WOUND CARE

By

Jocelyn M. Lledo, MD
Plastic Surgery Fellow-in-Training

BRIEF HISTORY OF
DRESSINGS
Homespun remedies ritualistic
teachings, observations
Three healing gestures - (circa)
2200 BC on an ancient clay tablet
(1) washing the wound,
(2) making plasters (mixtures of herbs,
ointments, and oils that were applied to
wounds to aid in the healing process), and
(3) bandaging the wound

 Lister (1867) - first antiseptic dressings

soaked lint and gauze in carbolic acid
(phenol) before applying them to wounds

Tulle gras - one of the earliest

nonadherent dressings; popular in World
War I; gauze impregnated with paraffin
Owens (1944) - fine mesh gauze as
minimally adherent intermediary
underlying more absorptive materials

 References to early wound care in:

Bible, . . .went to him, and bound his
wounds, pouring oil and wine (Luke,
10:34);
Ancient Assyrian writings, . . . the
surface of the sick part with butter you
shall anoint. . .; and
Ancient Greek texts, With bandage
firm, Ulysses knee they bound (Homer,
The Odyssey)

DESIRABLE DRESSING
CHARACTERISTICS
Protect wound from bacteria and foreign
material
Absorb exudate from wound
Prevent heat and fluid loss from wound
Provide compression to minimize edema and
obliterate dead space
Be nonadherent to limit wound disruption
Create a warm, moist occluded environment to
maximize epithelialization and minimize pain
Be esthetically attractive

 Scab formation
Alternative to dressing
Natures dressing
Crusts of dried serum with trapped
erythrocytes, platelets, and other bloodborne cells

 Advantages:
Barrier against
foreign material
Reduction of pain
Holding wound
edges in
approximation
Facilitation of
wound contraction
Minimizing loss of
fluid and proteins

Disadvantages:
Can fix bacteria on
wound surface
infection
Slow
epithelialization

ACUTE WOUND CARE

Patient information
Tetanus immunization status
Bleeding at the time of injury
Medical Illnesses
Smoking history

Examining the wound

Need for debridement
Cleansing the wound: irrigate

 Evaluate for any underlying injury

Vascular, nerve, tendon injury
Fracture or joint dislocation

Further treatment

CONCEPT OF OCCLUSION
Before: wounds kept dry, as advocated
by Pasteur to keep them germ-free
Winter: effects of occlusion on the rate
of epithelialization (1962)
Porcine model surgically created wounds
left to heal either open to air or occluded
under a transparent film
Rate of epithelialization under the occlusive
dressing twofold that of wounds left
undressed

 Occlusive dressings:
Limit transmission of fluids, water vapor, and gasses
from the wound bed to the external environment
Maintain a mildly acidic pH and a relatively low O2
tension on the wound surface
Prevents desiccation, which leads to cell death
Facilitates epidermal migration, angiogenesis, and
connective tissue synthesis
Supports autolysis of necrotic material by providing
the solute for enzymatic debridement
Limit pain associated with partial thickness wounds to
a much greater degree than nonocclusive dressings

 Low O2 tension
Angiogenesis, an important factor in
wound healing
Optimal conditions for fibroblast
proliferation and granulation tissue
formation

Cytokines
Granulation tissue formation and
epithelialization
More likely to be preserved in an
occluded wound environment

SPECIAL WOUND
REQUIREMENTS
Infected or heavily contaminated wounds
Occlusive dressing bacterial proliferation,
infection exacerbation
Dressing that diminishes bacterial count

Heavily exudative wounds

Priority: degree of absorption of excessive
exudate that no occlusive dressing can provide
Large amounts of exudate skin maceration
around wound, dilute intrinsic factors such as
cytokines retarded healing

 Dressing regimens that contribute to

wound debridement
Wounds with nonviable tissue
Wounds with foreign bodies or debris

Wounds involving toxins (brown recluse

spider bites or infiltrated
chemotherapeutic agents)
Debridement to limit ongoing damage by the
toxic agent
Surgical debridement generally required

DRESSING OPTIONS
NONADHERENT
FABRICS
ABSORPTIVE
DRESSINGS
Foams
Gauze

OCCLUSIVE
DRESSINGS
Nonbiologic dressings
Biologic dressings

CREAMS,
OINTMENTS, AND
SOLUTIONS
Antibacterial agents,
acetic acid, Dakins
solution, iodinecontaining
antibacterials, silverbased dressings,
wound debridement

MECHANICAL
DEVICES

NONADHERENT DRESSINGS
Derivatives of fine mesh Owens
gauze and tulle gras
Consist of fine mesh gauze with a
supplement provided to augment
its
its
its
its

occlusive properties
nonadherent properties
healing-facilitating capabilities
antibacterial characteristics

 Hydrophobic:

Scarlet Red
Vaseline gauze
Xeroform
Telfa

Hydrophilic:

Xeroflo
Mepitel
Adaptic
N-terface
Fine mesh gauze

ABSORPTIVE DRESSINGS
Wide mesh gauze
Foams
Lyofoam
Allevyn
Curafoam
Flexzan
Biopatch
Vigifoam
Mepilex

OCCLUSIVE DRESSINGS
Benefits:
Insulation
Moisture retention
Mechanical protection
Barrier function against bacteria

 Nonbiologic

Films
Hydrocolloids
Alginates
Hydrogels

Biologic

Allograft
Xenograft
Amnion
Skin substitutes
(Integra,
Dermagraft,
Apligraf, Alloderm)

FILMS
Clear polyurethane membranes with
acrylic adhesive on one side for
adherence
Advantages:
Waterproof but allow the transmission of
oxygen, carbon dioxide, and water vapor
Generally transparent wounds visualized
easily
Extremely thin do not interfere with
patient function

 Disadvantages:
Nonabsorptive fluid collection leaks
out, disrupting antibacterial seal, messy
Intact skin surrounding area being
dressed needed for dressing adherence
Wound contraction may be slowed
Removal of film can disrupt new
epithelium

 Tegaderm, Mefilm,
Carrafilm,
Bioclusive,
Transeal,
Blisterfilm, Op-Site

HYDROCOLLOIDS
Family of dressings containing a hydrocolloid
matrix composed of such materials as
gelatin, pectin, and carboxymethylcellulose
Contact with wound exudate matrix
absorbs water, swells, and liquefies moist
gel
Ability to absorb wound exudate
Products vary in absorption capacity

May or may not leave a residue in the wound

 Generally opaque
Advantages:
Limited moisture and gas transmission
Impermeability to bacteria

Slightly bulkier than films

May provide more protection for the wound
May interfere with function to a greater
degree

 Available as
adhesive wafers or
as pastes or
powders
Duoderm, NuDerm,
Comfeel, Hydrocol,
Cutinova, Tegasorb

ALGINATES
Composed of soft, nonwoven fibers of a
celluloselike polysaccharide derived from
the calcium salt of alginic acid (seaweed)
Primary use in exudative wounds
Contact with wound exudate insoluble
calcium alginate partially converted to a
soluble sodium salt hydrophilic gel as
by-product occlusive environment that
facilitates healing

 Packaged in a variety
of forms, including
ropes for packing
cavities, ribbons for
narrow wounds or
sinuses, and pads
Algiderm, Algosteril,
Kaltostat, Curasorb,
Carasorb, Melgisorb,
SeaSorb, Kalginate,
Aquacel, Sorbsan

HYDROGELS
Consist of a starch polymer, such as
polyethylene oxide, or a
carboxymethylcellulose polymer and
up to 80% water
Function as rehydrating agents for dry
wounds
Because of their high water content,
they do not absorb large amounts of
wound exudate

 Available as gels,
sheets, or
impregnated gauze
Vigilon, Nu-gel,
Tegagel, FlexiGel,
Curagel, Flexderm

BIOLOGIC OCCLUSIVE
DRESSINGS
Homograft - graft transplanted between
genetically unique humans
Xenograft - graft transplanted between species
Pigskin - most commonly used xenograft

Homografts and xenografts - temporary

dressings (both are rejected if left on a wound
for an extended period)
Amnion - derived from human placentas; use
has diminished with increased concern
regarding biologic materials

 Alloderm and Integra

Include components that are incorporated
into healing skin
Considered skin substitutes

Biobrane - a biosynthetic dressing

constructed of a silicone film with a
nylon fabric embedded into the film
Nylon fabric is constructed of a trifilament
thread to which collagen is chemically bound

CREAMS, OINTMENTS,
SOLUTIONS
Broad category
zinc oxide paste
preparations containing growth factors
enzymatic debriding agents
free radical scavengers (allopurinol, dimethyl
sulfoxide)
agents to decrease platelet aggregation (iloprost)
agents that bind growth factors (sucralfate)

Many designed to have antibacterial

properties

ANTIBACTERIAL AGENTS
Commonly used to treat infected
wounds
Acetic acid
Dilute acetic acid (vinegar)
Ancient therapy still used today
Effective against gram-negative organisms,
such as Pseudomonas
Slow down wound epithelialization and to
limit polymorphonuclear neutrophil function

 Dakins solution
Hypochlorite solution, dilute bleach
Initially described by Labarraque in 1820
Popularized by Dakin in 1915
Broad antibacterial spectrum, although
toxic to fibroblasts
Slower to epithelialize and
neovascularize than wounds treated
with less toxic solutions

 Iodine-containing antibacterials
Include 5% and 10% povidone-iodine
ointment and cadexomer iodine gel
(Iodosorb and Iodoflex)
Broad antibacterial and antifungal
spectrum
Betadine: most toxic of all agents tested
on fibroblasts
Impaired wound healing, reduced wound
strength, or promoted infection

 Silver nitrate
Used in the Middle Ages for cautery and, in
high concentrations (3% to 8%), for
hypertrophic granulation tissue
Broad antibacterial spectrum
Can slow epithelialization
Hyponatremia and hypochloremia sec. to
hypotonicity
Stains bedclothes and all it touches black
Methemoglobinemia

 Mafenide (Sulfamylon)
Broad antibacterial spectrum
Ability to penetrate eschar
Disadvantages: occasional pain on
application, inhibition of epithelialization, and
inhibition of carbonic anhydrase, which can
lead to metabolic acidosis
Disadvantages minimized while maintaining
antibacterial efficacy by using a 5% solution
placed on dressings three to four times a day

 Silver sulfadiazine (Flammazine)

Broad spectrum of antibacterial, antifungal,
and antiviral activity
Limitations: transient neutropenia,
occasional topical sensitivity
Accelerate epithelialization of partialthickness wounds
Increase in neovascularization
Most commonly used antibacterial agent in
burn wound management

 Acticoat
Silver-impregnated dressing
Occlusive and promotes a moist healing
environment
Broad spectrum of antibacterial activity
that persists for 3 days, eliminating the
need for frequent dressing changes
More effective antibacterial than silver
nitrate in a comparative study of burn
wounds

 Mupirocin
Derived from Pseudomonas fluorescens
Inhibits protein synthesis within bacteria
Primarily active against aerobic grampositive cocci, including streptococcal
species, S. aureus, Staphyloccocus
epidermidis, and methicillin-resistant S.
Aureus
Does not impair epithelialization or wound
contraction

 M.E.B.O.
Moist Exposed Burn Ointment
Composed of beeswax and sesame oil
as the main active ingredients
Used in burn regenerative therapy

WOUND DEBRIDEMENT
Sharp debridement - time-honored
approach to removing devitalized and
necrotic tissue from wounds
Clearly demarcated areas of living
versus dead tissue - required to avoid
damaging healthy tissue and to
minimize patient discomfort
Biologic debridement, wet-to-dry
technique, nonmechanical debridement

 Biologic debridement with sterile

maggots (fly larvae)
Centuries-old technique enjoying a
resurgence in popularity
Sterile maggots fiercely consume
necrotic tissue and reject viable tissue
Secrete peptide antimicrobials
(defensins), providing an antimicrobial
benefit

 Wet-to-dry debridement technique

Surgical standard where wound is cleansed
and packed with saline-moistened gauze
As the wound and gauze dry, fibrinous
exudate generated hardens and adheres to
the gauze
Non-discriminating: any adherent material
removed can slow the progress of the
healing wound and cause pain

 Nonmechanical debridement
Can be provided by absorptive and
enzymatic agents
Dextranomer polysaccharide: anhydrous,
highly porous beads that trap bacteria
and debris at the dextranomer layer of
the wound-dressing interface
Dressing changes effectively diminish the
bacterial counts in wounds

 Enzymatic debridement
Naturally occurring compounds that
degrade complex molecules
Enzymes induce chemical reactions
without being changed or consumed
themselves
Sutilain: an enzyme derived from the
bacterium Bacillus subtilis; digests soft
necrotic tissue composed primarily of
denatured collagen

 Collagenase (Santyl): from Clostridium

histolyticum; digests denatured collagen and
native collagen
Papain: a vegetable pepsin prepared from the
juice of the fruit and leaves of carica papaya;
effective against collagen in the presence of
a cofactor containing a sulfhydryl group (e.g.
urea)
Fibrinolysin: degrades fibrinous tissue
Deoxyribonuclease: degrades DNA and
nuclear proteins

MECHANICAL DEVICES
Augment functions normally provided
by dressings in wound management
VAC device most widespread utility
Enhance local blood flow, diminish edema,
limit bacterial proliferation, accelerate
granulation tissue formation in wounds
Facilitate complete wound closure or to
prepare the wound for a reconstructive
procedure

 Uses a reticulated foam dressing that is

cut to conform to an individual wound
Foam covered by an occlusive drape
under which a vacuum tube is placed
and connected to a pump, which
provides 50 to 125 mm of negative
pressure to the occluded wound
environment

CHOOSING A DRESSING
Ovington: six basic questions to help
guide the choice of wound dressing:
What does the wound need?
What does the product do?
How well does it do it?
What does the patient need?
What is available?
What is practical?

 Important:
Continually assess wounds with each
dressing change
Adjust the wound care regimen as
necessary to accommodate the evolving
condition

 Incisional wound
Three layer dressing
Ointment
Occlusive dressing

Partial thickness wounds (e.g., abrasions,

donor sites)
No dressing (scab)
Impregnated gauze
Creams/ointments
Occlusive dressings

 Full thickness wounds e.g. pressure

sores
Alginates or hydrogels- rarely applicable
Creams/gels (e.g., Silvadene,
Flammazine)
Wet-to-dry dressing changes
VAC device

THANK YOU