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Wound Care and Dressings

Back to Basics

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This is part of our back to basics series on wound care and dressings. Great for medical students and learners rotating on plastic surgery.

Podcast Notes

Evaluating Wounds

  • Granulation tissue : beefy red tissue that bleeds which is a sign of healing
  • Fibrinous tissue: white or yellow tissue that is non-healthy
  • Eschar: black rind like a big scab
  • Things to look for
    • Size of the wound
    • Depth
    • What is at the base – exposed bone, vessels, hardware, subcutaneous fat?
    • How much fluid is the wound putting out?
    • Are there signs of infection? (ex: Purulent fluid)
    • Appearance of the surrounding tissue

The Wound Vac

  • Wound vac = Sponge + seal (plastic tape) + suction  negative pressure wound therapy
  • Primary Functions
    • Increases wound healing
    • Promoting accelerated formation of granulation tissue
    • Removes fluid from wound while maintaining moist environment
    • Helps contract the wound by bringing edges together
  • Suction – Pressure Settings
    • continuous or intermittent
    • – 125 mmHg normally or lighter setting – 75 mmHg
      • In a sensitive area you can opt for the lighter setting
    • Some studies have showed that intermittent pressure can lead to better granulation tissue formation however this is painful for patients
  • Sponge Types
    • Black and white sponge – white sponge can be less traumatic in sensitive areas
  • Other types of vacs
    • Irrigation-capable vacs, can infiltrate with antibiotic fluids
    • Location specific vacs – abdominal or incisional vacs
  • Placement of the Wound Vac
    • Sponge / foam preparation
      • Cut into the size and shape of the wound so it does NOT overly the skin
      • Use shears or if in the OR a 10 blade to customize sponge
      • If you have a large wound you CAN put multiple sponges together as long as they are attached (for ex: with staples) however be sure to write on the tape how many pieces of foam/sponge are in the wound
    • Tape
      • The tape should cover the surrounding skin + the entire wound
      • Follow the numbering system to adhere the tape
    • Wound Tunneling and Bridging
      • Tunneling : communication to a deeper level in a wound, make sure you use one continuous sponge piece
      • Bridging: multiple wounds close in proximity can be connected and attached to 1 wound vac (2 lily pads connected to 1 machine)
      • Y-connectors: help connect two wounds and still only use 1 wound vac
    • When to use wound vacs
      • 1) Time
        • Waiting for final pathology or additional planning from a multi-disciplinary team – keeps the wound sterile and gives time to stage reconstruction
      • 2) Shrinking the wound
        • May not have exposed critical structures but can help make the wound smaller for a better later outcome
      • 3) Great dressing for patients to go home with (3x a week)
      • 4) Bolstering skin grafts
    • When to NOT use wound vacs
      • Infection
      • Exposed critical structures
      • Obvious malignancy
      • Necrotic tissue
      • Non-enteric or non explored fistula
    • Troubleshooting and Tips
      • Getting a good seal
        • Avoid rippling in the adhesive
        • Make sure surrounding skin is as dry as possible for adhesive to stick
        • Use of liquid adhesives like mastisol to ensure seal
        • Cutting a good sized hole in the sponge for the suction or “lily pad” to adhere to (avoid making a small slit as that can lead to coagulation)
      • Dealing with a beeping wound vac
        • Things to ask
          • Does the machine say leak or blockage?
          • Have you turned the vac on and off?
          • If leak, have you put additional adhesives like tegaderms on it?
        • More Tips
          • Ostomy paste and put it in crevices
          • If blockage, replace lily pad

Dressings

  • Gauze 4×4, 4×8, 2×2 – square single wrapped
  • Telfa – non adherent gauze; can put antibiotic or moisturizing ointment beneath it
  • Adaptic and xeroform – fine meshed, silicone, Vaseline coated gauzes
  • Abdominal pads (ABDs) – absorbent large pads
  • Rolls of gauze – Kerlix is thicker, more absorbent and Kling is finer smaller used for hand
  • Bias – yellow fabric wrap; here we use it for wrapping splints, others use coban or ace
  • Coban – has elasticity and is self adherent, careful of the compression it can create
  • Web roll & cast padding – rips easier, web roll is fluffy, has waffle pattern
  • Tegaderm – adhesive occlusive dressings; don’t stretch and place down (can blister which is often confused with allergy) ; alternative is Opsite IV3000
  • Silk tape, paper tape, med pore tape, foam tape
  • Antibiotic ointment
  • Nugauze – thin packing strips
  • Mepilex lite foam – foam dressing on an incision
  • Mepilex border – has the adhesive border

 

Other dressing changes

  • Soak and packing (2-3x a day)
    • packing to stent the wound open and allow drainage, changing allow for removal of residual drainage
    • soaking in betadine or peroxide and saline –cleaning of the wound
  • Pre-medicating patients is important prior to dressing changes
  • Adhesive removing spray

 

~Student tips~

  • Things to keep in your white coat
    • Trauma shears, Roll of tape, gauze, q-tips, kerlix, small packing strips (nugauze), a few abdominal pads (ABDs), suture removal kit, antibiotic ointment

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