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wound care
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wound care - March 5, 2005 2:12:00 PM
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InOrbit
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Can anyone recommend a book on wound care that they found useful ? Any pointers are appreciated !
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Re: wound care - March 5, 2005 2:57:00 PM
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Synergy
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"Wound Care - A Collaborative Practice Manual for Physical Therapists and Nurses" 2nd ed. by Carrie Sussman and Barbara M. Bates-Jensen (2001)
[URL=http://search.barnesandnoble.com/booksearch/isbninquiry.asp?ISBN=0834219735&pdf=y]Barnes and Noble[/URL]
Hope this helps! :)
_____________________________
Chris Adams, PT, MPT
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Re: wound care - March 10, 2005 3:41:00 PM
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InOrbit
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Chris,Thanks for the title .
I was also wondering , what you find useful when treating an eschar. What do you consider when deciding whether or not to debride it? Apart from that is it appropriate to leave the eschar on ?
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Re: wound care - March 10, 2005 6:31:00 PM
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Synergy
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InOrbit,
No problem! :)
I think your questions can be answered better by someone else. The only amount of wound care I received was during my clinicals and I've been in OP orthopedics since I graduated. I listed that reference becuase it was the book we used in school and it seemed to cover just about everything.
However, I'll take a stab at it. As you well know, hard black eschar is indicative of full thickness destruction and ischemia. If collateral circulation is present, it is usually okay to use sharp debridement. I would probably opt to use enzymatic debridement (making sure of course that I cross hatched the eschar first) on the hard black eschar and sharp debridement on the less 'caked on' eschar.
I don't think it's ever appropriate to leave eschar on a wound because it does not provide an optimal environment for healing to occur.
Once again, I haven't touched a wound in quite some time. :)
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Chris Adams, PT, MPT
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Re: wound care - March 12, 2005 12:37:00 PM
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ptdan23
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InOrbit...in regards to your question about eschar...it is dead tissue, why would you want it to stay on? Eschar and any non-viable tissue needs to be removed/debrided in order for the wound to heal. You can do this w/ dressings or by mechanical debridement (scissors, tweezers, scalpel).
I think the time where it would not be okay to use mechanical debridement is if the pt cannot tolerate it. If they can, debride as much as possible each time, in between tx times using some time of drsg for enzymatic debridement.
I also agree w/ Chris Adams for his book choice which is a very good resource. I have not read all of it but have used it for a reference several times.
Hope this helps.
Dan, PT.
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Re: wound care - March 13, 2005 12:10:00 PM
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InOrbit
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Hi Dan,
No doubt eschar is dead tissue , and typically you would want to debride it. But, for example if the patient has extensive eschar formation on both heels would you still want to actively debride it ? I was asking since I was looking for inputs on the net and I have read that some clinicians prefer letting the eschar stay as it is till the tissues heal beneath it ,and the eschar comes off by itself. Personally , I havent seen that happen since patients dont stay that long and get transferred to another setup.
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Re: wound care - March 13, 2005 12:20:00 PM
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ptdan23
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InOrbit...are you talking about a heel wound that is still closed but their is obvious tissue break down but no active wound as of yet??? Then in that case yes keep it closed and allow it to heel. Of course you have to take away the mechanism causing the wound in the first place - i.e. pressure from prolonged immobilization in bed. However, if it is an active wound, and their is eschar that needs to be taken off. The wound can't heel if that remains in place. If you delay removing the eschar it will causing inc healing times which may mean a possibly more severe wound which then may require surgical debridement, more immobilization - you can see how it can continue to cascade from there!
Dan, PT.
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Re: wound care - March 14, 2005 3:27:00 AM
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ehanso
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There is a wound website from the UK that has some useful information but i can't find the link at the moment.
The other option may to contact an Enterostomal Therapist (I know an interesting title) who is usually a nurse that works with Stoma's. They are good resources.
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Re: wound care - March 14, 2005 3:58:00 AM
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Dr.Wagner
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If there is EXTENSIVE eschar, then you call surgery or plastic surgery.
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Re: wound care - March 14, 2005 4:09:00 AM
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Yogi
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I usually see the heel eschar left on nowadays. Used to be debrided but no one stays in the hospital long enough now, I guess the Docs feel there's less chance for infection if the wound isn't open. Burns definitely should be debrided, and by who depends on the burn degree. The vac has pretty much replaced everything but dressings and topical stuff here.
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Re: wound care - March 14, 2005 4:14:00 AM
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ptdan23
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Doc...of course the therapist would consult surgery or get a 2nd opinion if the eschar is significant enough that they may need surgical debridement by an MD/DO.
Yogi...don't see why the eschar would be left on. Yes, the wound would be less exposed with it left on but how can it heal??? With the eschar removed it would allow the wound to begin the healing process. If it is well taken care of then you would think the chance of infection would be low, unless of course the patient is immunocompromised.
Dan, PT.
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Re: wound care - March 14, 2005 9:29:00 AM
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tucker
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Heel eschar is one of the rare exceptions to 'all eschar should be debrided'. Per the AHCPR guidelines on pressure ulcers,.."Heel ulcers with dry eschar need not be debrided if they do not have edema, erythema, fluctuance, or drainage."
The eschar provides a natural protective cover and if the wound is clean, dry, nontender, nonfluctuant, nonerythemous, and nonsupporative, it is stable. If it begins to drain or show any complications, debridement is mandatory.
And yes Wags, if there is extensive eschar, it probably needs surgical debridement by plastics...not a surgical candidate, I've seen maggot therapy do wonders on extensive eschar!
What do you consider when deciding whether or not to debride it?
As others have indicated, there are numerous factors in deciding to debride...or not to bedride...One that has not been mentioned is the patient's arterial flow when dealing with a leg wound. Can you palpate a pedal pulse? If you have a patient with a leg wound and you cannot paplate a DP or PT pulse, an ABI (ankle brachial index) must be performed to rule out arterial insufficiency. If less than .5, debridement is contraindicated and the patient needs a vascular consult. A wound will not heal if blood is not getting to it.
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Re: wound care - March 15, 2005 8:18:00 AM
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Yogi
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Thanks, Tucker, I had wondered about the heel ulcers. I was reporting what I see, Dan. I once had a plastic surgeon tell me three reasons a wound won't heal. 1. Too much bacterial colonization. This used to be monitored in burn centers, probably still is. 2. Unrelieved pressure and/or shear. 3. Circulation deficiency.
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Re: wound care - March 16, 2005 4:04:00 AM
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ptdan23
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Tucker, Yogi...do either of you have any stats on the healing time of leaving eschar intact vs debridement? That would be interesting.
Dan, PT.
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Re: wound care - March 16, 2005 8:53:00 AM
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Dr.Wagner
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Here is some good points, not every hospital has plastics in house, so often times general surgery will do the debridement (much cheaper to the patient also), certainly nothing special to the procedure. Either service will do it, I have found that plastics will only see the patients with adequate insurance coverage, while general surgery will see all comers. But there is hospital to hospital variance.
As for arterial deficiency. If one cannot palpate the pedal or posterior tibial pulses always check the opposite side to see if the pulses are palpable on that extremity. Concern evolves when there is a difference. If a difference is noted or palpation is limited, the next step is to place a doppler ultrasound to both areas to see if a pulse can be heard.
ABI's are more helpful in the acute situation (ie cold, white leg, without pulses). In either situation angiography is a strong consideration and likely vascular consult.
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Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: wound care - March 16, 2005 3:17:00 PM
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tucker
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From: Texas
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No I don't have any stats on leaving eschar for heel wounds vs. debriding..., that would be interesting. It really depends on the patient as well. For instance the patient with bilat. heel wounds in a NH that is dependent for all skills...I would stay conservative and leave it on. But if it is a previously active pt who has heel eschar from a prolonged ICU stay, it may be better to go ahead and start the debridement process even if the wound is stable,.. it's going to require removal anyways, so why not expedite the process. Just my thoughts.
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Re: wound care - March 16, 2005 6:37:00 PM
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ptdan23
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From: Orlando, FL
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tucker...I agree. Anyone know of any stats/research out there that is available on this topic?
Dan, PT.
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Re: wound care - March 16, 2005 6:57:00 PM
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Dr.Wagner
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From: Indianapolis
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Here is a start...
Standard, Appropriate, and Advanced Care and Medical-Legal Considerations: Part One -- Diabetic Foot Ulcerations
from Wounds
Posted 06/09/2003
Gerit Mulder, DPM, MS, David Armstrong, DPM, Susie Seaman, MSN, NP, CETN
Wound Healing in Diabetic Foot Ulceration: A Review and Commentary
from Wounds
Hau T. Pham, DPM; Jeremy Rich, DPM; Aristidis Veves, MD, PhD
Management of the Diabetic Foot: Preventing Amputation
from Southern Medical Journal
Marvin E. Levin, MD
Commentary: Surgical Perspective in Wound Healing
from Wounds
Morris D. Kerstein, MD; Ernane D. Reis, MD. From Mount Sinai School of Medicine, New York, New York
_____________________________
Dr. Wagner DO
Moderator of Medical Complexity Forum
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Re: wound care - March 18, 2005 6:35:00 PM
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InOrbit
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HOw can one assess circulation status for a sacral wound ?
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Re: wound care - March 18, 2005 7:28:00 PM
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tucker
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From: Texas
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I have never been asked that question, but I'll give it a shot.
Circulation is not an issue for sacral pressure wounds. If it is, there are much bigger problems to deal with than treating a sacral ulcer. (hemipelvectomy?)
You may be referring to when a sacral wound shows a pale pink or brownish color instead of healthy red granular appearance. In my experience, that is usually due to infection with an increased bacterial load or non-viable tissue still in the wound, not circulation problems.
To my knowledge, circulation is only assessed in the extremities, where one could do an ABI or a transcutaneous oxygen tension measurement (TcPO2) for a noninvasive, objective measurement.
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