How to Select Wound Care Products: A Review for the Podiatric
код для вставкиn ng io ui at in uc nt Ed Co ical ed M WOUND MANAGEMENT How to Select Wound Care Products: A Review for the Podiatric Physician Here are some guidelines to help choose the appropriate treatment. Goals and Objectives Primary Goal: To help the podiatric physician understand the factors involved in selecting an appropriate dressing for a particular wound. Further, to address specific patient issues to provide information regarding wound management. After reading this article, the podiatric physician should be able to: 1) Appreciate the history of wound care dressings. 2) Recognize the stages of wound healing and the factors that impede wound healing. 3) Identify reasons for wound closure failure as well as the podiatric treatment. 4) Describe wounds with regard to accepted definitions and classifications. 5) Be able to select the most appropriate wound healing product with regard to a presenting wound type. 6) Recognize wound product dressing considerations for lower extremity ulcers. 7) Be able to develop a wound care product formulary for use in a clinical practice. 8) Appreciate the clinical data regarding medicinal alternative wound care products. Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Continuing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $139 (you save $61). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 198. Other than those entities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at bblock@podiatrym.com. Following this article, an answer sheet and full set of instructions are provided (p. 198).—Editor By Robert G. Smith, D.P.M., Msc, R.Ph., C.Ped Introduction Literature reports have revealed that 1.25 million people in the www.podiatrym.com United States suffer from burn wounds yearly 1; while the prevalence of patients suffering from chronic skin ulcers caused by either pressure, venous stasis, or diabetic etiology is astonishing.2,3 Therefore, a podiatric physician, as a clinical provider, may be asked to treat patients as well as offer suggestions to Continued on page 184 JANUARY 2007 • PODIATRY MANAGEMENT 183 M C ed on ica tin l E ui du ng ca tio n vented their healing. Although he man discovered the multitude of advocated that the majority of wound coverings or ointments that wounds be kept dry, moist wounds were probably used. It can only be other healthcare providers on were covered with fat or oil-based speculated that prehistoric man the selection of the most approointments after being washed in probably observed that a covered priate lower extremity wound care wine or vinegar. The most widely wound bled less, and that applying product. This selection is a used ointments were honey, oil, pressure to a more serious hemorthought-provoking one involving and wine; wool boiled in water or rhage could stop the bleeding. many factors such as the wound wine was considered a useful dressThere are three environment, efing. Bandaging had become an art major problems fectiveness, paby the fifth century BC and surwith the presence tient acceptabiliThroughout history, geons knew that bandaging a limb of an open ty, and cost. too tightly could cause gangrene. wound: hemorCurrently, a wounds have been rhage, mechaniplethora of dressed in an The Mystery of Infections cal disruption of wound care prodThe problem of infection was tissues, and infecucts are available attempt to prevent considered a great mystery for tion. Historical for use. Thus, the 4,000 years due to its insidious narecords indicate podiatric physicontamination, ture. Wound redness, swelling with that Samarians cian is chalinfection, and heat, and pain were described by identified these lenged with the Celsus in De Medicinia in approxiproblems and set task of selecting morbidity. mately 25 A.D. A dichotomy preforth the techthe most approsented itself to early physicians niques of washing priate product to with regard to wound presentation. wounds, bandagmeet the patienA patient usually survived a wound ing wounds, and preparing of plast’s needs. Podiatric physicians if it was localized with thick creamy ters to treat these wounds.4 must understand that the essential discharge; but then another would goal of a wound care dressing is to Also, other records indicate die when the wound presented provide an optimum healing envithat in Mesopotamia, wounds with a thin watery, brown, foulronment. Further, they should unwere washed with water or milk smelling discharge.4 derstand the principles involved and then were dressed with honey when formulating a wound care or resin, conifer, myrrh and frankEarly accounts from 1650 BC plan. This empowers them in unincense. It can be speculated that describe the standard treatments derstanding the factors involved bandages could have been made for wounds to include grease, when selecting a particular wound of wool or linen; however, nothhoney, and lint. The reason oil or care product given a particular ing is known of the ways that grease were used was that they prewound type. A brief chronicled bleeding was controlled during vented sticking of the bandages to perspective highlighting the evoluthis time.5 the wound and they did not spoil tionary hallmarks of wound care over time. Honey provided antibacBy 3000 B.C., minor hemorproducts should allow the podiaterial properties, while lint promotrhage was controlled by cauterizatric clinician to realize the pheed capillary action and packed the tion. The practice of bandaging nomenal progress that has taken wound. Later wounds to applace during the development of both wine and proximate diswound care products. vinegar were used rupted tissues, as The problem of Secondly, a vivid narrative debecause of their well as taping of scribing the wound healing process, antibacterial wounds to assist infection was wound type classification, and properties. Variwith skin approxiwound assessment is offered to ous metallic salts mation, appears considered a great serve as a foundation for product were used as anto be over 4,000 mystery for 4,000 selection. Finally, to enable the cient topical anyears old. Other podiatric physician to formulate a tibacterial treatmeans of closing years due to its wound care product formulary, ments.4 wounds included insidious nature. both a narrative section and deusing insect The Egyptians scriptive tables of specific product mandibles as introduced a classes are offered as easy, readable clamps. Finally, number of minerreferences. the art of suturing als to be used as traumatic wounds is documented treatment alternatives for infected History as early as the third and fourth cenwounds. For instance, green copper Throughout history, wounds tury B.C.4 pigment (obtained from malachite) have been dressed in an attempt to and chrysocolla had powerful asHippocrates advanced medicine prevent contamination, infection, tringent and antiseptic properties. by describing diseases and their and morbidity. Because of the lack Mercury compounds were also used natural history. He considered that of records, it is understandably difby the Egyptians for their antibacwounds were diseases and thus, by ficult to determine how prehistoric analogy, a humoral imbalance preContinued on page 185 184 Wound Care... PODIATRY MANAGEMENT • JANUARY 2007 www.podiatrym.com terial properties.5 The Greeks introduced the use of verdigris as an antiseptic which showed to be more powerful than either malachite or chrysocolla.5 During the middle ages, Paulus Aegineta’s work set forth the treatment of many kind of wounds as well as a variety of skin diseases. During this time, treatment selection was based on the product’s curative properties. First, copper ore, cimolian chalk, cold water, vinegar and wine were all used as styptics. Secondly, myrrh, frankincense, egg-white, cooked honey, a sponge or wool squeezed out in wine or vinegar acted as astringents. Thirdly, verdigris, pine resin, turpentine, radish or ray honey were all used to cleanse wounds. Finally, Alum brine, chrysocolla, verdigris, red copper, ox bile, bitter almonds or their oil were used as erodents.5 Wound Sepsis Joseph Lister addressed wound sepsis, leading to the use of a specific chemical therapy in managing a wound.4-7 Lister’s work was important in reducing both morbidity and mortality from traumatic injuries. The importance of a moist wound environment for healing has become well established since Winter’s observations in 1962.8 Podiatric physicians may be overwhelmed by over-abundance of wound care products to choose from since Winter’s observations. Therefore, it is essential that when the podiatric physician selects a wound care product the decision is ground in science and not an arbitrary one. n ng io ui at in uc nt Ed Co ical ed M Wound Care... underlying support structures of fascia, muscle and bone.9-11 Wound healing is a complex biologic process that involves chemotaxis and division of cells, neovascularization, synthesis of extracellular matrix, proteins, and reThe Wound Healing Process modeling of scar tissue. The process Human skin is composed of two of wound healing begins when disdistinct fused layruption of skin ers, each with difintegrity occurs ferent tissue cell below the epiderHuman skin is types which have mis. Although distinct functions this process is a composed of two (Figure 1). Skin is continuous comdistinct fused layers, the largest organ plex of interplay of the body and is between various each with different approximately cell types found 10% of the body’s in the resulting tissue cell types weight.9-11 Epiderwound, it is comwhich have distinct monly described mis is the outeras occurring in most layer of the functions. stages: inflammaskin and normally tory, proliferaregenerates every tive, and maturafour to six weeks. tion. Findlay further subdivides this It is avascular and develops from process into four distinct phases: ectodermal origin. It is the outerinflammatory/defensive, destrucmost layer of the skin and consists tive/migratory, proliferative/granuof five cell types, also arranged in lation, and maturation.12 Hunt’s relayers. The dermis is composed of colview emphasizes both the contribulagen, elastic fibers, fibroblasts and tions of coagulation and inflammais from mesodermal origin. It protion to the formidable eruption of vides strength, support, blood, and cell replication which is the founoxygen to the skin. It contains dation of healing.13 blood vessels, hair follicles, lymphatic vessels, sebaceous glands, as Tissue Injury well as sweat glands. Thick bundles Tissue injury causes the disrupof collagen anchor the dermis to tion of blood vessels and extravasathe subcutaneous tissue and the tion of blood constituents. A blood clot forms, reestablishing homeostasis, and provides a provisional extracellular matrix for cell migration. Edema, erythema, heat, and pain are characteristics of the inflammatory or first phase, which begins at the time of the injury and lasts four to six days. Macrophages migrate into the wound area around the fourth day to destroy bacteria and clean the wound of cellular debris.3,10,12-15 The Proliferative Phase The proliferative phase, the second phase in the process, lasts from four to 24 days. During this period, red, beefy, shiny tissue with a granular appearance is generated. This tissue consists of macrophages, fi- Figure 1 www.podiatrym.com Continued on page 186 JANUARY 2007 • PODIATRY MANAGEMENT 185 M C ed on ica tin l E ui du ng ca tio n Wound Care... broblasts, immature collagen, new blood vessels, and ground substance.3,10,12-15 type, nutritional status, vascular status, and immunosuppression.10 The podiatric physician may have a dramatic impact on a patient’s healing outcome by recognizing and preventing those factors Maturation Phase The third phase of wound repair is the maturation phase, also known as the remodeling phase, lasting from 21 days to two years. Collagen fibers change the red granulation tissue to white vascular tissue as vascularity decreases, resulting in a scar with maximum tensile strength. Myofibroblast and actin-rich fibronectin are responsible for wound contraction.3,10,12-15 Tissue injury causes the disruption of blood vessels and extravasation of blood constituents. Factors That Impede Wound Healing A number of both local and systemic conditions may delay or impede wound healing. Some local factors include: pressure of the area, dry wound environment, wound edema, repetitive trauma, local infection, and tissue necrosis. Systemic factors include age, body that will impede wound healing. Also, the podiatric physician may be the one to identify possible problems of patient’s nutritional barriers, patient’s noncompliance, local wound infection, or wound trauma as the cause of impeded wound healing. Malnutrition Malnutrition has been shown to be a major factor affecting wound healing.16-20 Ongoing nutritional assessment is essential when managing the progress of a healing wound. The roles of specific nutrients are discussed below with regard to wound healing. Protein depletion impairs wound healing by inhibiting angiogenesis, fibroblast proliferation, and synthesis, accumulation, and remodeling of collagen. 16,20 Glutamine has a central role in many major metabolic pathways. It provides the substrate for the synthesis of purines and pyrimidines for the proliferating stimulated lymphocytes.21 Both carbohydrates and fats supply cellular energy. Additionally, fats supply esse nt ial f at t y acid s f o r ce llular membrane manufacture and prostaglandin production. Vitamin A moderates cell differentiation, controlling growth factors and their receptors.22 It is responContinued on page 187 TABLE 1 Recognized Reasons for Wound Closure Failures 186 SIGNS PODIATRIC INTERVENTION Excessive Dry Wound Bed Use a dressing that maintains moisture (Hydrocolloid or hydrogel dressing) Rolling Wound Skin Edges Moisture-retentive dressing White Skin Macerated Wound Edges Protect Skin with Petrolatum ointment-Zinc oxide Use a more absorptive dressing Underminding or ecchymosis of surround skin Protect the area Tunneling Protect the area from pressure Inspect/Irrigate tunnel for foreign body (suture or dressing material Necrosis Perform debridement if living tissue has adequate circulation No change in size and depth for 2 weeks Reassess the patient for local and systemic problems Increase in size or depth of wound bed Reasses the patient for circulation and infection PODIATRY MANAGEMENT • JANUARY 2007 www.podiatrym.com facilitate wound closure, the podiatric physician should be able to sible for collagen synthesis and match the associated probable epithelialization. Vitamin C is a cause for the failure to thrive and vital co-factor in the formation of then select an appropriate intervenhydroxyproline residues in protion to expedite wound closure. 28 collagen, and its deficiency results Probable causes for wound closure in a decrease of collagen formafailure are pressure, dryness, moistion and a decrease in membrane ture, ischemia, and infection. integrity.23 If a wound shows no change in its size or depth during a two-week Pyridoxine, riboflavin, and thitime period, then the causes may amine are important co-factors that be pressure or trauma to the area, may stimulate antibody and white infection, or patient issues that inblood cell formation. They have clude poor circuroles as co-factors lation, poor nuin cellular develtrition, poor conopment and protrol of disease mote enzyme acMalnutrition processes, and intivity. has been shown adequate hydraIron is a cotion.28 factor in the hyto be a major factor drolyzation of the If a wound amino acids lypresents with inaffecting wound sine and proline, creased size or healing. which are essendepth the causes tial for collagen may be excess synthesis. Also, pressure, poor ciriron enhances culation, or infecleucocyte bacterial activity. tion.28 When a tunnel presents, it Zinc supplementation may may be caused by pressure over speed wound healing, but only in bony prominences, the presence of the presence of zinc deficiency. 24 a foreign body, or the presence of a deep infection. 28 Excess shearing Zinc acts as a co-factor for enzymes during cell proliferation. Copper is force to the wound area will reveal a co-factor in a number of enzymes undermining or ecchymosis of the involved in wound healing, the surrounding skin. most notable being lysyl oxidase, When a wound presents as dry which catalyzes the cross-linkage of or with rolled skin edges, the explacollagen.20 nation may be inadequate hydration. 28 White skin or macerated wound edges may be caused by exMedications cessive moisture, while increase in Medications are known to affect drainage or a change in nature of wound healing. Inhibition of drainage as in color from clear to wound healing has been reported purulent may be autolytic or enzywith the use of glucocorticosteroid, matic debridement or an infection anti-inflammatory drugs and antiof the wound bed.28 neoplastic agents. Exogenous glucocorticosteroids inhibit wound contraction, collagen synthesis, and Necrosis of the Wound Bed connective tissue formation. Both Necrosis of the wound bed may nonsteroidal anti-inflammatory be caused by ischemia and wound agents and antineoplastic agents edges that appear red, hot, tenhave been studied in animal moddered, and indurated may be exels to demonstrate impaired wound plained by inflammation due to exhealing.25-27 cess pressure or infection.28 Table 1 summarizes wound bed conditions and interventions that may be seFailure Causes lected by the podiatric physician to One of the key elements the treat the corresponding cause for a podiatric physician should master wound’s failure to thrive. when treating wounds of the lower Finally, essentially all facets of extremity is to recognize the most wound healing have been reported common signs involved when a to decrease with age. Decreases in wound does not thrive. In order to www.podiatrym.com n ng io ui at in uc nt Ed Co ical ed M Wound Care... wound healing processes that are directly related to increased age include: glucose metabolism, oxygen consumption, inflammatory cell infiltrate, macrophage function, fibroblast function, capillary growth, collagen remodeling, contraction rate, and re-epithelialization rate.29 The podiatric physician should advise elderly patients that even superficial wounds heal at a slower rate. Wound Types Wounds may be classified as acute or chronic.30,31 Risk factors associated with chronic wounds include excessive pressure, diabetes mellitus, poor circulation, immunodeficiency, and infection. The most common chronic, cutaneous wounds include venous leg ulcers, arterial leg ulcers, neuropathic ulcers, and pressure ulcers.10,28 Venous leg ulcers, in which the efficient return of blood to the heart is impeded by lost valve function in central veins, are the most common ulcers of the lower extremities. Venous leg ulcers can be quite large and usually occur on the medial side of the ankle. They always present as a dark-brown stain. The wound edges are shallow and diffuse. Venous ulcers produce large amounts of fluid (Figure 2).10,28 Arterial leg ulcers can occur on any part of the leg, but are commonly found below the ankle. Continued on page 188 Figure 2 JANUARY 2007 • PODIATRY MANAGEMENT 187 M C ed on ica tin l E ui du ng ca tio n Wound Care... Trauma is often a precipitating event. Usually, patients experience pain at rest and when the leg is elevated. These ulcers generally have well-defined borders, are dry or necrotic, and are deeper and smaller than venous ulcers. The wound floor is described as deep with a cliff edge.10,28 Diabetic Ulcers A diabetic foot ulcer is caused by neuropathy and vascular disease related to diabetes mellitus. These ulcers are usually small and deep with steep edges and are often sur- rounded by calluses. Callus often surrounds the ulcer floor. 28 The ulcer floor is often dry and necrotic with localized edema (Figure 3). Pressure Ulcers Pressure ulcers also called decubitus ulcers, bedsores, and pressure sores. They are lesions caused by unrelieved pressure, resulting in damage to underlying tissue. They occur almost exclusively on the tissue located over a bony prominence.10,28 Wound Assessment Assessment of any wound should begin with the extent of the wound, and include tissue level involved, the wound dimensions, and its effect on the patient.10,28,32 Each ulcer should be classified by wound morphology, severity, and location. Common terms used in connection with a healing wound include exudate, necrosis, slough, fistula, sinus tract, and tunneling 2,10,28 Exudute is material composed of serum, fibrin, and white blood cells that escape from blood vessels into a superficial lesion or area of inflammation. Necrosis is death of living tissue due to lost blood supply, corrosion, local injury, or burning. Slough is dead tissue that has Continued on page 189 TABLE 2 Wound Product Classes 188 CLASS TRADE NAMES PURPOSE PRECAUTIONS Hydrogel Amerigel Carrasyn gel Curasol gel Elta hydrogel Rehydrate wound bed Reduce pain Facilitate autolytic Debridement Intrasite gel Macerates Periwound area Some require Second dressing Pouches Hollister wound Draining collector Collect and contain Drainage Time-consuming Skin Sealants Allkare Protective Hollister skin gel Prep-site Sween prep Skin Protectant Avoid contact with Patient's eyes Skin Substitutes Apligraf Dermagraft Transcyte Support Wound Closure Tapes 3M Transpore Curity Standard Porous Durapore Surgical Micropore Tape 3M Sta-fix Secure Dressings Direct use on Open wounds Transparent Films Blisterfilm Carrafilm Comfeel Dermaview Opsite Polyskin II Tegraderm Facilitate autolytic Debridement Reduce friction May adhere to Some wounds Maceration PODIATRY MANAGEMENT • JANUARY 2007 www.podiatrym.com wounds anatomically by the tissue layers involved.10 Pressure ulcers are classified into separated from healthy tissue. four stages using criteria established A fistula is an abnormal pasby the National Pressure Ulcer Adsage leading from an abscess or visory Panel Consensus Develophollow organ to the body surface, ment Conference and the Wound permitting the passage of fluids or Ostomy and Continence Nurses secretions. A sinus tract is a narSociety.2,10,33 row, elongated path extending Staging classifrom a focus of fication may be suppuration to useful when seEssentially the skin’s surface lecting a wound all facets of wound and often discare product. charges pus. TunStage I ulcers inhealing have been neling is a term volve nonused to describe blanchable eryreported to tissue destruction thema of intact decrease with age. underlying intact skin with discolskin. Finally, the oration, warmth term wound buror hardness. Stage den is the extent II ulcers are suof the wound and its attributes, perficial lesions similar to abrawhile wound severity reflects sions, blisters, shallow craters with wound burden, host factors, and partial thickness skin loss involving environment.30,32 the epidermis, dermis, or both. Stage III ulcers are full-thickness, skin loss involving damage or Classification Systems necrosis to subcutaneous tissue that Several classification systems may extend to the underlying fasidentify wounds with regard to cia. It presents clinically as a deep stages. The podiatric physician crater with or without undermining should be familiar with the followadjacent tissue. Stage IV ulcers ining classification systems: Meggitt’s volve full-thickness, skin loss with surgical management of the diabetextensive destruction, tissue necroic foot, Wagner’s the dysvascular sis, and damage to muscle, tendon, foot, the University of Texas, San joint capsule, or bone. Stage IV Antonio classification, and the wounds frequently present with S(AD) SAD classification. tunneling characteristics and sinus tracts. Clinimetrics The podiatric physician must Wound Dressings then be able to apply clinimeterics The principle function of a to these classification systems to wound dressing is to provide an opensure that their validity can be timum healing environment. It is readily applied to clinical pracessential for the podiatric physician tice. 33,34 Staging systems identify to understand the primary goals of topically managing a wound which should include: keeping the local environment moist, keeping the wound clean from debris and bacteria, and preventing further disruption to the wound from trauma. Also, the podiatric physician must understand that no one wound care product is appropriate for all wounds. The choice of a wound dressing is dependent on the cause, presence of infection, wound type and size, stage of wound healing, cost, and patient acceptability.12 According to Lawrence,35 dressFigure 3 www.podiatrym.com n ng io ui at in uc nt Ed Co ical ed M Wound Care... ing materials should be sterile, strong, absorbent, protective, inexpensive, and conform to the contours of the body. A dressing should be reasonably strong, to provide mechanical protection to the wound, but not so rigid that the lower limb’s movement is impaired, or so abrasive that movement irritates the wound. It should be nontoxic and should not sensitize the skin. Further, a dressing material needs to be free of particulate or fibrous material that may shed into the wound. It needs to be easy to remove and not adhere to the wound. A dressing should be free of bacteria, preventing the wound from acquiring bacteria from the environment and preventing any wound bacteria from being dispersed into the environment. Dressings should be compatible with therapeutic agents that might be used with them. Finally, a dressing should have an acceptable appearance to patients, nursing staff, and others.36 Primary vs. Secondary All wound dressings can be classed as either primary or sec- Arterial leg ulcers can occur on any part of the leg, but are commonly found below the ankle. ondary. Primary dressings are placed directly over the wound.10,3640 They provide protection, support, absorption, prevent desiccation, infection, and serve as an adhesive base for the secondary dressing. Secondary dressings provide additional support, absorption, further protection, compression, and occlusion.10,36-40 Often the secondary dressing serves as a pressure dressing. Secondary dressings absorb moisture and exudate that are not Continued on page 190 JANUARY 2007 • PODIATRY MANAGEMENT 189 M C ed on ica tin l E ui du ng ca tio n Wound Care... absorbed by the primary dressing. The selection of materials for primary or secondary dressings is governed by the particular application. Goals of Topical Therapy Podiatric physicians should be familiar with the essential goals of topical therapy when selecting a product. These wound care products must provide adequate oxygen and circulation to the tissues, insulate and protect the healing wound, eliminate clinical infection by removing excess exudate from the wound, maintain a clean and moist environment, and obtain complete wound closure. There- Several classifications systems identify wounds with regard to stages. fore, an ideal wound care dressing promotes healing without toxicity by acting as a barrier between the wound and the environment. Sev- eral different types of products may be needed as the wound progresses through the stages of healing. There are numerous categories and classifications of wound dressing products. Table 2 presents wound dressings products and wound types.10,28,36-40 Alginates These products are produced from naturally occurring calcium and sodium salts of alginic acid found in a family of brown seaweed (Phaeophyceae). They are soft, nonwoven fibers twisted in a rope fashion or shaped in fibrous mats. AlgiContinued on page 191 TABLE 3 Dressings Considerations for the Lower Extremity Ulcers DIABETIC FOOT ULCERS DRESSING ARTERIAL LYMPHATIC VENOUS Aliginate Not Indicated Not Indicated Use for Copious Drainage Wet Ulcers Tunneling Ulcers Deep Ulcers Bleeding Ulcers Foam Protect Ulcer Use for dry gangrene Use for moisture with Revascularized Ulcer Protect Ulcer Absorb drainage Protect Ulcer Use under Compression Wet Ulcers Gauze Protect Ulcer Maintain wound environment for dry gangrene Use for absorption or as Padding Use for absorption Protect Ulcer Hydrocolliods Use for autolytic debribement Do not use on Ischemic Tissue Protect skin Promote Epithelialization Do not use withCopious Drainage or cellulitis Promote Granulation Pain Management Do not use with Copious Drainage Necrotic Ulcer Shallow Ulcer Hydrogel Use to Debride Use to maintain moist wound environment Use to Debride Pain Management Do not use with Copious Drainage Necrotic Ulcer Tunneling Ulcers Dry Ulcer Transparent Film Use after ulcer healed Use to protect fragile skin Not to be used in presents of cellulitis Not indicated 190 PODIATRY MANAGEMENT • JANUARY 2007 www.podiatrym.com n ng io ui at in uc nt Ed Co ical ed M Wound Care... Composites Foams Composites are manufactured Foam dressings are nates are rich in either mannuronic as a single product that combines manufactured as either a acid or guluronic acid; the relative the physical products of different polyurethane or silcone foam amount of each influence the dressing types. For example, one with either hydrophilic or hyamount of exuduate absorbed and product may include an absorptive drophobic properties. They transthe shape the dressing will retain. layer, a bacterial barrier, and a mit moisture vapor and oxygen and Alginates moisture-retentive provide thermal insulation to the conform to the property. Comwound bed. Foams are indicated for wound’s shape posites are used partial to full thickness wounds Alginates form and are approfor both partial with minimal to heavy amounts of priate for partial and full thickness drainage. A principle advantage is a soft gel and and full-thickwounds as either being non-adherent, which preness, moderately primary or secvents injury to the surrounding absorb up to 20 times to heavily drainondary dressings. skin. their weight of ing sinus tract, They are effective Another advantage of a foam cavity, or tunnel for wounds with product is its ability to contain exuexudate. wounds, with or moderate to date. Some foam products require a without infecheavy exudate, cover dressing and tape; others are tion. While in healthy granular waterproof with an adhesive border contact with the wounds, necrotic and may be used under compreswound, alginates form a soft gel tissue with slough or eschar, or any sion. They are not recommended and absorb up to 20 times their mixed wound. One disadvantage is for wounds with no exudate or weight of exudate. that their adhesive borders may wounds with dry eschar. Alignate dressings are primary limit their use on fragile skin. dressings and can be left in the Gauzes wound for up to seven days. A secEnzymatic Debriders These cotton products have a ondary dressing can be applied These products are proteolytic, relatively wide weave through over the alginate dressing to facilichemical agents that break down which new tissue can grow. Gauze tate absorbency. Major contraindidevitalized tissue. Enzymatic dedressings are manufactured in cations to their use are the presbriders are used as a non-surgical many forms. Impregnated gauze ence of dry eschar, third degree method of debridement for fullwith petrolatum prevents it from burns, and surgical implantation. thickness necrotic wounds, pressure adhering to the wound. Gauze can Disadvantages of using alginates ulcers, dermal ulbe used on draininclude possible dehydration of cers, and infected ing wounds, the wound bed, a foul odor from wounds. Their necrotic wounds, Enzymatic debriders the gel, and the need for a secprinciple disadand infected ondary dressing. vantage is that wounds and may are used as a they are inactivatbe used as packCleansers ed by soaps, deing materials for non-surgical method These solutions are indicated to tergents, acidic dead shape, tunof debridement be used on superficial, partial-thicksolutions, and nels, and sinus ness, and some full-thickness metallic ions. tracts. Their prifor full-thickness wounds. Their chemical properties Some enzymatic mary advantage is adjust wound pH and create a agents can damtheir widespread necrotic wounds, moist environment. These agents age healthy tisavailability and pressure ulcers, are not recommended for infected sue. cost effectiveness. wounds. Their disadvandermal ulcers, and Exudate tages include the Collagen Absorbers tendency to tear infected wounds. Collagen dressings stimulate This class of away new skin on cellular migration and contribute to products funcremoval and shed new tissue development. Collagen tions by absorblint on to the is a body protein that stimulates ing five times their weight of exuwound. Therefore, a non-adhering wound debridement. They are abdate. An exudate absorber conforms dressing should be applied first and sorbent, non-adherent, and conto the wound’s surface, thus elimithen gauze should be used as a secform to the wound’s surface. They nating dead space and maintaining ondary dressing. should not be used and not recoma moist wound environment. This mended for necrotic wounds. allows for an eschar to soften as Hydrocolloids Collagen is contraindicated in well as allow for slough to liquefy. Hydrocolloids are hydrophilic third degree burns. Their use is also They should be used on full thickcolloid particles (sodium contraindicated in patients with ness wounds with necrotic tissue caroboxymethlycellulose, gelatin, bovine product sensitivities. and moderate to heavy exudate. Continued on page 192 www.podiatrym.com JANUARY 2007 • PODIATRY MANAGEMENT 191 M C ed on ica tin l E ui du ng ca tio n Wound Care... pectin, elastomers, and adhesives) bound to polyurethane foams that are impermeable to bacteria and facilitate wound debridement. Cross-linkage of the material used influences the viscosity of the gel under the dressing. A new dressing should be applied when the accumulation of wound fluid causes separation of the dressing from the wound. They are occlusive and come in many sizes, shapes, and forms. Hydrocolloids should be used on superficial or partial thickness wounds with light to moderate exudate. They may be used under compression and may be left in place for three to seven days. Although they are comfortable to wear, particularly when placed on high friction sites, they may be difficult to remove. The principle disadvantage is their opaque nature, making wound evaluation difficult. They are contraindicated for use in full thickness wounds, infected wounds or in the presence of sinus tracts. Surrounding fragile skin may be torn with removal of this product. Patients must be warned of the rather malodorous characteristic of yellow-brown draining fluid under some of these dressings. Hydrogels Hydrogel products are non-adherent, water-based, or glycerinbased amorphous, cross-linked polymer gels. Due to their chemical nature and high water content (8099%), they are non-absorbent and therefore are not recommended for wounds with heavy exudates. Hydrogel dressings are complex lattices in which the dispersion medium is trapped. They are indicated to be used on light exudate, partial and full-thickness wounds with depth, burns, and tissue damage by radiation. Hydrogels can help reduce pain, decrease wound temperature, and reduce inflammation. These products soften and loosen necrotic tissue as well as fill wound dead space. If used alone, they do not keep bacteria out of the wound. They are not recommended for 192 wounds with moderate to heavy exudate or where there is evidence of gangrenous tissue that should be kept dry to reduce the risk of infection. Pouches Pouches are to be used on wounds that drain more than 50 cc. per day and wounds with highly excoriating exudate. These dressings do not need to be changed as often as other dressing types. They protect the surrounding skin and provide a means to measure wound exudate production during a fixed period of time. Their only disadvantage is that it may be time consuming to apply them. Skin Sealants These products are film barriers that create a plastic-like coating on Impregnated gauze with petrolatum prevents it from adhering to the wound. the skin that protects the injury from mechanical epidermal stripping or maceration. They are to be used on intact skin surrounding the wound. Skin sealants contain alcohol that may cause pain and denude skin. Skin Substitutes Skin substitutes are derived from human origin tissue or are bio-engineered. They are used to support wound closure and serve as a replacement for skin and surgical grafting. A bio-engineered skin substitute closely resembles human skin in structure, function, and handling; and may provide both epidermal and dermal components. They are indicated for the treatment of partial and full-thickness skin ulcers due to venous insufficiency of greater than one month’s duration, which have not adequately responded to conventional ulcer therapy. PODIATRY MANAGEMENT • JANUARY 2007 Skin substitutes are also indicated for the treatment of full thickness diabetic foot ulcers. The podiatric physician should check the expiration date to ensure product viability and follow manufacturer’s instructions for use and application. Tapes Tapes are used to secure wound care products, pouches, tubes, and drains in place when the surrounding skin is healthy. Their composition, widths, adhesive properties and hypoallergenic qualities are variable. Cloth or clear tape should be used where strength is needed; and paper tape when gentleness is required. Tape placement should be rotated with each dressing change to minimize skin irritation. Tapes may cause epidermal stripping if applied inappropriately or removed from fragile skin. Tapes do not stretch to accommodate swelling. Therapeutic Moisturizers Collectively these products include creams, gels, liquids, or ointment preparations used to soothe, soften and moisturize the skin. Moisturizers should be applied after cleansing with a gentle agent and when the skin is dry. The ingredients for these agents vary based each particular manufacturer’s formation generally containing water, humectants, emollients, and vitamins. Some products also may include an antimicrobial ingredient. Therapeutic moisturizers are the second step in the prevention of skin breakdown. The process consists of cleaning, moisturizing, and protecting the skin. Transparent Films Transparent films have either a sterile semi-permeable polyurethane membrane or a co-polymer membrane with a porous adhesive layer that allows for wound visualization. They are water-proof, permit oxygen and water vapor to cross the membrane barrier, and therefore are not absorbent. They are impermeable to bacteria and contaminants. Transparent films are indicated for partial thickness wounds, superContinued on page 193 www.podiatrym.com ficial burns, and skin graft donor sites. They retain moisture while facilitating autolysis, and do not require a secondary dressing. Films are very flexible and are good for wounds on difficult anatomical sites, particularly over joints. They are not recommended for use in infected wounds with moderate to heavy exudate or with fragile skin edges. Due to their highly adhesive nature, they are difficult to apply and may not stay in place on high friction areas. Untimely dressing removal can potentially strip away new skin growth. contaminate the wound. For this reason, an antibiotic ointment or cream should be used before any bandages are applied. A topical antimicrobial agent should inhibit pathogenic microorganisms in wounds without slowing the normal rate of tissue repair.98 n ng io ui at in uc nt Ed Co ical ed M Wound Care... polymyxin B may be combined with a quinolone and an antimycotic agent providing broad antimicrobial activity and faster healing rates.53 Alternative Treatment Selections The history of wound care is reNo Ideal Agent plete with examples of alternate The ideal topical antimicrobial practices. Numerous case reports in agent does not exist. Topical anthe literature, for timicrobial agents example, describe have the potential wound treatment to affect the Hydrogels can with various subrate of healing stances such as through a number help reduce pain, honey, sugar, ioof possible mechadine, and meat nisms. These posdecrease wound Topical Antimicrobial tenderizer. Podiasibilities include temperature, Educational Interventions tric physicians the antimicrobial An opportunity for the podiamay be faced effect of these and reduce tric physician to intervene on bewith patients agents, which inflammation. half of a patient’s wound healing who are demandalter the wound’s process and ensure a positive outing more inforenvironment and come is to clarify the appropriatemation, more opany other effect, ness for the use of a topical antibitions, and greater whether it be biootic on a wound during its healing. ability to participate in their treatchemical, metabolic, or physical Researchers have shown that a ment decisions. caused by the vehicles or the active wound heals faster and with less inOver time, people have innoagents themselves. By more effecflammation if it is allowed to heal vated with creative topical dresstively eradicating bacteria, topical without a scab. ings to treat wounds: aloe vera, antibiotics may produce a faster rate Normally, a wound left to run antacids, vegetable shortening, of healing in some cutaneous infecits course will form a scab. In this honey, baby powder, gentian viotions than a placebo or no treatenvironment, where a relative loss let, and golden seal, inappropriate ment.44-53 of hydration occurs, resistance to unmonitored applications of heat, Geronemus and associates comepidermal cell migration increases urea of chloroform, sugar and povipared four commonly used topical due to obstruction by dead and done-iodine, and the use of legend antimicrobial agents on the rate of crusty tissue. If the surface tissue is drugs off-label as wound healing re-epithelialization of clean wounds excessively dehydrated and has a agents.54-64 in white domestic pigs.45 thick wound crust or a scab, epiderNeomycin-Bacitracin-Polymixin Few of these treatment modalimal cells may B accelerated ties have beneficial properties, and have to burrow to healing by 25% there are no research studies to supa deeper plane bewhile its vehicle port their use in wound healing. neath the scab to accelerated healPodiatric physicians should educate Tape placement reach moist, live ing by only 9%; themselves about the myths about should be rotated cells where they when compared topical treatments for wounds and can migrate and with no treatapply evidence-based medicine to with each dressing perform their ment. Silver sulfadetermine if these wound care function.41-49 diazine also protreatment myths are valid. change to minimize duced a 28% inTherefore, the skin irritation. Aloe Vera crease, but the podiatric physirate was not sigThe effects of aloe vera on the cian must advise nificantly differskin has met with much controa patient to keep ent from the veversy. Historically, reports of its healing wounds hicle’s improvement of 21%. beneficial effects are found in the covered despite the long term myth Mertz et al., demonstrated that writings of Hippocrates and of leaving wounds open. A wound mupirocin accelerated healing by Alexander the Great. In most should be kept covered with a ban8% and its vehicle retarded healing cases, the distribution of aloe dage to ensure a moist healing enby 5% compared to wounds exproducts often are accompanied vironment; however, the same with misinformation and claims posed to air.50 moist environment that encourages that promote skepticism. healing also encourages the overBoyce and colleagues suggest growth of any bacteria that may that neomycin, mupirocin, and Continued on page 194 www.podiatrym.com JANUARY 2007 • PODIATRY MANAGEMENT 193 M C ed on ica tin l E ui du ng ca tio n Wound Care... gram-positive organisms. Its antibiReports of the use of a comotic properties are attributed to its pounded mixture of sugar and low pH, a thermolabile substance povidone-iodine have been cited to Antacid Products called inhibine, and its hygroscopic show enhanced wound healing in The topical application of an properties. 63 Honey also contains both animal and human subantacid product to protect a wound jects.61,62 Knutson et al., documenthas been utilized for many years.55 enzymes such as catalase which aid 63 in the healing properties. ed the use of sugar and povidoneThe pH of the skin is acidic, acting iodine to enhance wound healing as a natural antibiotic and preventMolan summarized the cliniover a five year period when treating the growth of bacteria normally cally-based evidence supporting ing 605 patients found residing on the skin. Applythe use of honey with wounds, ing an antacid to protect a wound as a wound dressburns, and ulcers and its surrounding skin will ining.64 This review The use of honey with granulated crease this acidic pH, thus allowing reported the findsugar and povibacteria to grow and increase the ings of 17 ranfor decubitus ulcers done-iodine. chance of infection. Also, the applidomized, conand burns has been Their compoundcation of an antacid to the wound trolled trials ined mixture was base or surrounding skin will dry volving 1965 pardocumented in the prepared in a out the wound and delay the healticipants, as well ratio of 3 to 4 ing process.54 as five clinical triliterature. parts sugar to 1 als of other forms part povidone-ioinvolving 97 parHoney dine ointment, ticipants treated The use of honey for decubitus with the addition of 60 to 80 ml of with honey. The wound types ulcers and burns has been docupovidone-iodine solution per treated with honey during these mented in the literature.56-60 Subrahkilogram. control trials were either superfimanyam reported that a total of Rapid healing ensued, due to a cial burns, partial thickness 104 cases of superficial burn inreduction in bacterial contaminawounds, moderate burns, third dejuries were studied to assess effition, rapid debridement of eschar, gree burns, chronic leg ulcers, ciency of honey as a dressing in probable nourishment of surface pressure ulcers, and surgical comparison with silver sulfadiazine cells, filling of defects with granulawounds.64 gauze dressing. In the 52 patients tion tissue, and covering of granutreated with honey, 91% of the These studies compared honey lation tissue with epithelium. These wounds were rendered sterile in to either silver sulfadiazine, amniinvestigators further discovered seven days. Of the 52 patients treatotic membrane, Vaseline gauze, an that the requirements for skin grafted with silver sulfadiazine, 7% occlusive dressing, mupirocin, ing and antibiotics were greatly reshowed control of infection in povidone-iodine, or a boiled potato duced, as were hospital costs for seven days. Of the wounds treated peel. 64 Molan comments on the wound care.62 with honey, 87% healed within 15 very large amount of evidence as days as compared to 10% in the silwell as the clinical observations ver sulfadiazine group. Allergy and demonstrating honey has signifiDeveloping a Wound Care side effects were not observed in cant anti-inflammatory activity.64 Product Formulary the group who There are many wound care This review was exposed to dressing products available for the presents a large the honey applipodiatric physician to select when body of evidence Transparent cation.58 treating a lower extremity wound; supporting the however, clear, robust evidence of use of honey as a S u b r a h films are indicated for the comparative effectiveness of wound dressing manyam also these products is limited. There is for a wide range compared the use partial thickness a lack of evidence from well-conof wounds beof honey impregwounds, superficial trolled, randomized trials evaluatcause its antibacnated gauze verus ing the clinical and cost-effectivet e r i a l a c t i v i t y polyurethane film burns, and skin graft ness of wound care products. On rapidly clears in(Opsite В® ) in the donor sites. the other hand, there is some relifection and protreatment of able clinical evidence on the mantects the wound, burns as a proagement of leg ulcers that the podand it provides a spective randomiatric physician can use when demoist healing ized study. He veloping a wound care product environment without the risk of demonstrated that honey impregformulary. bacterial growth occurring. Also, nated gauze dressing wounds The podiatric physician must honey rapidly debrides wounds showed earlier healing as compared begin the process of development and removes malodor, its anti-into Opsite В® (10.8 days versus 15.3 of a formulary by first reviewing flammatory activity reduces days).59 the literature of all wound care edema and exudates, and preHoney consists of simple sugars products available. Available revents or minimizes hypertrophic and is both sterile and inhibits scarring.64 growth of both gram-negative and Continued on page 195 194 PODIATRY MANAGEMENT • JANUARY 2007 www.podiatrym.com sources must be used in the most efficient way possible to avoid selecting products that may not meet the needs of the podiatric physician’s patients. Then a shortlist of two or three products from various wound care classification (depending on how they will be dispensed and stored) should be developed.65 The podiatric physician should evaluate each product from the list either by clinical or non-clinical means. 65 Effective clinical evaluation of a product relies on using expert opinions from the literature or from colleagues to ensure the product selected is the most appropriate one to represent a particular class of products. Once each product has been evaluated, a final product inclusion list should be formulated and published.65 Product Cost Product cost must play a role in formulating a wound care formulary.65,66 The price of products used in the treatment process is a relatively minor part of the overall cost.66 The podiatric physician should consider that the lowest priced product is not necessarily the most cost-effective choice because the dominant There is a lack of evidence from well-controlled, randomized trials evaluating the clinical and cost-effectiveness of wound care products. element of a product is the cost of the provider’s time. Other Considerations Other elements the podiatric physician should consider when formulating a list of products is to reflect upon patient acceptability, safety, ease of use, availability, and www.podiatrym.com type of storage required.65 The podiatric physician should not only use current compendiums to determine if clinical evidence is available for each product, but also The lowest priced product is not necessarily the most cost-effective choice because the dominant element of a product is the cost of the provider’s time. search out wound care resources on the Internet.67 Fikar and Delinois have complied a comprehensive list of URLs for Internet sites providing information on wound and ulcer care that the podiatric physician can utilize during the development of their wound care product formulary.67 Summary New products are being introduced to the healthcare market frequently and podiatric physicians should have a fundamental knowledge of their indications and the process of wound healing. Once they have mastered the principles of wound healing and have become familiar with each category of wound care products, they can have a profound effect as members of the wound care team. Numerous products exist, and at times it may be difficult to assess the most appropriate wound care product necessary to facilitate patient healing. The podiatric physician, as an active member of the wound care team, should assist in the selection of an appropriate dressing for a particular wound. Some variables to be considered by the podiatric physician when making this selection are the etiology of the wound, the amount of exudate present, the location of the wound, the presence of infection, the dressing’s cost, and the long- n ng io ui at in uc nt Ed Co ical ed M Wound Care... term goals set for the patient by the wound care team. The ability to assess the wound clinically and recommend an appropriate dressing is essential when providing podiatric care to patients with lower extremity wounds. в– References 1 Brigham PA, McLoughlin E. Burn incidence and medical care use in the United States: estimates, trends, and data sources. J Burn Care Rehabil 1996;17:95-107. 2 Treatment of pressure ulcers guideline panel (1994). Treatment of pressure ulcers. Clinical practice guidelines. (AHCPR Publication No 95-0652). Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. 3 Singer AJ, Clark RAF. Cutaneous wound healing. NEJM, 1999;341(10):738746. 4 Caldwell MD. Topical wound therapy-a historical perspective. J Trauma 1990;30(12):S116-22. 5 Forrest RD. Early history of wound treatment. J. Royal Soc. Med 1982; 75:198205. 6 Lister J. An address on the antiseptic management of wounds. Br. Med J 1893; 1:161-162;277;337. 7 Lister J. An address on the treatment of wounds. Lancet 1881; 2:863-866;901. 8 Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature 1962; No.4812. 293-294. 9 Bickers DR. Photosensitivity and other reactions to light. In Harrison’s Principles of Internal Medicine, 13th edition. (eds) Isselbacher KJ, Braunwald E, Wilson JD, et al. New York McGraw-Hill, 1994 pp 307-308. 10 Hess, CT. Nurse’s Clinical Guide: Wound Care. Springhouse, Springhouse Corp,1995; pp 1-14 & 74-81, 92-260. 11 Skin, Hair, and Nails. In Mosby’s Guide to physical examination 3rd edition. (eds) Seidel HM, Ball JW, Dains JE et al. T Louis, Mosby, 1995 pp 131-132. 12 Findlay, D. Modern dressings: what to use. Aust Fam Physician 1994; 23(5):824-839. 13 Hunt, TK. Basic principles of wound healing. J Trauma 1990; 30(12): S122-S128. 14 Schaffer CJ, Nanney LB. Cell biology of wound healing. Int Rev of Cytology 1996; 169:151-181. 15 Kirsner RS, Eaglstein WH. The wound healing process. Dermatol Clin 1993; 11(4): 629-639. 16 Telfer NR, Moy RL. Drug and nutrient aspects of wound healing. Dermatol Clin 1993; 11(4):729-737. 17 Irvin TT. Effects of malnutrition and Continued on page 196 JANUARY 2007 • PODIATRY MANAGEMENT 195 M C ed on ica tin l E ui du ng ca tio n Wound Care... hyperalimentation on wound healing. Surg Gynecol Obstet 1978; 146:3337. 18 Spanheimer R, Zlatev T, Umpierrez G, et al., Collagen production in fasted and food restricted rats: response to duration and severity of food deprivation. J Nutr 1991; 121:518-524. 19 Utley R. Nutritional factors associated with wound healing in the elderly. OstomyWound Management 1992; 38:22,24,26,27. 20 Levenson SM, Demetriou AA. Metabolic factors. In Cohen IK, Diegelmann RF, Lindblad WJ eds): Wound healing: Biochemical and clinical aspects. Philadelphia, WB Saunders 1992, pp. 248273. 21 Smith RJ, Wilmore DW: Glutamine nutrition and requirements. JPEN J Parenter Enteral Nutr 1990; 14: S94-S99. 22 Hayashi K, Frangieh G, Wolf G, et al: Expression of transforming growth factor-B in wound healing of vitamin A-deficient rat corneas. Invest Ophthalmol Vis Sci 1989; 30:239-247. 23 Pirani CL, Levenson SM. Effect of vitamin C deficiency on healed wounds. Proc Soc Exp Bio Med 1953; 82:95-99. 24 Haley JV. Zinc sulfate and wound healing. J Surg Res 1979; 27:168-174. 25 Min DI, Monaco AP. Complications associated with immunosuppressive therapy and their management. Pharmacotherapy 1991; 11(5):119S-125S. 26 Dahners LE, Gilbert JA, Lester GE, et al. The effect of a nonsteroidal antiinflammatory drug on healing of ligaments. Am J Sports Med 1988; 16(6):641-646. 27 Laing EJ. Problems in wound healing associated with chemotherapy and radiation therapy. Probl Vet Med 1990; 2:433-441. 28 Schilling McCann JA, Wound care made incredibility easy. Lippincott Williams and Wilkins Co, Philadelphia PA 2003 71-213. 29 Gerstein AD, Phillips TJ, Rogers GS, et al. Wound healing and aging. Dermatol Clin 1993; 11(4):749-757. 30 Lazarus GS, Cooper DM, Knighton DR, et al., Definitions and guidelines for assessment of wounds and evaluation of healing. Arch Dermatol 1994; 130:489493. 31 Eaglstein WH, Falanga V. Chronic wounds. Surg Clin North Am 1997; 77(3):689-700. 32 Stotts NA, Cavanaugh CE. Assessing the patient with a wound. Home Healthcare Nurse 1999; 17(1):27-36. 33 National Pressure Ulcer Advisory Panel. Pressure ulcers prevalence, cost and risk assessment: consensus development conference statement. Decubitus 1989; 2(2):24-28. 34 Smith RG. Validation of Wagner’s 196 Classification: A literature Review. OstomyWound Management 2003 49(1) 5462. 35 Lawrence JC. What materials for dressings ? Injury 1981; 13: 500-512. 36 Jones V, Grey J, and Harding KG. ABC of wound healing: Wound Dressings. British Medical Journal 2006; 332: 777780. 37 Smith RG. Wound Care Product Selection. US Pharmacists April 2003 48 (4) 107-120. 38 Patient conditions. In: wound source-the kestrel wound product sourcebook 2006; Motta G, (ed) 9TH ed. Bristol Vermont, 35-48. 39 Baranoski S. Wound Dressings: challenging decisions. Home Healthcare Nurse 1999; 17(1):19-26. 40 Choate CS. Wound dressings: a comparison of classes and their principles of use. JAPMA 1994; 84(9): 463-469. 41 Dyson M, Young SR, Hart J, et al. Comparison of the effects of moist and dry conditions on the process of angiogenesis during dermal repair. J Invest Dermatol 1992; 99 (6):729-733. 42 Heifetz CJ, Lawrence MS, Richards FO. Comparison of wound healing with and without dressings. Arch Surg 1952; 65: 746-751. 43 Whittington K. Debunking wound care myths. RN 1995;(8):32-33. 44 Mack RM, Cantrell JR. Quantitative studies of the bacterial flora of open skin wounds: the effect of topical antibiotics. Ann of Surg 1967; 166(6):886-895. 45 Geronemus RG, Mertz PM, Eaglstein WH. Wound Healing: the effects of topical antimicrobial agents. Dermatol 1979;115:1311-1314. 46 Smoot EC, Kucan JO, Roth A, et al. In vitro toxicity testing for antibacterials against human keratinocytes. Plast Reconstr Surg 1991; 87(5): 917-924. 47 Cooper ML, Laxer JA, Hansbrough JF, et al. The cytotoxic effects of commonly used topical antimicrobial agents on human fibroblasts and keratinocytes. J Trauma 1991; 31(6):775-784. 48 Rodeheaver G. Controversies in topical wound management. Wounds 1989; 19-27. 49 Hirschmann JV. Topical antibiotics in dermatology. Arch Dermatol 1988; 124:1691-1700. 50 Mertz PM, Dunlop BW, Eaglstein WH: The effects of Bactroban ointment on epidermal wound healing in partial thickness wounds, in Dobson R, Leyden JJ, Nobel WC, et al. (eds) Bactroban (Mupirocin). Princeton, NJ Excerpta Medica, 1985, pp 211-215. 51 Lineaweaver W, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg 1985;120: 267-270. 52 McCauley L, Hugo AL, Pelligrini V, et al. In vitro toxicity of topical antimicrobial agents to human fibroblast. J Surg Res PODIATRY MANAGEMENT • JANUARY 2007 1989; 46(3):267-274. 53 Boyce ST, Warden GD, Holder IA. Noncytotoxic combinations of topical antimicrobial agents for use with cultures skin substitutes. Antimicrob. Agents Chemother 1995; 39(6):1324-1327. 54 Whittington K. Debunking wound care myths. RN 1995; (8) 32-33. 55 Mikulic MA. Treatment of pressure ulcers. Am J Nurs 1980; 80:1125-1128. 56 Cuzzell JZ. Wound care forum, readers’ remedies for pressure sores. Am J Nurs 1986; (8): 923-924. 57 Blomfield R. Honey for decubitus ulcers.(letter) JAMA 1973; 224(6):905. 58 Subrahmanyam M. Topical application of honey in treatment of burns. Br J Surg 1991;78:497-498. 59 Subrahmanyam M. Honey impregnated gauze versus polyurethane film (Opsite R) in the treatment of burns-a prospective randomized study. Br J Surg 1993;46:322-323. 60 Bergman A, Yanai J, Weiss J, et al. Acceleration of wound healing by topical application of honey: an animal model. Am J Surg 1983; 145:374-376. 61 Archer HG, Barnett S, Irving S, et al. A controlled model of moist wound healing: comparison between semi-permeable film, antiseptics and sugar paste. J Exp Path 1990; 71:155-170. 62 Knutson RA, Merbitz LA, Creekmore MA, et al. Use of sugar and povidone-iodine to enhance wound healing: five years experience. S Med J 1981; 74(11):1329-1335. 63 White JW, Subers MH, Schepartz AI. The identification of inhibine, the antibacterial factor in honey, as hydrogen peroxide and its orgin in a honey glucose-oxidase system. Biochem. Biophys. Acta 1963; 73:57-70. 64 Molan PC. The evidence supporting the use honey as a wound dressing. Lower extremity wounds 5(1) 2006 40-54. 65 Preece J. Development of a woundmanagement formulary for use in clinical practice. Professional Nurse 2004 20 (3) 2729. 66 Posnett J. Making cost effectiveness the bassis of product selection. J of Wound Care 2006 15 (1) S14-S15. 67 Fikar CR and Delinosi BD. Woundcare resources on the Internet: a second update. JAPMA 2006 96 (3) 264-268. Dr. Smith is in private practice in Ormond Beach, Florida and is a Fellow of the American Professional Wound Care Association. His E-mail is Robert. Smith@FHMD.org. www.podiatrym.com See answer sheet on page 199. 1) All the following products function as skin substitutes to support wound closure, except A) ApilgrafВ® B) DermagraftВ® C) Collagenase SantylВ® D) TranscyteВ® 2) The podiatric physician must begin the process of development of a wound care product formulary by first A) Creating a long list of 300 to 500 products from one wound care class. B) Not evaluating any wound care products by clinical or nonclinical means. C) Purchasing an entire line of products from several manufacturers, regardless of cost. D) Reviewing the literature of all wound care products available. 3) Which statement regarding nutrition and the wound healing process is true? A) Glutamine has a minor to non-active role in many metabolic pathways. B) Vitamin C is a vital co-factor in formation of hydroxycarbolic acid residues in mini-collagen. C) Iron peroxide is a co-factor in hydrolyzation of amino-acids glutamine and serine. D) Zinc acts as a co-factor for enzymes during cell proliferation 4) With regard to the National Pressure Ulcer Staging System, which statement is correct? A) Stage one is a superficial lesion of full thickness depth. B) Stage three lesions may extend to underlying fascia structures. C) Stage two lesions are nonblanchable lesions. D) Stage five lesions result in entire foot amputations. 5) Which statement is correct with regard to wound care products? A) The principle function of a wound dressing is to provide an optimum healing environment. www.podiatrym.com B) The most expensive product is always the most appropriate product. C) Wounds should be allowed to dry out, and dressing should be avoided until the scar is present. D) There is no benefit for the podiatric physician to develop a wound care product formulary. 6) A 46 year old male diabetic patient presents with a deep, wet, tunneling foot ulcers. Please select the most appropriate dressing with the correctly matched class for this patient? A) Scarlet Red Ointment : Enzymatic Debrider B) Lyofoam : Cleanser C) Accuzyme : Composites D) Sorbsan : Alginates 7) Identify the true statement about the following wound care products. A) Alginates form a soft gel and absorb up to 20 times their weight in exudate. B) Enzymatic debriders are used as surgical-sharp methods of debridement. C) Foams are recommended for non-draining wounds. D) Cleansers are recommended for infected wounds. 8) Which statement is not correct concerning wound care products ? A) Enzymatic debriders are inactivated by soap detergents. B) Foams are described as being semipermeable, with either hydrophilic or hydrophobic properties. C) Hydrocolloids are described as being hydrophillic colloid particles bound to polyurethane foam. D) Alginates are recommended for both arterial and lymphatic lower extremity ulcers 9) Select the wound care product that is correctly matched with its class. A) Micropore : Hydrocolloids B) Sween Prep : Skin Sealant C) OpSite : Hydrocolloids D) Xerofoam Gauze: Pouches n ng io ui at in uc nt Ed Co ical ed M E X A M I N A T I O N 10) Which statement is true concerning Hydrogel products? A) Hydrogels cause increased pain at the wound site. B) Hydrogels can be left in place for periods of one to three months without being examined. C) Hydrogels are not recommended for wounds with moderate to heavy exudates. D) Hydrogels often harden and lead to wound necrosis. 11) Identify the false statement concerning wound care products. A) Tapes do not stretch to accommodate swelling. B) Transparent films have semipermeable membranes either of polyurethane or co-polymer. C) Skin sealants create a plasticlike coating on the skin. D) Patients should not be warned of the rather malodorous characteristic of yellowbrown draining fluid under some of hydrocolloid dressings. 12) Identify the correct statement concerning honey as a wound care product. A) Inhibine is a thermolabile substance in honey responsible for its antibiotic properties. B) Honey has not been utilized as a topical wound care dressing product. C) Honey consists of complex sugars that inhibit fungal and yeast organisms only. D) Honey contains catalase, which does not aid in wound healing. 13) Which of the following statements regarding alternative approaches to wound care is supported by clinical study? A) Antacids, when applied to the skin, act as natural antibiotics decreasing bacterial growth. B) Literature reports identify that a compounded mixture of sugar and povidone-iodine facilitates enhancing wound healing in Continued on page 198 JANUARY 2007 • PODIATRY MANAGEMENT 197 M C ed on ica tin l E ui du ng ca tio n E X A M I N A T I O N (cont’d) both animals and human subjects. C) Topical applied heat is always indicated to dry up a wound bed to remove exudate. D) Aloe vera is universally accepted as a topical wound product. 14) Which wound care product selection is correctly matched with its appropriate ulcer type? A) Transparent Film: Venous Ulcer B) Alginate: Arterial Ulcer C) Hydrogel: Venous with Copious Drainage D) Foam: Arterial Revascular Ulcer 15) Which wound product is correctly matched with its most appropriate purpose (indication)? A) Tapes: Secure dressings B) Gauze: Rehydrate wound beds C) Enzyme Debriders : To secure wound sites D) Hydrocolloids : Non-surgical method of debridement 16) All of the following products inactivate enzymatic debriders, except? A) Metallic ions B) Acidic solution C) Water D) Soaps 17) According to Lawrence, dressing materials should possess all the following qualities, except: A) Protective B) Sterile and strong C) Inexpensive D) Nonconforming 18) Findlay subdivides wound healing into how many distinct phases? A) three B) four C) five D) six 19) Identify the wound care product that is not indicated for patients allergic or sensitive to bovine products? A) Algicell B) Carrafilm C) Amerigel D) Collagen 20) Which of the following is not one of the phases of wound healing? A) Proliferative B) Maturation C) Inflammatory D) Transition See answer sheet on page 199. 198 PODIATRY MANAGEMENT PM’s CPME Program Welcome to the innovative Continuing Education Program brought to you by Podiatry Management Magazine. Our journal has been approved as a sponsor of Continuing Medical Education by the Council on Podiatric Medical Education. Now it’s even easier and more convenient to enroll in PM’s CE program! You can now enroll at any time during the year and submit eligible exams at any time during your enrollment period. PM enrollees are entitled to submit ten exams published during their consecutive, twelve–month enrollment period. Your enrollment period begins with the month payment is received. For example, if your payment is received on September 1, 2006, your enrollment is valid through August 31, 2007. If you’re not enrolled, you may also submit any exam(s) published in PM magazine within the past twelve months. CME articles and examination questions from past issues of Podiatry Management can be found on the Internet at http://www.podiatrym.com/cme. Each lesson is approved for 1.5 hours continuing education contact hours. Please read the testing, grading and payment instructions to decide which method of participation is best for you. Please call (631) 563-1604 if you have any questions. A personal operator will be happy to assist you. Each of the 10 lessons will count as 1.5 credits; thus a maximum of 15 CME credits may be earned during any 12-month period. You may select any 10 in a 24-month period. The Podiatry Management Magazine CME program is approved by the Council on Podiatric Education in all states where credits in instructional media are accepted. This article is approved for 1.5 Continuing Education Contact Hours (or 0.15 CEU’s) for each examination successfully completed. Home Study CME credits now accepted in Pennsylvania www.podiatrym.com Note: If you are mailing your answer sheet, you must complete all info. on the front and back of this page and mail with your credit card information to: Podiatry Management, P.O. Box 490, East Islip, NY 11730. TESTING, GRADING AND PAYMENT INSTRUCTIONS (1) Each participant achieving a passing grade of 70% or higher on any examination will receive an official computer form stating the number of CE credits earned. This form should be safeguarded and may be used as documentation of credits earned. (2) Participants receiving a failing grade on any exam will be notified and permitted to take one re-examination at no extra cost. (3) All answers should be recorded on the answer form below. For each question, decide which choice is the best answer, and circle the letter representing your choice. (4) Complete all other information on the front and back of this page. (5) Choose one out of the 3 options for testgrading: mail-in, fax, or phone. To select the type of service that best suits your needs, please read the following section, “Test Grading Options”. TEST GRADING OPTIONS Mail-In Grading To receive your CME certificate, complete all information and mail with your credit card information to: Podiatry Management P.O. Box 490, East Islip, NY 11730 There is no charge for the mail-in service if you have already enrolled in the annual exam CPME program, and we receive this n ng io ui at in uc nt Ed Co ical ed M вњ„ Enrollment/Testing Information and Answer Sheet exam during your current enrollment period. If you are not enrolled, please send $20.00 per exam, or $139 to cover all 10 exams (thus saving $61* over the cost of 10 individual exam fees). Facsimile Grading To receive your CPME certificate, complete all information and fax 24 hours a day to 1-631-563-1907. Your CPME certificate will be dated and mailed within 48 hours. This service is available for $2.50 per exam if you are currently enrolled in the annual 10-exam CPME program (and this exam falls within your enrollment period), and can be charged to your Visa, MasterCard, or American Express. If you are not enrolled in the annual 10-exam CPME program, the fee is $20 per exam. Phone-In Grading You may also complete your exam by using the toll-free service. Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday through Friday. Your CPME certificate will be dated the same day you call and mailed within 48 hours. There is a $2.50 charge for this service if you are currently enrolled in the annual 10-exam CPME program (and this exam falls within your enrollment period), and this fee can be charged to your Visa, Mastercard, American Express, or Discover. If you are not currently enrolled, the fee is $20 per exam. When you call, please have ready: 1. Program number (Month and Year) 2. The answers to the test 3. Your social security number 4. Credit card information In the event you require additional CPME information, please contact PMS, Inc., at 1-631-563-1604. ENROLLMENT FORM & ANSWER SHEET Please print clearly...Certificate will be issued from information below. Name _______________________________________________________________________Soc. Sec. #______________________________ Please Print: FIRST MI LAST Address_____________________________________________________________________________________________________________ City__________________________________________________State_______________________Zip________________________________ Charge to: _____Visa _____ MasterCard _____ American Express Card #________________________________________________Exp. Date____________________ Note: Credit card is the only method of payment. Checks are no longer accepted. Signature__________________________________Soc. Sec.#______________________Daytime Phone_____________________________ State License(s)___________________________Is this a new address? Yes________ No________ Check one: ______ I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______ I am not enrolled. Enclosed is my credit card information. Please charge my credit card $20.00 for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______ I am not enrolled and I wish to enroll for 10 courses at $139.00 (thus saving me $61 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone. Over, please 199 M C ed on ica tin l E ui du ng ca tio n вњ„ ENROLLMENT FORM & ANSWER SHEET (cont’d) EXAM #1/07 Selecting Wound Care Products (R. Smith) Circle: 1. A B C D 11. A B C D 2. A B C D 12. A B C D 3. A B C D 13. A B C D 4. A B C D 14. A B C D 5. A B C D 15. A B C D 6. A B C D 16. A B C D 7. A B C D 17. A B C D 8. A B C D 18. A B C D 9. A B C D 19. A B C D 10. A B C D 20. A B C D LESSON EVALUATION Please indicate the date you completed this exam _____________________________ How much time did it take you to complete the lesson? ______ hours ______minutes How well did this lesson achieve its educational objectives? _______Very well ________Somewhat _________Well __________Not at all What overall grade would you assign this lesson? A B C D Degree____________________________ Additional comments and suggestions for future exams: __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ __________________________________________________ 200 PODIATRY MANAGEMENT • JANUARY 2007 www.podiatrym.com
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