cleaning, known PSI, sterile w/ no additives, temperature range, site specific, portable, disposable, few contraindications

Negatives: $$, aerosolization risk, confined space, cover horizontal surfaces

When is pulsed lavage with suction (PLWS) contraindicated?

1. Exposed structures

2. Body cavities

3. Facial wounds

4. Recent grafts or surgical procedures

5. Actively bleeding

Positives vs. negatives: ultrasonic mist

Positives: bactericidal, cleanses the wound, stimulates tissue healing, less aerosolization risk, known PSI, sterile w/ no additives, site specific, portable

Negatives: $$

When is ultrasonic mist contraindicated?

1. Do NOT use near electronic implants/ prosthesis (e.g., near or over the heart or over the thoracic area if patient is using a cardiac pacemaker)

2. On the lower back during pregnancy or over the pregnant uterus

3. Over areas of malignancies

How is pulsed lavage with suction different from ultrasonic mist therapy?

PLWS = delivers pressurized irrigation w/ simultaneously removing fluid and debris via suction (i.e., mechanical debridement)

- non-selective

- PSI pulsatile stream

- higher aerosolization risk

Ultrasonic mist = delivers ultrasound waves through a saline mist to promote healing and gently debride biofilm

- more selective

-ultrasound energy

- lower aerosolization risk

List the purpose and goals of debridement.

1. Decrease bioburden & risk of infection

2. Increase effectiveness of topicals

3. Improve bactericidal activity of leukocytes

4. Shorten inflammatory phase

5. Decrease energy required by the body to heal

6. Eliminate physical barriers

7. Tissue protection or examination

8. Decrease wound odor

9. Prepare wound for grafting, skin substitutes, or surgical closure

What considerations are there for determining whether or not to debride?

Considerations: resources, skill, wound etiology (non-viable tissue - i.e., slough or eschar), potential for the wound to close, health status of the patient (meds, INR, glucose, nutrition), goals

What is the red-yellow-black system and how does it guide us with debridement?

Classic wound-care framework used to quickly assess the wound bed and determine the appropriate type of debridement or treatment needed.

Red = granulation tissue (healthy, healing tissue) = NO debridement = protect

Yellow = slough = debride

Black = eschar/necrotic tissue = debride

Describe the physical therapist's scope of practice and what they can and cannot debride.

Irrigation and debridement IS within our SOP under physician orders BUT we CANNOT induce bleeding!!

What are the contraindications for debridement?

1. Arterial compromise (stable, dry, hard eschar)

2. Viable tissue

3. Hypergranular tissue (bleeds SUPER easily --> refer back out)

4. Deeper structures

What are the types of debridement?

1. Sharp

2. Mechanical

3. Enzymatic

4. Autolytic

5. Biologic

6. Surgical

Pros vs. cons: sharp debridement

Pros: fast, selective

Cons: can be painful

What are precautions or contraindications of sharp debridement?

Precautions: anticoagulants/clotting issues, pain, immunosuppression, unable to be still

Contraindications: ischemic ulcers, pyoderma gangrenosum (similar to a Hydra in Greek mythology)

When should you stop sharp debridement? What are some warning signs?

1. Patient request/pain control issues

2. Wound is clean

3. Outside of comfort level as provider

4. Impending exposure of structures

5. Excessive bleeding

If there is bleeding, what must be done prior to applying a dressing? What is the best method to stop the bleeding?

Elevate, pressure x5-10 min, silver nitrate (NOTE: PTs CANNOT put silver nitrate on, but we CAN put on Surgicel)

Also, contact the physician is bleeding has a pulse, won't stop, fever/chills, downhill course, no improvement, impending exposure of structures, unexpected abscesses/purulence.

How is mechanical debridement (ex: soft abrasion, hydrotherapy, wet to dry or wet to moist, low frequency contact ultrasound) different from sharp debridement?

Nonselective, painful?, can be effective IF used correctly, familiar to healthcare workers

What is enzymatic debridement and how does it work?

Denatured collagen filaments anchor debris to the wound bed --> collagenase digests these collagen filaments!!

**NOTE: discontinue when "clean"**

What are indications and contraindications of enzymatic debridement?

Indications: infected wounds, burns

Contraindications: silver or iodine products (kill the enzyme), hydrogen peroxide, acetic acid, timeframe would be too long, deeper wounds, facial burns

**NOTE: some adverse effects include burning/stinging, allergic reactions, periwound irritation**

What is autolytic debridement and how does it work?

LEAST painful variation. Cheaper as well, but takes time. Involves occlusive dressings to maintain moistness and warmth (hydrocolloid, transparent films, foams, hydrogel) to use the body's own moisture for trapping tissues!!

**NOTE: there may be some odor upon removal**

What are its indications and contraindications of autolytic debridement?

Indications: pain, palliative treatment, can't be still

Contraindications: infection, dry gangrene, deep cavity wounds

What is cross-hatching?

Technique of overlapping lines w/ sharp that allows enzymatic and/or autolytic debridement to also take place.

What is biosurgical or biologic debridement and how does it work?

Maggot Therapy (MT) or larval debridement therapy (LDT) - selective, quick, painless. Ingest nonviable tissue & decrease odor. Release enzymes that degrade nonviable tissue & biofilm. Antimicrobial effects = change in pH, killing & ingesting of bacteria, excretions & movement stimulate granulation tissue.

What are its indications and contraindications of biologic debridement?

Indications: NOT a surgical candidate

Contraindications: exposed blood vessels, uncontrolled bleeding disorders, allergy or sensitivity, psychological or emotional intolerance, dry wounds, extensive ischemia, deep tunnels or sinus tracts, body cavities

When should we consider referring for surgical debridement?

Complex wounds, infection, structures

E-Stim: What is the current of injury? How do we maintain it as practitioners?

"The Current of Injury" -- once the tissue is injured, it creates a current of injury as the interior is (+) charged and exterior is (-) charged. This means there is a (-) charge overall on the skill.

As practitioners, we maintain it as practitioners by optimizing the wound environment (ex: moisture, scab formation, protection) w/ HVPC (short pulse duration w/ high voltage (75-150 V)) for comfortability, while decreasing risk of skin damage from ion shifts and decreasing skin resistance.

E-Stim: What is galvanotaxis? What polarity of cells does the anode attract? What cellular polarity does the cathode attract?

Galvanotaxis - process by which cells are attracted to an electrode by their polarity.

- anode (+) attracts (-) cells

- cathode (-) attracts (+) cells

E-Stim: How can we adjust the electrodes to make the treatment more superficial or deep?

The further apart the active and dispersive electrodes, the deeper the current.

vs.

The closer the active and dispersive electrodes, the more superficial the current.

E-Stim: Consider when we may want to use the anode to induce wound healing at different stages.

Use an ANODE (+) when the goal is to attract NEGATIVE (-) cells.

- neutrophils (-)

- macrophages (-)

- mast cells (-)

Best for: infected wounds or we are trying to initially clean up the wound(s). Antibacterial, phagocytic attraction of immune cells.

E-Stim: Consider when we may want to use the cathode to induce wound healing at different stages.

Use a CATHODE (-) when the goal is to attract POSITIVE (+) cells.

- fibroblasts (+)

- epidermal cells (+)

- some neutrophils (+)

Best for: proliferation, development of the ECM w/ granulation tissue.

E-Stim: What types of wounds can electrical stimulation be used for treatment?

ALL TYPES!! (pressure injuries, arterial ulcers, venous ulcers, diabetic foot ulcers) -- any wounds w/ stalled or decreased healing!!

E-Stim: What precautions are present with electrical stimulation? What contraindications are there for electrical stimulation use?

Precautions:

- cleanse heavy metal-based dressings (i.e., silver) or petrolatum products prior to applying e-stim -- may interfere w/ normal bioelectric nature of the tissues

Contraindications:

- directly over malignancy

- directly over the anterior neck or upper chest (carotid sinus)

- anyone w/ pacemaker or internal defibrillator

E-Stim: What are frequent treatment parameters for the direct method of electrical stimulation?

For people w/ intact sensation, turn the intensity to just below a visible muscle twitch. Optimal tx time 45-60 min (5-7 days/wk).

Ultrasound: What type of energy does ultrasound deliver? What setting would be best to treat a deeper wound?

Biophysical energy delivered via sounds waves (mechanical energy) that influence inflammatory conditions and facilitate healing.

1 MHz = deeper wound

3 MHz = shallower wound

Continuous mode = heat formation (increases blood flow, increases NCV, increases elasticity of scar tissue)

Pulsed mode = non-thermal (releases histamine, enhances collagen production via fibroblasts, helps progress through inflammation)

Ultrasound: When may ultrasound be indicated? What types of wounds can ultrasound be used for treatment?

Indications: debridement (contact, low-freq ultrasound), pain reduction (thermal & nonthermal), infection (reduces bacterial load/bioburden through cavitations)

Wounds: ALL TYPES based on physiological need(s) (to stimulate healing, split-thickness donor sites, vasculitis (pulsed only to reduce inflammation), neonatal extravasation injuries

Ultrasound: What contraindications are there for ultrasound use?

Acute inflammation (thermal US only), pain associated w/ use over fracture site, over burns (thermal US only), untreated osteomyelitis, profuse bleeding + arterial insufficiency (thermal US only), DVT, thrombophlebitis

Ultrasound: What are low frequency ultrasonic mist devices? How do they work?

They are non-contact ultrasound systems that use very low-frequency acoustic waves (typically 20-40 kHz) delivered through a fine saline mist to treat wounds.

Typically promote healing via microstreaming, cavitation, and biofilm disruption.

What is ultraviolet C light therapy and what is its primary use or indication in wound care?

UV radiation is non-thermal energy that produces physiological effects through photochemical reactions in the tissues after a variable latent period. UVC is the most commonly used variation in wound care for ionizing, bactericidal, and virucidal.

What is laser therapy and how does it work?

LASER = Light Amplification by Stimulated Emission of Radiation (LASER)

Works via photobiomodulation - use of non-ionizing source of photonic energy that generate non-thermal, therapeutic effects

- influences mitochondria, which have cytochrome oxidase (absorbs red and near infrared light)

- energy is converted to ATP --> promotes tissue healing and repair + generates two other molecules: NO and reactive oxygen species

- together, this process stimulates other molecules and releases NO back into the body to restore the respiratory chain of the cell and enhance circulation as the smooth muscle relaxes within the blood vessel walls

What are the beneficial outcomes of laser therapy?

Alleviation of pain/inflammation, immunomodulation, and promotion of wound healing.

What are the three primary types of pneumatic compression pumps and what are they each used to treat?

1. Vasopneumatic (veins)

2. Arterial (arteries)

3. Lymphedema (lymphatics)

How do intermittent pneumatic pumps work? When are they contraindicated?

Pumps reduce hydrostatic pressure to minimize swelling and compliment compression therapy for VENOUS congestion. Chambers will successively fill and intermittently compress distal to proximal.

Contraindications:

- active phlebitis

- DVT

- untreated cellulitis

Are standard IPC appropriate for lymphedema?

NO!! Use caution!! -- the lymph system is VERY fragile and require very light compression. If the patient has primarily lymphedema, best to consult a lymphedema certified therapist and obtain pumps specific for lymphedema.

How are arterial pumps different from intermittent pneumatic compression pumps? When are they indicated for use? What is the optimal treatment protocol for arterial pumps?

Arterial pumps work on a completely different premise vs. IPC!! -- they use rapid high-pressure compression w/ relief cycle which rapidly pushes blood proximally out of the LE to create a negative pressure gradient --> arterial blood rushes in, creating turbulence at bifurcations!!

Optimal tx: regular, daily wear to stimulate angiogenesis due to repetitive chemical signaling related to turbulent flow.