New advancements bring wound care into the 21st century. Cut yourself at home with a kitchen knife, and you might wash it with hot soapy water, put on some antibiotic cream and bandage it. In many cases, severe pressure or surgical wounds are treated by certified wound care experts with the same clean-debride-bandage procedure. However, recent technological advancements coupled with new reimbursement approvals from Medicare has brought wound care technology into the 21st century. Here are a few of your options.
Diathermy
Clinical research has long supported the efficacy of warmth in wound healing. As a result, many wound care products capitalize on the healing powers of heat. Short-wave pulsed diathermy induces an electrical current in the tissues, which produces an electromagnetic field to promote new tissue growth in the wound bed, explains Carrie Sussman, PT, a writer, lecturer and wound care consultant in Torrance, Calif. Evidence has shown that induced electrical current is useful for treating large and painful wounds, such as those from surgery. Electrical Simulation
Using electrical stimulation to promote wound healing is backed by enough clinical evidence that it's moved from adjunctive therapy to primary care in many areas, such as pressure ulcers, diabetic ulcers and leg ulcers, Sussman says. Health care providers have found e-stim helpful in pain management, destruction of bacteria and new tissue growth. Pulsed current inhibits small myelinated fibers that block the pain sensation. High-volt pulsed monophasic current — for many years the primary type of e-stim used in wound care — remains a safe and effective alternative, Sussman says, adding that recent studies examining biphasic current (TENS) have shown promise as well. "Evidence seems to indicate that monophasic seems better for wound contraction to reduce surface area," she says. "Biphasic [is superior] for granulation tissue production to close deeper wounds." Although many clinicians incorporate e-stim only after more traditional techniques fail to achieve results, it remains an inexpensive modality that requires only a small e-stim unit and electrodes that can be fashioned out of aluminum foil. Debridement
Aside from traditional sharp debridement — the use of scalpels, scissors, and tweezers to remove devitalized tissue — there are a number of debridement options. They are broken down into three subgroups: autolytic (allowing eschar to naturally self-digest through enzymes present in wound fluids, most ideal for pressure sores, venous disease ulcers and arterial ischemic ulcers); enzymatic (the application of enzymatic ointment to break down dead tissue, also helpful in the above wound types), and mechanical (using physical means such as wound irrigation, vacuum pump and whirlpool to remove contaminated tissue.)1 What follows is a brief look into these forms of mechanical debridement. Wound Irrigation
Scott Newton, PT, CWS, uses wound irrigation to clean almost all wounds he sees. "Irrigation is often the easiest, most cost-effective means of wound care available to us," says Newton, director of physical rehab at Hillside Hospital, Pulaski, TN. While a wide range of irrigation units are available to ensure accurate and steady flow, from spring-loaded to battery-operated to ultra-expensive computerized models, Newton has found the best outcomes with a simple 30mm syringe coupled with a 20-gauge soft angiocatheter tip. Not only does this generate the correct water pressure to remove bacteria and debris, but patients can remain in a comfortable, independent position during treatment. In cases of severe infection, you can include additives with the normal saline solution to kill bacteria, Newton explains. But because these additives will also kill healthy tissue, Newton limits this phase of treatment to a few days. Another strength of wound irrigation is its ability to be combined with other methods. For patients with a low pain threshold, Newton will set the e-stim unit on a setting to block pain, and place it above the wound while he irrigates. Whirlpool
A final form of debridement takes place in leg tanks, arm tanks, body tanks or Hubbard tanks. Whirlpool jets remove debris from wounds while killing bacteria. New evidence has shown that whirlpool therapy isn't harmful to granulating wounds, as was originally thought, Sussman says, and can be used to remove necrotic tissue. But whirlpool therapy isn't generally the most effective means for treating wounds, Newton says. Some downsides exist, such as the need to place the patient in a dependent position. "For instance, if you're dealing with a venous insufficiency ulcer, and you have to suspend the patient for 10 to 15 minutes during treatment, you're almost defeating the purpose," Newton said. For this reason, he added, many health care providers use whirlpools only occasionally, and are beginning to move away from this type of therapy and into other tested methods, such as irrigation. Whirlpool therapy should be followed by a clean water rinse to remove debris, Sussman says. Dressings
New on the market is a fibrous fleece dressing for difficult wounds. Made of a biopolymer that liberates more hyaluronic acid to the moist wound-healing environment than would be biologically possible under normal healing conditions, the dressing creates a vital, moist healing setting by interacting with wound exudate. The dressing is intended for use on difficult-to-heal wounds such as diabetic ulcers, leg ulcers and pressure ulcers. A dry wound dressing is made from small intestinal submucosa, a naturally occurring extracellular matrix that provides a natural environment for wound management. The device was designed for the management of partial and full-thickness skin injuries, including diabetic, venous and pressure ulcers, as well as abrasions, lacerations and surgical wounds. Intended for one-time use, the sheets are available in 10 or 20 cm lengths, and fenestrated and non-fenestrated configurations. The use of thermal energy from infrared radiant heat sources to treat chronic human wounds has decreased during the past 25 years, due largely to the widespread use of moisture-retentive dressings. Reference 1. Brown, P., et al. (2001). Quick reference to wound care. Gaithersburg, MD: Aspen.
Jonathan Bassett is on staff at ADVANCE. |