Wound Care

The majority of wounds can be treated by utilizing wound care methods aimed at controlling bacterial contamination, maintaining the proper amount of moisture in the wounds, treating edema, and preventing further injury.

Wounds with necrotic or grossly infected tissue or with purulent drainage and fibrinous exudate are more prone to bacterial contamination because these tissues and fluids can act as a culture medium for bacterial growth.  These tissues and exudate can be debrided mechanically or enzymatically.

Wet to Dry gauze dressings cause some mild mechanical debridement of dead tissue when applied and removed properly.  Proper placement includes damp gauze applied only to exposed subcutaneous tissues (off the skin to prevent breakdown and enlargement of the wound).  This gauze should be damp enough to adhere to the tissue but not so damp that it is still wet when it's time for a dressing change (thus defeating its debridement purpose).  Additional mechanical debridement techniques include a trip to the operating room for sharp debridement.

There are several products that enzymatically remove exudates that collect in the wound bed.  The product usually used at County is Collagenase Santyl(r).  Collagenase acts by digesting collagen in necrotic tissue causing micro-debridement.

Another method of controlling bacterial growth is the use of antimicrobial agents and systemic antibiotics.  If the patient has signs and symptoms of a systematic infection (fever/chills, cellulitis, etc.) then systemic antibiotics should be considered.  However overuse of systemic antibiotics leads to superinfections and bacterial resistance.  Topical antimicrobial agents are a good alternative for local wound care.  Products we have seen at County include: Dakin's solution and Sulfamylon.  Dakin's solution is a type of hypochlorite solution. It is made from bleach that has been diluted and treated to decrease irritation. Chlorine, the active ingredient in Dakin's solution, is a strong antiseptic that kills most forms of bacteria and viruses and can also break down a well healing wound.  Sulfamylon (mafenide acetate) is most often seen in burn wounds dressed with moist dressings.   It is bacteriostatic against many gram-positive and gram-negative organisms including Pseudomonas aeruginosa.

Controlling the level of moisture in a wound is not only important to help control bacterial growth but also to promoted healing and prevent skin breakdown.  Dry wounds do not epithelialize as well as wounds covered with an occlusive dressing.  Clean wounds should have a dressing that that retains moisture.  Moist/draining wounds should have an absorptive dressing.

Edema can lead to chronic wounds by preventing adequate circulation and diffusion of oxygen and nutrients from the capillaries to the wound.  Edema, if a problem, can be managed with elevation and compressive stockings and/or dressings.

Wound VACs (vacuum-assisted closure) are another wound dressing that is commonly used.  A wound VAC is a negative pressure dressing that is applied to wounds to help control exudates, promote granulation tissue formation, improve blood supply, maintain moisture, lessen edema, and protect the wound from trauma.

Thanks to Dr. Lisa Gray for this post.