Wound Care article

[cougarnurse]

From ICT. A bit old, but still appropriate: Wound Care

Gerald Lazarus, MD, professor of dermatology and director of the Johns Hopkins Wound Center, says that it’s important to address the whole patient. Accurate diagnosis is first and foremost, he points out. “You may say it’s a venous ulcer, because the veins are shot and there’s edema, but they may also have arterial disease.”

It can be easy to misdiagnose the cause of an ulcer; one 20-year old female from Bermuda presented with venous ulcers, but had systemic lupus erythematosus. “One must consider, ‘Is there a serious underlying disease?’” Lazarus says.

“A key issue in wounds is that all wounds contain bacteria. We have our chronic difficulty in deciding if the wound is infected — trying to decide if bacteria are pertinent. A swab from the middle of a filthy wound is useless. We take tissue at the rim of the ulcer, submit it to the lab where it is ground and cultured, and most of the time we have a pretty reasonable idea of what we’re looking for,” he says. “With the emergence of resistance, it’s critical to ensure you have the right organism before you start throwing antibiotics at it. Gentamycin cream basically breeds resistance. Many topical antibiotics will cause contact dermatitis around the wound and that slows wound healing.”

Not only that, but the wound may become redder and result in the addition of some other treatment, because healthcare workers assume the inflammation is from an infection. “Is it in- flamed from infection, from the underlying disease, or because of an allergy to the medicine? The most common allergen in the United States is Neosporin, causing contact dermatitis. Bacitracin is up to No. 6 or No. 7,” he observes.

“The promiscuous use of oral and topical antibiotics is inappropriate, because what you’re doing is selecting for resistant organisms. You do not give antibiotics indiscriminately by mouth or vein until you know what the organism is. A number of topical drugs will not do the trick because the patient may become allergic to them, or there may be penetration problems. You’re asking a lot of a topical prep to go through a necrotic bucket of dead tissue to get to the bugs at the bottom. There must also be adequate debridement. Get the necrotic tissue out of there; otherwise it doesn’t heal,” Lazarus says.

If a wound is chronic, one method is to make it acute to restart the healing process. Get a good “base,” he recommends, debriding all dead tissue, thereby reducing it to an acute wound, and allow the healing process to begin.

“The care of wounds is in its clinical infancy,” Lazarus observes. But the basics have been established. “Look for underlying disease, quantify ability of infection, clearly debride, and keep the wound moist and treat with adequate doses of antibiotics for significant organisms,” he concludes.