Wound Care Treatment Modalities PDF

WOUND MODALITIES LAB- PRACTICE SET UP FOR ELECTRIC STIMULATION  MODALITIES AND WOUND CARE Modalities to facilitate reduction of bioburden and necrotic tissue Consider other adjunctive interventions to facilitate healing Chronic wounds defined as wounds that fail to respond to stand...

WOUND MODALITIES LAB- PRACTICE SET UP FOR ELECTRIC STIMULATION  MODALITIES AND WOUND CARE Modalities to facilitate reduction of bioburden and necrotic tissue Consider other adjunctive interventions to facilitate healing Chronic wounds defined as wounds that fail to respond to standard care showing stalled healing or worsening of wound over the past 30 days. PROBLEMS WITH RESEARCH TO SUPPORT ADJUNCTIVE INTERVENTIONS Patient-related variables Wound-related variables Treatment-related variables Research-related problems Manufacturer-sponsored research MODALITIES TO ENHANCE WOUND HEALING Wound irrigation Low-intensity laser Whirlpool Negative pressure wound therapy Pulsed lavage Hyperbaric oxygen Electrical stimulation Topical Oxygen Ultrasound Extracorporeal Shock Wave Therapy Diathermy (ESWT) Ultraviolet Cold atmospheric plasma (CAP) WOUND IRRIGATION Purposes/Effects Removes loosely adhered debris, bacteria, exudate, residual topical agents Facilitates debridement  WOUND IRRIGATION Indications Standard component of treatment for all wound types Syringe irrigation is good for use in narrow tunneling wounds Contraindications/ Precautions Wounds with active, profuse bleeding Be careful with splash back WOUND IRRIGATION Method Irrigation goal pressure of 4–15 psi Syringe Pressurized saline canister Irrigation devices Irrigant: saline, tap water, antimicrobial solution Alone or in combination with other modalities WOUND IRRIGATION ADVANTAGES DISADVANTAGES Simple Messy Quick May not use adequate amount of Inexpensive irrigant Effective Splash back Can use for wound in any location Can use in any setting WHIRLPOOL § Purposes/Effects § Removes loosely adhered debris, bacteria, exudate, topical agents § Facilitates debridement by softening and loosening necrotic tissue § Promotes circulation § Decreases pain § Makes range of motion exercises easier § Helps remove adhered dressings WHIRLPOOL Contraindications/ Precautions Indications Clean, granulating, epithelializing wounds Infected wounds Active bleeding Thick eschar or slough Need to reduce temperature with arterial Thick or heavy exudate insufficiency ulcers due to difficulty with heat dispersion Pain management Patients who are hydrophobic, confused, combative, with seizures Dependent position may increase edema May cause drying of surrounding skin Impaired sensation WHIRLPOOL Advantages Disadvantages Comfortable, pain control Potential for maceration, edema, cross- Effectively removes debris contamination Warms tissue promoting perfusion of Time intensive for setup and cleanup tissue Expensive equipment, extra support staff needed WHIRLPOOL: EVIDENCE FOR AND AGAINST Additives may be cytotoxic, however limited evidence shows proper concentrations are not significantly cytotoxic Force from jets may be traumatic however limited evidence indicates less force than pulsed lavage If used on infected and necrotic wounds, reduction of bioburden and removal of non-viable tissue are primary goals. PULSED LAVAGE WITH CONCURRENT SUCTION Delivery of irrigant under controlled pressure (4-15 PSI)with handheld device Applies negative pressure to wound bed May enhance granulation tissue formation, epithelialization, and tissue perfusion Facilitates debridement Removes dirt and foreign contaminants Softens necrotic tissue Removes toxic residuals from topical agent Nonspecific mechanical debridement, need to protect granulation tissue Aerosolization of contaminants requires clean room or draping PULSED LAVAGE Indications Wounds requiring irrigation or debridement Wounds with tunneling/ undermining Contraindications/ Precautions Exposed deep tissue, body cavities Facial wounds Recent surgical procedure Latex allergy/sensitivity Precaution: anticoagulants Precaution: deep tunnel, insensitivity PULSED LAVAGE Method Irrigation pressure of 4–15 psi Handheld device with tubing attached to irrigant reservoir and suction device/canister 1–3 liters of normal saline Time: typically takes 15–30 minutes Wear appropriate PPE to protect from splash injury and aerosolization (all people in treatment room) Prevent cross-contamination: Room with four walls and a door, cover IV sites/open areas not being treated, wipe down all horizontal surfaces Use surgical drape and PPE PULSED LAVAGE Advantages Disadvantages Messy Allows for thorough irrigation More expensive than simple irrigation Can be used in isolation rooms Not appropriate for large wounds Tips and some tubing designed for one- time use Aerosolization contaminates environment ELECTRIC STIMULATION Promotes wound healing independent of diagnosis Treats wounds of all depths Manages necrotic tissue, inflammation, & infection Facilitates wound contraction and wound resurfacing Enhances lymphatic and venous drainage, blood flow Attracts macrophages and neutrophils Promotes epithelialization, wound contraction, ATP generation, and collagen synthesis  ELECTRIC STIMULATION High volt pulsed current, monophasic (creates polarity) Restore current of injury Causes Galvanotaxis Negative pole(cathode): Moves fluid from area, Dilates capillaries, Stimulates nerves, Retards microorganism growth (bactericidal), liquefies proteins, softens tissue, stimulates granulation, decreases edema, fibroblasts proliferate and make collagen, basic environment, promotes angiogenesis, attracts neutrophils when infection present, attracts fibroblasts, attract keratinocytes and epidermal cells Positive pole-(anode)- constricts capillaries, sedative to neurons, facilitates healing, attracts macrophages, neutrophils (when infection not present), and epidermal endothelial cells, acidic environment, coagulates protein, hardens tissue, reduces mast cells.  ELECTRICAL STIMULATION Indications Adjunct to healing for chronic or recalcitrant wounds that are clean or infected CMMS: category III/IV that fail to respond after 30 days of standard care Contraindications/ Precautions General precautions for electrical stimulation Untreated osteomyelitis Not in combination with topical agents containing heavy metal ions Precaution: sensory neuropathy When cell proliferation is contraindicated i.e. malignancy, when there is evidence of osteomyelitis ???? (could heal over infection and mask problem, but may be beneficial in healing osteomyelitis), Where electrode placement is i.e. reflex center, or where current could interfere with electric implant i.e. pacemaker  ELECTRICAL STIMULATION Advantages Extensive research supports use as adjunct to enhance wound healing Meta-analysis: 144% decrease in wound size compared to standard care Majority use high volt pulse current however, significant variation in parameters Can use in any setting/ universally available Does not cause pain (often reduces pain) Disadvantages Time consuming Risk of contamination Not appropriate for large wounds  ELECTRICAL STIMULATION Methods Direct (indirect technique does not deliver as much current due to skin resistance.) Frequency: 120 Hz Intensity: 75–200 V, submotor Active cathode: infected, to reduce bioburden, to start granulation Active anode: promote granulation and epithelialization, reduces hypertrophic scarring Ground electrode should be double the size of treatment electrode to improve delivery of current Position ground adequate distance away from treatment electrode to improve depth of penetration, (minimum of10 cm away) Use clean technique Change polarity every 1-3 days Time: 45–60 minutes Frequency: 3–5 day/wk ULTRASOUND Purposes/Effects -High frequency (traditional) Most studies on animals or acute, traumatic wounds Appears to have sufficient evidence for facilitating healing in recalcitrant wounds Enhances all 3 phases of wound healing Accelerates inflammatory phase progression to proliferative phase. Increases: Collagen deposition Granulation tissue formation Angiogenesis Enhances wound contraction Improves scar pliability Purposes/Effects of Low-frequency ultrasound Debridement and to decrease wound bioburden ULTRASOUND Indications Adjunct for chronic or recalcitrant wounds Low frequency US for high level of necrotic tissue/bioburden High frequency may be helpful in scar management Contraindications/ Precautions General precautions for ultrasound Untreated osteomyelitis Wounds with active profuse bleeding Severe arterial insufficiency Deep vein thrombosis Malignancy TRADITIONAL HIGH FREQUENCY ULTRASOUND Methods Direct, Immersion, Periwound Frequency Superficial wound: 3.0 MHz Deep wound: 1.0 MHz Intensity Pulsed: 0.5–1.0 W/cm2 Continuous: ≤1.5 W/cm2 for remodeling closed wounds Time: 2–3 minutes per zone Frequency: 2x/day or 3 day/wk TRADITIONAL HIGH FREQUENCY ULTRASOUND ADVANTAGES DISADVANTAGES Can use in any setting Less research support Quick Not appropriate for large wounds Less setup/cleanup time May be painful or difficult to perform Does not hyperhydrate Risk of contamination Does not require dependent positioning NONCONTACT LOW-FREQUENCY ULTRASOUND (Mist) Method Frequency: 25–40 kHz Time: 20–60 seconds per cm2 Minimum of 4 minutes for wounds 1.5 ATM 14x greater oxygen dissolved in plasma Tissue oxygen pressures must be >40 mm Hg for normal wound healing Requires physician on-site HYPERBARIC OXYGEN Purposes/Effects Increases oxygen concentration gradient May reduce bacterial growth May enhance angiogenesis, granulation tissue formation, epithelialization, and wound contraction May reduce edema HYPERBARIC OXYGEN CONTRAINDICATIONS/ INDICATIONS PRECAUTIONS Gas gangrene DVT Peripheral ischemia CHF Crush injury Claustrophobia Wagner grade 3 or higher ulcer Pregnancy Progressive necrotizing fasciitis Severe arterial insufficiency Osteomyelitis Noncomplicated wounds Osteoradionecrosis  HYPERBARIC OXYGEN Method Patient in chamber breathing 100% oxygen at 1.5–2.5 ATM Treatment time: 90–120 minutes Treatment frequency: 2x/day–3x/wk Treatment length: 10–60 sessions If 50% decrease in wound surface area not noted after 10 HBO treatments, wound is unlikely to respond to this modality. HYPERBARIC OXYGEN Advantages TCOM test can help predict efficacy May prevent limb loss Disadvantages Extremely high cost Extensive treatment time Average patient requires 37–44 Rx costing $75,000 TRANSDERMAL /TOPICAL OXYGEN THERAPY The application of oxygen to the surface of a wound. Oxygen applied to a wound surface dissolves in tissue fluids It is bacteriostatic and stimulates angiogenesis and wound healing 3 types of delivery systems: Continuous Low constant pressure in a contained chamber Cyclically pressurized and humidified in a contained chamber EXTRACORPOREAL SHOCK WAVE THERAPY (ESWT) non-invasive treatment that generates shockwaves though sound and pressure Stimulation of microcirculation (blood, lymph) and metabolism (nitric oxide, vasodilation, reduction of oxidative stress) Mechanotransduction – cell matrix stimulation NO release (eNOS) Antibacterial and anti-inflammatory effects Release of growth factors (e.g. VEGF) Stimulation of stem cells, i.e. cell proliferation, transport and differentiation Use on acute soft tissue wounds, chronic wounds, and chronic pain and injuries COLD ATMOSPHERIC PLASMA (CAP) a mixture of charged particles, neutral particles, electromagnetic waves, and UV radiation Bactericidal Promotes proliferation of fibroblast and keratinocytes Promotes angiogenesis and release of growth factors  CLINICAL DECISION MAKING Consider: patient characteristics, wound location/etiology/size, treatment setting, and equipment availability Determine wound needs Know purported effects of intervention Know indications/contraindications Carefully weigh intervention advantages and disadvantages If no appreciable change in wound status after 2 weeks of appropriate wound care/ adjunctive therapy, the intervention should be discontinued