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World Wide Wounds
invites responses from other readers.
Please submit your response to
The Editor, www.editor@smtl.co.uk.

Questions with Answers:

Refractory Pressure Sores
Tee Tree Oil
Wound Measurement
Ferrous Subsulphate Solution
Hydrogels
Treating Scars
Black dry wounds
Managing necrotic wounds
Acetic Acid and Pseudomonas
Additions to the Drug Tariff
Lasers and Wound Healing


Awaiting an answer ...
Hydrogen Peroxide and Sutures
To bathe or not to bathe ?
Immunization and wound management
Hydrotherapy in wound management
Cytotoxic
Shower
Boric Acid
Silver Sulphadiazine
Piercing Problems
Silicone Oil

Question: Hydrogen Peroxide & Sutures ?

From: BJ Krob [Quest1615@aol.com]

I am curious to know if there have been any studies on the efficacy of using hydrogen peroxide on granulating surgical wounds that are held together with dissolvable sutures.
(June 1998)

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Question: To bathe or not to bathe?

From: Tracey McClean [kolapore@kolapore.demon.co.uk]

We have had a 'debate' with some of our medical colleagues regarding the exposure of surgical wounds after surgery. I have always believed that, in general, most sutured wounds would have sealed 48hours after surgery.

If the wound appeared to be healing well, with no obvious ooze or infection then it could be exposed so that the patient could have a bath or preferably a shower. Has anyone got any further information on this matter?
Some good quality research would be ideal.
(May 1998)

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Question: Immunization and burns.

From: Martinez Zenaida [zenaida.martinez@lakenheath.af.mil]

Hello, I'm not sure if you can assist, I'm seeking information on the effect immunizations has on recovering burn victims.
(March 1999)

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Question: Hydrotherapy in wound management

From: Steve Moskowitz [smoskow498@aol.com]

Does anyone know of any studies showing the efficacy or necessity of hydrotherapy (whirl pool) in wound management? Pros and cons? If so, any information suggesting the efficient use of that modality?
(March 1999)

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Question: Cytotoxic Leaks

From: Jerry Roberts [jsnap@blomand.net]

Information needed on what to do if extravasation of adriamycin occurs from an implanted cathether in the shoulder area

The catheter was removed once the leak was found.
(May 1998)

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Question: Boric Acid

From: Connie [booboo@citrus.infi.net]

I am a wound clinician at a hospital where our infectious disease physician orders Boric Acid to "clean out" all types of wounds. However, it is never discontinued and they are using it in dry, necrotic wounds as well as those that are draining.
I just have not found anything on the use of boric acid, except that it is a good roach exterminator! Thank you for your assistance. I have found no literature defending its use.
Can anyone shed some light on this?
(April 1998)

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Question: Silver Sulphadiazine

From: JMoore5368

When is it appropriate to use silver sulphadiazine (Silvadene/Flamazine) in wound care?
I find many doctors using it, but they can't really tell me why.
(April 1998)

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Question: Body Piercing Problems

From: Desta Spence [bitchboy@earthlink.net]

I am a body piercer and am researching effective means of cleaning puncture wounds. I am currently suggesting the use of Nutri-biotic as I have found many people to be sensitive to the anti-bacterial soaps using Triclosan. I am also extremely interested in finding cost-effective means of dealing with hypertrophic and keloid scarring, both of which are common in navel, cartiledge and guich piercings.
Does anyone have any suggestions?
(April 1998)

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Question: Refractory Pressure Sores

From: Mustafa Akgun [Akgun@atlas.net.tr]

The patient is a 34 years old male, who was involved in a traffic accident six months ago. He now has several neurologic deficits due to serebral hypoxia. The patient is mobilised three or four time day. He has left hemiparesia but can be mobilised with another person. He moves in bed with help. The patient can walk with the help of two people.

An active rehabiltation programe has been commenced, but his decubitus ulcers (pressure sores) are proving to be a major problem. One ulcer is on the right hip, its dimensions approximately 4x6 cm, red in colour. There is some necrotic fascia but it is debridated with every dressing change. On the wound there is some new tissue but it does not yet to fill the wound.

The most recent culture shows a single bacteria, pseudomonas aeroginosa. There is some pus on the wound every dressing, but it does not appear to be spreading to other subcutanous or subfascial plane. The second ulcer is on the sacrum, its diameter 6x10 cm, red in colour, with no necrotic tissue. There are some new tissue, depth is not to the bone. New tissue does not yet fill the wound.

Cultures of them have grown pseudomonas aeroginosa. Currently, the wounds are debridated twice a day, and antiseptic solution is applied. There has been no regression of the wounds. Antibiogram showed ciprofloxacine to be the only useful antibiotic, and it is given orally after a week of intravenous therapy. The wounds are open - we have not attempted suturing

Anticeptic solutions include 1% povidone iodine (aqueous) rivanol, hydrogene peroxite. The wounds are dressed with sterile surgical cotton gauze, fixed with hypoallergic surgical tape (Hypafix). Due to economic considerations, modern dressings are not available From: Mustafa Akgun [Akgun@atlas.net.tr]

M.D. Mustafa Akgun
Mustafa Kemal Paa Hospital
Neurosurgery Clinic
Bursa
Turkey

[January 1998]

Answer:

From the editorwww.editor@smtl.co.uk

Because of the complexity of this problem, and the urgency (if the patient is to benefit) I posted the details on sci.med.nursing. I received seven replies within three days. I present a digest of the main points offered:

Nutrition:
Four respondents emphasised the importance of ensuring appropriate nutrition (high in protein and energy; sufficient of all food groups)

Debridement:
recognised as a good way of getting rid of sloughy tissue. One recommended 'a heavy duty desloughing agent, such as Varidase' as an alternative to surgery.

Another said 'what about maggot therapy to de-slough the wounds? To quote a patient's husband's view; "Everyone looked expectant. They were awaiting the maggots. Eventually the maggots arrived in the care of a team of three and were duly deposited into the, by now very large, wound in my wife's buttock. They now have three days to do their work on the dead tissue before they are removed. The tissue nurse will be working almost around the clock for the next three days ensuring that the gauze is kept moist every six hours." Note: Sterile maggots are always used; see
Biosurgical Research Unit; http://www.smtl.co.uk/WMPRC/BioSurgery/index.html

Promotion of healing:
One suggestion: "iodine irrigant solutions can support pseudamonas at times. I would suggest Dakins solution be tried instead (dilute sodium hypochlorite or "bleach"). After the wounds culture out sterile switch to a sugar/shortening mix: Pack the depths of the wounds and cover with a dry sterile dressing and change twice daily. Switch to nonadherant dressings (what ever is available) when they heal to stage 1 -2 (all most all filled in). "

Another suggested "wet to dry dressing with solution of 0.9% NaCl every eight hours; sterile normal saline will help to clea naturally all debris and pus and will promote granulation in natural moist environement for tissue. Stop using other antibacterial agents which damage sensitive new tissue. When the wound is pink / may have some yellow fibrin tissue too/ will show tendency to constrict, dicrease size - it maybe left for healing self or to be closed surgically. Antibiotic therapy may be recomended. This is the most inexpensive and very effective wound therapy."

A further suggestion: "a wound will progress healing for a while then just stop. That is when it is time to change the solution or healing agent being used, for a while, e g, a week, then return to the previous solutions/agents. Do this as necessary. Most of the docs in my area do not use povidone or peroxide because both retard tissue healing. The only time peroxide is used is a solution of equal parts normal saline & peroxide to irrigate if there is purulent drainage but then rinse well with saline. I have had excellent results by just doing a wet to dry dressing change twice a day. I irrigate the wound with saline then pack it loosely with saline dampened gauze and cover it with a dry sterile dressing secured with tape."

Finally:
"Don't debride at every change - you are causing trauma. Twice a day is too often!! You will cause trauma and the skin will never get a chance to heal. Depending on how deep it is, the wound may never 'fill'. You should aim for it to heal over. There is an underlying infection. For the necrotic hip wound; Clean with saline every 48 hours. Pack with Instagel (a starch based gel) which should soak the wound and debride the necrotic parts for you. Cover with Tegaderm or similar occlusive dressing. For the sacral wound; Clean with saline every 48 to 72 hours and pack with alginate.Cover with an occlusive dressing or even gauze and tape. Nurse the patient on a good airbed. For pressure care, nurse on bottom for one hour, nurse on wounded hip for one hour then on good hip for 3 hours. If you follow this and don't see positive results in 7 to 10 days I will be very surprised. "

Several people noted that the expense of appropriate dressings and equipment would prove to be an economy, as wound healing would be more rapid.

Thanks to all who assisted

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Question: Wound Measurement

From: David Kinmond [David.Kinmond@btinternet.com]

I am writing an article on wound measurement and have found that most measuring tools are unreliable to a certain degree. Does anyone know of a reliable tool that can be used effectively in the ward setting?
David Kinmond, David.Kinmond@btinternet.com

Rhonda Lollar [ GLollar98@aol.com] adds:

How do you calculate wound surface area? How do you calculate measurement of undermining, relative to the total wound surface area?
Rhonda Lollar, GLollar983@aol.com

[December 1997, amended January 1998]

Answer:

From: Peter Plassman [pplassma@glamorgan.ac.uk]

Unfortunately there is no perfect tool for the measurement of skin wounds. All measurement devices produce a certain amount of error. You may be interested in having a look at the MAVIS (Measurement of Area and Volume Instrument System) instrument which we have developed here at the University of Glamorgan. To my knowledge MAVIS is the most precise instrument currently available.

An outline description of the instrument is available at: http://www.comp.glam.ac.uk/pages/research/mavis/

If you require any further information, please don't hesitate to contact me:

Dr Peter Plassmann
Department of Computer Studies
University of Glamorgan
Pontypridd
Mid Glamorgan, CF37 1DL
Tel: (+44) 1443 483486
Fax: (+44) 1443 48 2715
E-Mail: pplassma@glamorgan.ac.uk

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Question: Silicone Oil

From: Ms Snehal Shah

We have been asked by medical colleagues to obtain information on the use of silicone oil in the treatment of wounds following the amputation of fingers.

We are aware that silicone oil has been used on intact skin during physiotherapy but can find no reference to its use in wound management.

Any information on this technique would be welcome.

Ms Snehal Shah
Pharmacy Dept
Royal Free Hospital
Pond Street, Hampstead
London, NW3 2QU, UK

[Submitted November 1997]

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Question: Tea Tree Oil in Wound Care

From: Chris Lewandowski [christopher.lewandowski@virgin.net]

I would like to know more about the use of Tea Tree Oil as a wound treatment, its benefits and drawbacks. The only research I have come across is in relation to MRSA in which it appears to be very effective.
Is it being used in a hospital setting?
Are there any products licensed for use in a hospital for the treatment of wounds?

[Submitted November 1997]

Answer:

From Andrew Heenan www.editor@smtl.co.uk

The Tea Tree (melaleuca alternifolia) is a member of the Myrtaceae family and is an indigenous species to Northern New South Wales, Australia. The oil is found within the cells of the leaves of the fast-growing tree.

The oil has a reputation based on four main functions; bactericide and antiseptic, anti-fungal agent, active aginst certain viruses and providing a boost to the immune system. Tea Tree Oil is also used in dilute form for hard surface cleaning and as a general household disinfectant. A few drops of oil mixed in a base of kaolin can make a poultice for abscesses, while adding some to a bland cream or ointment base can be used for other skin problems. Creams are said to be particularly good for treating conditions caused by various types of Tinea fungus, such as ringworm or athlete's foot. Aromatherapists also use the oil.

Microbiologists in London have been in trials involving tea tree oil and vancomycin in parallel for their effectiveness against MRSA. Preliminary findings suggest that tea tree oil may well have a role; and it is probably much safer than vancomycin.

One hospital in London is reported to be using tea tree soap to wash new patients entering wards, and as an alternative to normal handwashing agents for its staff. I can find no information on product licences; I suspect there are none. Its widest use seems to be for minor cuts and abrasions, in Australia, and as a cleanser now available in many countries.

Medline lists 32 publications on a search for Tea Tree Oil; the majority discuss allergic reactions to the oil or poisoning. None appear to establish a firm case for its value.

Much useful information can be found on the Tee Tree Oil website; a service of a UK importer (Thursday Plantation). They also provide many useful links to related sites - http://www.teatree.co.uk/ (unfortunately, this site now apppears to be dead. Ed).

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Question: Ferrous subsulphate solution

From: Kate Wagstaff [kate.wagstaff@university-b.wmids.nhs.uk]

Do you have any information about using ferrous subsulphate solution on facial biopsy sites to stop bleeding? I have recommended Kaltostat but the consultant is keen to use the solution.
Kate Wagstaff
Drug Information Pharmacist
Selly Oak Hospital
Birmingham

Answer :

From: Charles S. Krin, DO FAAFP (ckrin.nospam@Iamerica.net)

Ferrous Sub sulphate solution, also known as Monsel's solution, is one of several "corrosives" which are also used as "styptic" (as in "styptic pencils," those white sticks of chalky material that your dad used to keep in the medicine cabinet for those days when he drew more blood than whiskers...)

Available in a semi solid or syrupy liquid formula, it is very effective at cauterizing wounds to stop bleeding. It leaves less of a mark than Silver Nitrate (Arygol sticks), but more than Alum would.

It is more effective on small bleeders than either alum or silver nitrate, often allowing you to stop them with out electro cautery or a stitch. It is often used in GYN surgery on the cervix. [published January 1998]

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Question: Hydrogels

From: Karen Prososki [prososki@uslink.com]

I felt that the Drug Tariff article contained some very good information, but I would like more information on the hydogels.
Karen Prososki
Hcr 60, Box 399A, Pine River, MN 56474

Answer :

From: Andrew Heenan

Two of the five products featured have data cards in the Wound Management Practice Resource Centre; Granugel Hydrocolloid Gel (Convatec) and Intrasite Gel (Smith & Nephew).

Information on Purilon Gel (Coloplast Ltd) and EpiView (ConvaTec) can be obtained from the manufacturers; please see David Morgan's question on additions to the Drug tariff, below for addresses.

Information on Sterigel can be obtained from Seton Healthcare Group.

Finally, for general information on hydrogels, and related references, do try entering hydrogel dressing on the PubMed site (http://www.ncbi.nlm.nih.gov/PubMed/). PubMed is a branch of the US National Library of Medicine, and includes Medline.

[Published October 1997]

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Question: Treating Scars

From: Mahmuda Begum [mbegum@orange_ag.oac.usyd.edu.au[

Can anyone advise on the possible effect of "Cica-Care" in removing scars on both cheeks. These had developed as a result of 'boils' when the infant was only few months old.

[Submitted September 1997]

Answer :

From: Dr Steve Thomas

Cica-care consists of a silicone sheet that has been claimed to exert a beneficial effect upon raised unsightly tissue that is sometimes produced following healing of a burn or some other similar injury. The mechanism of action of Cica-care is not fully understood but it is thought to induce a degree of softening of the affected area allowing it to become flattened to some degree. It has been postulated that this effect may be due either to the transfer of silicone from the dressing to the tissue or, and probably more likely, result from changes in the degree of hydration of this skin caused by the retention of moisture vapour brought about by the impermeable nature of the silicone sheet. For more detailed information on Cica-Care see the data sheet .

Although a number of published studies are available that record the successful use of silicone sheet dressings in raised scars, little clinical information is available to support their use on depressed scars of the type that result from minor skin lesions. If these are depressed and are regarded as a particular problem, it might be worth consulting your doctor to discuss the possibility of obtaining collagen injections into the affected area.

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Question: Black Dry Wounds

From: John Unsworth [john.unsworth@unn.ac.uk]

I have read recently about the use of Hydrofibre dressings such as Aquacel in the management of black dry wounds as a method of debridement.

Are such dressings recommend for these wounds and what would be the method of application.

[Submitted Aug 1997]

Answer :

From: Dr Steve Thomas

The removal of black necrotic tissue can generally be achieved by the application of dressings that increase the moisture content of the devitalised area and thus facilitate autolysis. Products such as hydrogels that contain large amounts of water are most commonly used for this purpose but other products such as hydrocolloids that form a barrier to moisture vapour and prevent the loss of fluid from the area of the wound can also be used with good effect.

Hydrofibre dressings such as Aquacel are generally used to absorb fluid from exuding wounds. They do not contain significant amounts of water moisture or form an effective barrier to moisture vapour loss from the skin. They could not, therefore, be expected to facilitate the removal of dry necrotic tissue.

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Question: Necrotic wounds.

From: Emma [smaug@dial.pipex.com]

I am a student nurse seeking information on the following:
Why should necrotic tissue be removed from a wound?
How may this be done?

Answer :

From: Dr Steve Thomas

If an area of tissue is deprived of an adequate supply of oxygen or nutrients, it will eventually become non-viable. Such an event may be caused by the application of sustained levels of excessive pressure, the occlusion of blood vessels by a clot, or it may be the result of some metabolic or physiological disorder.

Within a few days, proteolytic enzymes released from the damaged cells combined with the action of proteolytic bacteria, will cause the devitalised tissue to begin to breakdown resulting in the formation of foul smelling semi-liquid material within the wound. This is called'necrotic tissue'.

The term 'necrotic tissue' is also sometime incorrectly applied to the viscous yellow material which accumulates in a previously clean wound often as a result of an infection. This is more correctly known as 'slough'.

It is generally accepted that the presence of necrotic tissue and slough within a wound can inhibit or delay the healing process. Perhaps more seriously, it may also act as a reservoir for bacteria which can multiply resulting in the formation of an infection.

The process of removal of necrotic tissue is called debridement.

A number of techniques may be used, the quickest is surgical debridement using a scalpel or a pair of scissors where appropriate. This requires considerable care and expertise and should only be attempted by experienced staff.

Other methods of debridement include the use of hydrogels or hydrocolloid dressings which re-hydrate necrotic tissue and facilitate autolytic debridement.

Enzyme preparations are also used to cleanse wounds as are sterile maggots.

For a recent review of wound debridement see Journal of Wound Care, 1997, 6 (4), 179-182.

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Question: Acetic Acid in wounds colonised with Pseudomonas.

From: Miss Judy Harker
Clinical Nurse Specialist, Wound Care
The Royal Oldham Hospital, Rochdale Road, Oldham.

I am a wound care specialist nurse working in a hospital where acetic acid solution is often requested by my medical colleagues.

I am however unaware of any research based evidence to support the use of acetic acid for this application. Do you have any information?

Answer:

From: Dr Steve Thomas

The use of acetic acid to treat Pseudomonas aeruginosa in superficial wounds dates back to 1916 when it was discovered that a 1% solution applied to war wounds led to elimination of this organism then called Bacillus pyocyaneas (Ref 1).

In 1968 a 5% solution of acetic acid was shown to be reasonably effective at eliminating Pseudomonas aeruginosa from infected wounds but unfortunately, during the treatment, the number of Staphylococcus aureus and proteus species increased significantly (Ref 2). Applications of the solution was also said to cause significant pain or discomfort.

In 1992 a prospective study involving the use of 5% acetic acid was undertaken in 9 patients. No patients complained of discomfort after the soaks which were applied daily. Two wounds lost Pseudomonas species within 2 days and a further four within one week. Only one patient remained contaminated after three weeks. Following eradication of the organism, healing occurred rapidly (Ref 3).

It is possible the application of acetic acid may confer other benefits to the healing process as well as the removal of bacteria. Acidification of a wound would also increase the pO2 and reduces the histotoxicity of ammonia which may be present (Ammonia is less toxic in an acid environment). Unfortunately acidification of a wound is relatively short lived. Other published work suggests that the wound does not maintain acidity for periods longer than about one hour and therefore soaks would require frequent replacement (Ref 4).

In summary, acetic acid may have a role in the treatment of wounds infected with Pseudomonas although there are no randomised controlled studies to support its use. Conflicting evidence concerning the pain associated with the use of this treatment. To exert an optimal effect frequent replacement of the acetic acid soaks would be required.

References

  1. Taylor-K;Treatment of Bacillus pyocyaneas infection;JAMA;Vol 67 (1916):1598-1599
  2. Phillips-I et al;Acetic acid in the treatment of superficial wounds infected by Pseudomonas aeruginosa;The Lancet;Vol 1 (1968):11-14
  3. Milner-S;Acetic acid to treat Pseudomonas aeruginosa in superficial wounds and burns - (letter);The Lancet;Vol 340 (1992):61
  4. Leveen-HH et al;Chemical acidification of wounds;Annals of Surgery (1973);Vol 6:745-753

Published 28 July 1997.

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Question: Additions to the Drug Tariff

From: David Morgan, Director Pharmaceutical Services,
North Wales Health Authority, Preswylfa

The latest edition of the Drug Tariff identifies two new wound management materials available on prescription, as follows:

Please can you identify the manufacturers of these two new dressings.

Answer:

From Dr. Steve Thomas

Purilon Gel is produced by Coloplast Ltd and their address is:-

Coloplast Ltd
Peterborough Business Park
Peterborough
PE2 0FX

Tel:01733 392000
Fax:01733 233348

EpiView is produced by ConvaTec and their address is:-

ConvaTec Europe Ltd
Harrington House
Milton Road
Ickenham
Uxbridge
UB10 8PU

Tel:01895 678888
Fax:01895 628398

Published 28 July 1997.

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Question: Lasers and Wound Healing

From: Jim Polaski [jpolaski@wwa.com] I'm wondering what information you may have on the use of photobiostimulation by low-intensity sources, like LED's on wound healing, specifically 660nm red light and the treatment protocols, devices etc, or possibly how the units are constructed...

Answer:

From Dr. S Lannigan
Consultant Dermatologist

Further to your request for information on photobiostimulation by low intensity sources, I regret that I have no first hand experience of the use of this technique. For further information I recommend the following references:-

  1. Ohshiro T, Calderhead RG (1988) "Low level laser therapy: A practical introduction.", J. Wiley & Sons.
  2. Ohshiro T (1991). "Low reactive-level laser therapy: Practical application.", J. Wiley & Son.
  3. Smith KC (1991): "The photobiological basis of low level laser radiation therapy.", Laser Therapy 1991;3:19-24

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