Wound Series Part 2b: Wound Care (FL INITIAL Autonomous Practice- Differential Diagnosis)

Think of this as the "TIME" for wound care. The wound bed preparation concept describes a systematic approach to addressing the wound bed's specific needs in full-thickness open wounds (Sibbald et al., 2021; Doughty & McNichol, 2015). Evidence-based literature describes this mnemonic, such as T-I-M-E or T-I-M-E-S, to help clinicians perform evidence-based wound care (Gupta et al., 2017).

T is for Tissue:

Tissue in the wound bed should be described and documented. This includes the appearance (color, consistency) of wound bed tissue and the presence and amount of any non-viable or necrotic tissue, as well as any hypergranulating tissue, hypertrophic scarring, or foreign bodies in the wound bed. Necrotic or non-viable tissue (including biofilm if detected) should be removed as appropriate or addressed. Hypergranulating tissue should be treated.

I is for Infection:

Signs of infection should be identified and documented. Determine if a critical infection is present. This wound may need systemic treatment versus non-critical chronic bacterial colonization that may require only local management by debridement and topical therapies.

M is for Moisture:

Moisture in the wound bed should be managed. A balance of moisture is important for wound healing. Topical wound care, especially dressings, are used to prevent the wound bed from drying out while eliminating excessive moisture in the wound bed. When excessive moisture in the wound exceeds the dressing's capabilities, it often causes moisture damage to the skin surrounding the open wound (maceration). Dressing selection is most important for addressing this specific need of the wound bed.

E is for the Edge of the wound:

Attention should be given to the wound edges. Rounded, "rolled" wound edges prevent epidermal cell migration, which may impair wound closure. Tracking or tunneling in the wound bed and undermining (a 'lip' or ledge under the wound edge) may impair healing. Undermining is often caused by shearing forces upon the wound area. It is frequently seen in pressure ulcers around the sacral area when the patient repeatedly slips down while sitting up in the bed.

Other mnemonics are changing the T in T-I-M-E to D (for debridement), resulting in D-I-M-E, and adding an S to the anagram to address the skin and tissue surrounding the wound opening. In this case, S reminds us that the surrounding skin and tissue should be examined for the presence of or worsening of erythema (redness), edema (swelling), warmth, and skin lesions (blistering, rash, irritation, callus, or maceration).

Additional publications have described algorithms for wound management or mnemonics to guide clinicians in deciding if local treatment is adequate or if systemic treatment may be advised. The following two mnemonics help to identify just that. Using the NERDS mnemonic, if three or more of the following symptoms are present, treat the wound topically:

• Nonhealing wounds
• Exudative wounds
• Red and bleeding wound surface granulation tissue
• Debris (yellow or black necrotic tissue) on the wound surface
• Smell or unpleasant odor from the wound

Using the STONES mnemonic, if three or more of the following symptoms are present, treat the wound systemically:

• Size is bigger
• Temperature is increased
• Os (probe to or exposed bone)
• New or satellite areas of breakdown
• Exudate has increased
• Smell from the wound

You volunteer at a summer camp. Mike is a 23-year-old young man working at the camp as a counselor. He is 6ft tall and weighs 155 lbs. He was skateboarding with some of the teens at camp. He fell on a wooden ramp resulting in several superficial abrasions to the right forearm below the elbow and his right upper shin below the right knee.

As the camp health care provider, you would approach Mike like any other first-aid patient and determine if he needs more than simple first aid.

What should you know about Mike before you try to provide first aid to his wounds?

1. Pertinent medical factors:
   1. Is he diabetic? (No)
   2. Does he have any blood clotting disorders? (No)
   3. Any allergies? (No known allergies)
   4. Autoimmune disorders or other medical history? (No)
   5. Is he on any medications? (No)
2. Did anyone see the fall? (Yes, 3 other teens)
3. What sort of protective gear was Mike wearing? (Helmet, both knee, and elbow pads)
4. What did he fall against - Objects, flooring, ground, soft sand? (Fell against plywood ramp with right knee hitting first and then right elbow and forearm as he skids off into the dirt)
5. Was the plywood rough or smooth? (Smooth on top but rough edges)
6. What was the distance of the fall? (About 3 feet from the top of the ramp where he lost control)
7. Did he hit anything else during his fall, such as his head? (No)
8. Any reason to call 911? (Not obvious)

Current symptoms:

• What is his pain level on a scale of 0-10? (8-9 in right forearm and shin; 6-7 in the right knee, right elbow).
• Does he have difficulty moving any extremity or joint? (His right elbow is sore to move, and he demonstrates about 90% range of motion; he also complains of pain in his right knee, although he can bear weight and walk on it with a limp).
• Was he able to walk on his own to your first aid station? (Yes, with a limp).

Visible inspection:

• Has the bleeding stopped? (Just some slight oozing from the right upper shin abrasion).
• Visible edema, bruising/discoloration? (Redness to right knee extending down to right upper shin abrasion and some edema to right elbow and knee has started since he arrived in your first aid station).
• Any visible contamination like dirt, clothing fabric, wood, etc.? (Yes, dirt and pieces of fabric, which you gently cleansed with saline).
• Other injuries? (Nonvisible).

Right shin wound measures and description:

• Right shin wound is an abrasion that starts 2 cm below the inferior edge of the patella/kneecap and extends to 5 cm below the knee.
• It is a rough oval shape 3 cm long x 2 cm wide with shallow ~1mm depth.
• Debris such as dirt and small wood splinters and some fabric threads were cleansed from the wound bed to reveal a 100% pale pink wound base after cleaning.
• Slight erythema extends from the edges of the wound, approximately 0.5 cm.
• Some slight edema of this area extending to the knee itself is noted.
• Slight serosanguineous (blood-tinged clear amber fluid) oozing is still noted from the wound.

Right inferior forearm wound measures and description:

• Superficial abrasion is noted over the lateral aspect of the right forearm that begins 3 cm distal to the elbow prominence and extends to 8 cm from the elbow prominence.
• The wound measures 5 cm long by 3 cm wide at the widest axis x less than 1 mm deep.
• The wound bed is jagged and rough, and dirt/debris was washed out of the wound with gentle irrigation with saline.
• The wound bed is red, with a small amount of serosanguineous oozing noted.
• The entire right elbow extending to the wound has some slight edema, warmth, and noted erythema.

After a quick triage assessment, you determine that even though Mike wore knee and elbow protectors and the abrasion wounds are superficial, the nature of his fall to knee and elbow could entail a potential deeper injury (consider sending to the emergency room (ER) for x-rays to rule out fractures).

You are also aware that the forearm and shin wounds present potential complications. Why? The location (close to the joint) and thickness of the skin over these parts of the body make these superficial abrasions full-thickness wounds.

How will you perform first aid to Mike to send him to the ER for x-rays? Using universal precautions and clean or aseptic technique, gently cleanse the wounds with saline pat with gauze (Kent et al., 2018; Pickering & Marsden, 2015). Apply a wound hydrogel, or petrolatum impregnated gauze, cover with sterile gauze, secure in place with tubular gauze, cotton stockinette, or self-adherent wrap. This will be simple for ER providers to remove to inspect wounds and not interfere with x-rays. You note that you do not have any at camp. Still, if you had had a silicone interface self-adherent border dressing, this would have worked nicely too and would have been easily removed and reapplied (this could potentially be left in place for 3 days if only scant wound drainage).

Mike comes back to your station the next day for a dressing change. His x-rays of the knee and elbow were all within normal limits. The ER staff told him to rest and elevate the elbow and knee and ice them (10 min on and 30 min off) for 24 hours and continue daily wound care with you. They also told him to take 600mg of ibuprofen as needed every 6 to 8 hours.

Today, his right elbow/forearm self-reported pain level is 6-8, and his right knee/shin is 4-5. Using universal precautions and clean technique, you change the dressing, continuing to use a hydrogel wound gel or petrolatum impregnated gauze over the entire wound, secured in place by a secondary dressing and tubular netting. You also protected the wound edges using a skin protectant wipe applied to the skin immediately around the open wound. This approach maintains a moist wound bed, prevents the dressing from sticking to the wound, allows for continued extremity motion, and protects the surrounding skin.

You change this dressing daily for the next 5 days. You note the shin wound is healing as expected, and the knee joint edema is resolved, with some bruising now evident. However, the elbow area and forearm wound remain edematous, painful to touch, and movement. There is still a moderate amount of serosanguineous to yellow exudate (no unusual odor) as well as dark red erythema extending 0.7 cm from the proximal wound edges. This wound is not following the expected pathway to healing.

What are some possible reasons?

1. He reinjured it yesterday (re-injury would certainly put the wound back to square one as far as an inflammatory state).
2. He is still taking 600 mg of ibuprofen every 6 to 8 hours (non-steroidal anti-inflammatory medications can impair wound healing, but please note his shin is healing).
3. He is constantly removing and reapplying the same dressing himself because it is uncomfortable (this certainly could impair wound healing if he is not using clean technique and introducing contamination, as well as disrupting the wound bed often, however, why is the wound so uncomfortable? (We need to ask Mike to describe this discomfort in more detail).
4. He is not getting adequate nutrition (yes, this certainly could impair wound healing, but his shin wound is healing, so let us look to more local factors).

While any of these may interfere with wound healing, we should also consider other potential complications. The two biggest ones to consider in Mike's case are:

1. A missed foreign body (especially a wood splinter from the edge of the ramp).
2. An infection.

A missed wood splinter or organic foreign body may not have been detected by x-ray. Close examination of the wound and gentle probing with the wood end of a sterile cotton-tipped applicator reveals a hard embedded splinter that you can remove with forceps. It is a thin 0.7 cm long wood splinter at the proximal end of the forearm wound pointing deep into the wound towards the elbow. You note that it did not measure long enough to potentially invade the joint space, even fully embedded.

After it was removed, Mike states he felt some immediate pain relief. You decide to use an antimicrobial wound dressing for this wound while continuing the same petrolatum impregnated gauze dressing for the shin wound (though now you can change it 3 x per week along with the new dressing orders for his forearm). You also just happen to have a sample tube of Cadexomer Iodine gel you brought with you in your first aid kit.

Mike's new forearm wound dressing includes:

1. Applying skin protectant wipe to the wound edges every dressing change.
2. Applying Cadexomer iodine gel to the wound bed.
3. Covering with gauze.
4. Securing dressing with tubular gauze or self-adherent wrap.
5. Changing dressing 3 times per week.

You follow Mike's wounds for wound care 3 x a week for the next 2 weeks, and the wounds close within 3 weeks.

Mike's wounds should have both healed as expected. However, one did not. We have discussed that we should look to local factors within the wound itself for the impaired healing of the forearm wound (his other wound was healing as expected even though it was the most distal wound); this may (although not always) point to something more local within the forearm wound itself. When looking at wounds, remember to look at the whole person, not just the wound. It is also important to consider all the initial factors which led to the wound if things start to take a turn away from the anticipated pathway to healing.

Strengths:

• A global, whole person assessment was conducted just after the injury.
• You, the camp healthcare provider, decided to be conservative because of the nearness of the wounds to 2 joints where bones could have been easily broken or chipped and the nature of the fall.
• Getting the extremities x-rayed was advantageous when the one wound was not healing because it answered the question of a possible broken bone or other non-organic foreign objects in the wounds.
• You thought about the nature of the wound pain and began asking more questions and gently probing, which allowed you to discover the embedded wound splinter. If this were not found and removed, it would have continued to fester, possibly becoming infected, which could have put the joint at risk of spreading infection and had a very unpleasant ending.
• Staying on top of symptoms and acting quickly when things did not go as expected.

Weaknesses:

• The fact that this was a camp setting and there were a limited number of wound supplies on hand was a weakness.
• We assume the camp healthcare provider had Cadexomer Iodine on hand, but that is unlikely in real life. A camp clinic would more likely have just the basics, so finding an antimicrobial solution could have been a lot more difficult and is a weakness of this case.
• Instead, was manuka honey available? Could you make your own dilute Dakin's solution? In every situation, healthcare providers can think of what should be included in their first aid kits and on-hand clinic supplies and know enough about basic wound care and that basic options for the four main types of wounds are available:
  • Deep and dry wounds
  • Shallow and dry wounds
  • Deep and wet wounds
  • Shallow and wet wounds
• Including antimicrobial options to be used in these situations can also be helpful. Still, you want to also take care to minimize the use of cytotoxic products.