Wound Care and Healing – PharmaTopo™

Stuart R. Gallant, MD, PhD

CAVEAT: THIS POST INCLUDES PHOTOGRAPHS OF TISSUE INJURIES AND MAY CAUSE SOME READERS DISCOMFORT.

An 81-year-old, retired accountant is on a walk with friends. He overestimates his agility crossing a rickety bridge over a stream and ends up waist deep in the murky water. Fortunately, he does not strike his head during the fall, but unfortunately, he injures his left forearm.

Today’s post is about wound care and healing with a focus on a type of wound typical in older patients in the emergency department.

Overview of Wound Healing

Medically speaking, there are two types of wounds: those that close by primary intention and those that close by secondary intention. Primary intention wound closure is through suturing in which both sides of a wound are brought together, leaving a linear scar after healing. Healing by secondary intention involves a wound in which both sides of the wound cannot be brought together—a portion of subcutaneous tissue is left exposed, and the wound shrinks as granulation tissue proliferates along the sides of the wound and across the base of the wound.

Features of wound healing include:

Wounds typically heal in 4 to 6 weeks.
Risk factors for poor wound healing include: some chronic conditions such as diabetes and venous stasis disease, smoking, poor nutrition, and advanced age. Such wounds require a more intense interaction with the patient’s healthcare provider.
In the first stage of wound healing, hemostasis is achieved through the clotting cascade and through vasoconstriction.
During the inflammatory phase, white blood cells and thrombocytes flow into the injury and release cytokines to support destruction of damaged tissue and proliferation of new health tissue. Platelet derived growth factor and transforming growth factor attract and enhance division of fibroblasts. Fibroblasts synthesize new collagen and glycosaminoglycans.
Immune cells, particularly neutrophils, remove cell debris and invading bacteria. However, it has been found that the enzyme collagenase is often in short supply, and providing pharmaceutical collagenase (Santyl ointment) speeds healing by prevent the build up of necrotic tissue within the wound.
Though the initial injury may have removed the epithelial cells completely from the area of the wound, epithelial cells quickly migrate to the base of the wound. Formation of new vessels (angiogenesis) supports tissue growth.
As debris is removed from the center of the wound and wound remodeling occurs, the wound contracts.

Health care professionals involved in care of wounds include: emergency department and surgical staff who initially treat the patient, the patient’s primary care provider, visiting nurses, wound clinics which are often overseen by the vascular surgery service, and pharmacists.

A Risky Crossing

Our 81-year-old accountant walks every day for exercise, usually on paved surfaces, but on this day the route is through a small nature preserve. He fails to bring along his hiking poles, so his fall is headfirst off the bridge which has no handrail. In the fall, he strikes his left arm on the edge of the wooden bridge creating a laceration that appears as if the skin has been pushed down his forearm exposing deeper layers of tissue.

This type of injury is fairly common among older folks because of the weaking of the layers of subcutaneous tissue with age. The accountant is evaluated in the emergency department and receives the following treatment:

Irrigation of the wound with saline.
Approximation of the tissue and closure along the medial side of the laceration with 11 sutures. Because of some tissue loss, the lateral side has some uncovered subcutaneous tissue, and that portion of the wound can only be secured with Steri-Strips.
Antibiotic coverage with Keflex. Tetanus booster. Follow up visit to primary care physician on the following day. Also, appropriate imaging is completed given the patient’s age and anticoagulated status—head imaging is negative.
Until sutures were removed on Day 14, the dressing was a simple two-layer dressing (nonadherent inner pad and absorbent outer pad held in place with 3M Coban wrap).

As can be seen, the wound is fairly bloody (the patient receives a baby aspirin and clopidogrel as part of his daily medications), but more than 2/3 of the laceration could be covered with epidermis:

Initial Follow Up

Initially, the wound receives daily dressing changes and cleaning with saline moistened gauze. By Day 4 (see below), swelling is present due to the disruption of the flow of lymph in the area. There is no sign of serious infection (warmth, excessive redness, or tenderness), but there is some grey necrotic tissue at the proximal end of the laceration and a marked ammonia smell. Some bleeding continues due to the fact that the patient receives a baby aspirin and clopidogrel daily. The patient is covered by Keflex for 10 days. Dressing changes continue daily or every other day.

Debridement

On Day 14, sutures are removed. The ammonia smell remains, though no other signs of infection are present. The wound is cultured and light growth of Aeromonas hydrophila/punctata and E. coli are found; the patient receives a prescription for ciprofloxacin. Below is the condition of the wound on Day 14 prior to and following debridement:

During manual debridement, the yellow tissue at the base on the wound is removed. The ammonia smell resolves with debridement.

Wound Care Following Debridement

At this point, the patient has a fairly significant deficit to close on his left forearm. Because he is capable of following detailed instructions, he is trained to do his own dressing changes. Self-dressing at home has significant benefit to the patient because: 1) the patient is personally invested in getting the dressing correct and 2) the patient can do daily dressing changes, rather than stretching out the interval if he was seen in a wound clinic. The features of the dressing procedure are as follows:

Remove nonadherent portion of the dressing and submerge arm in basin of tepid water with 1 tablespoon of delicate skin soap (such as CVS Cleansing Wash for Sensitive Skin). Do not touch the wound itself, but gently wash the surrounding skin with a wet paper towel in the bath. Any adherent dressing should float free during the bath. Rinse the arm in the basin with tepid tap water to remove soap.
Flush the wound 3 times with Vashe low pH wash. (Vashe has antimicrobial action and is widely available at pharmacies and through Amazon.) Dry arm and around the wound without touching the wound. Photograph the wound to provide period updates to wound clinic.
Spread Dynarex Skincote on the tissue surrounding the open wound. (Skincote is a barrier material which is available in individual towelettes. It prevents the surrounding tissue from become wet and breaking down (“maceration”).)
Put on a nitrile glove because this portion of the dressing will require touching the wound. Spread a thin coat of Santyl (“nickel thick”) over the wound itself. (Santyl is a collagenase ointment that does chemical debridement of dead tissue within the wound.)
Initially the dressing is three layers thick, but subsequently it is modified to a single layer as discussed below:
Inner Layer—Curity Oil Emulsion Non-Adhering Dressing Gauze (mesh): Oil emulsion mesh prevents the dressing from adhering to the wound. By Day 16, the mesh was no longer required to prevent adherence—it was discontinued because mesh can hold moisture at the wound surface. Some moisture is critical, but too much moisture can lead to maceration of the healthy surrounding tissue.
Middle Layer—Hydrofera Blue Bacteriostatic Foam: This foam dressing impregnated with gentian violet and methylene blue has bacteriostatic properties. In addition, the foam suppresses excessive growth of granulation tissue which can delay overall wound healing. The foam has minimal absorbent properties—enough to collect any small amount of drainage when the inner and outer layers were discontinued on Day 16.
Outer Layer—ABD Absorbent Pad: This absorbent pad captured drainage from the wound during the early stages of healing. It was employed until Day 16 when the drainage was so minimal that the pad was no longer required.
The dressing was held in place with 3M Coban wrap. Because Coban is elastic, it is important not to apply too much tension, or circulation could be reduced.

Progressive views of the wound following dressing removal are shown below. On Day 19, the wound remains relatively large and consists of area that could not be reapproximated during the initial procedure in the emergency department, along with the area of the tissue flap that became necrotic. The wound is healthy looking with no signs of infection. Granulation tissue covers the wound base.

On Day 29, the wound is largely covered with granulation tissue. Significant wound contraction is evident. Because nerve growth lags in wound healing, the patient reports that the region around the wound feels numb; however, the loss of sensation should resolve over time.

On Day 35, the wound is almost completely closed. A small manual debridement was conducted to speed healing and the area was treated with silver nitrate (seen in photo at center of wound) applied with a sterile cotton swab. The size of Hydrofera Blue Bacteriostatic Foam became correspondingly minimally small.

The patient was discharged from clinic with the following instructions:

Provide periodic digital photos by email until the wound is fully closed (expected by Day 42). Contact the clinic with any concerns.
Periodically, apply a thin layer of petroleum ointment to the site to ensure that the scar remains supple during the six months to one year that are required to reach full tensile strength.

Conclusions

Lacerations in the elderly can be difficult to heal due to reduced immune function, slower healing, and sometimes poor diet. Fortunately, this patient had no risk factors for poor wound healing other than advanced age. Proper wound care ensured prompt healing in six weeks.

It is worth noting that the patient was able to return to normal activities on Day 1 because the location of the injury did not affect his use of the arm. As a result, no deconditioning occurred. It is not uncommon that elderly patients can require physical therapy if this type of injury limits them in their activities of daily living during the wound healing process.

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