Download Wound Care Basics

2/8/2013
Wound Care Basics
Shereef N. Ali PharmD
Department of Pharmacy Services
Kennedy Memorial Hospital, Cherry Hill
1
Disclosure Declaration
• I do not have (nor does any immediate family
member have) a vested interest in or affiliation
with any cooperate organization offering
financial support or grant monies for this
continuing education activity, or any affiliation
with an organization whose philosophy could
potentially bias my presentation.
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Goals
• To be able to stage pressure ulcers based on appearance
and location
• Understand the basic principles of wound healing
• Know when and how often one should change wound
dressings
• Understand the pharmacology behind the topical
agents used to treat pressure ulcers
• Know the most common pathogens associated with
infections secondary to pressure ulcers
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Objectives (Pharmacist)
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At the conclusion of the program, the attendee will be able to:
Differentiate among the different stages of pressure ulceration
List the most common types of pathogens associated with infections
secondary to pressure ulcers
Evaluate appropriate antimicrobial therapy for infections due to pressure
ulcers
Explain the importance of opioid and anxylotic use prior to initiation of
wound dressing in patients.
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Recognize the pharmacology behind the different types of wound
dressings and topical agents used to treat pressure ulcers
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State when and how often wound dressings should be changed.
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Explain the importance of nutrition in pressure ulcer treatments
Objectives (Technicians)
• At the conclusion of the program, the attendee will be
able to
• Differentiate the different types of agents used in the
treatment of pressure ulcers.
• Differentiate between types of dressings used in the
treatment of pressure ulcers
• Recognize common side effects associated with agents
used to treatment pressure ulcers
Pressure Ulcer Staging
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Stage I:
Intact skin with non-blanchable redness of a localized area usually over a bony
prominence. Darkly pigmented skin may not have visible blanching; its color may differ
from the surrounding area.
Further description:
The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Stage
I may be difficult to detect in individuals with dark skin tones. May indicate “at risk”
persons (a heralding sign of risk)
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Stage II:
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound
bed, without slough. May also present as an intact or open/ruptured serum-filled blister.
Further description:
Presents as a shiny or dry shallow ulcer without slough or bruising*
This stage should not be used to describe skin tears, tape burns, perineal dermatitis,
maceration or excoriation.
*Bruising indicates suspected deep tissue injury
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Stage III:
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are
not exposed. Slough may be present but does not obscure the depth of tissue loss. May
include undermining and tunneling.
Further description:
The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the
nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can
be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III
pressure ulcers. Bone/tendon is not visible or directly palpable.
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Stage IV
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be
present on some parts of the wound bed. Often include undermining and tunneling.
Further description:
The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the
nose, ear, occiput (back of the head) and malleolus (bony prominence on each side of the
ankle) do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can
extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule)
making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.
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Un-stageable
Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan,
gray, green or brown) and/or eschar (tan, brown or black) in the wound bed.
Further description:
Until enough slough and/or eschar is removed to expose the base of the wound, the true
depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without
erythema) eschar on the heels serves as “the body’s natural (biological) cover” and should
not be removed.
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Pressure Ulcer Staging Guide
Deep Tissue Injury
Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of
underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful,
firm, mushy, boggy, warmer or cooler as compared to adjacent tissue.
Further description:
Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may
include a thin blister over a dark wound bed. The wound may further evolve and become covered by
thin eschar. Evolution may be rapid exposing additional layers of tissue even with optimal treatment.
Copyright: NPUAP 2007“Reproduction of the National Pressure Ulcer Advisory Panel (NPUAP) materials
document does not imply endorsement by the NPUAP of any products, organizations, companies, or any statements
made by any organization or company.” Wound Care Education Institute - www.wcei.net
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Moist Wound Healing, why we do it
• George Winter in 1962 conducted a study by
creating multiple small partial thickness wounds
on the backs of pigs. Portion of the wounds
were allowed to dry out and form scabs, while
others were covered with a polymer film
• Results: Wounds that had been covered by a
polymer film, epithelialized twice as quickly as
the wounds exposed to air.
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Why this occurs?
• Epithelial cell in dry wounds have to negotiate the scab,
consuming energy and time, whereas in moist wounds
they migrate freely across a moist, vascular wound
surface.
• Also Winter’s theory about a moist environment has
been proven by various studies. Thus, a moist
environment can accelerate the inflammatory
response leading to faster cell proliferation and
wound healing in deeper dermal wounds
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The Principle of Moist Wound
Healing
• Mimics the function of the epidermis. Our body is mainly composed of
water , and the natural environment of a cell is moist; therefore, a dry cell is a
dead cell.
• The diagram below demonstrates the benefits of moist wound healing from
the use of an occlusive dressing.
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Advantages of moist wound healing
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Decreased dehydration and cell death (neutraphils, macrphages, & fibroblast necessary
for wound healing cannot thrive in a dry environment)
Increased angiogenesis
Enhanced autolytic debridement
Increased re-epithelialization (dry crusted wounds decrease supply of blood and
nutrients which thus results in a barrier to cell migration and slowing of
epithelilization.)
Decreased pain (Moist wound bed insulates and protects nerve endings thereby
reducing pain.)
References:
J. Bryan, RN Moist wound healing: a concept that changed our practice, Journal of Wound Care,
VOL 13, NO 6, June 2004
Wayne, P.A., Krasner, D., Rodenheaver, D., Sibbald, R.G. Chronic Wound Care: A Clinical
Source Book for Health Care Professionals 245-252. HMP Comm. 1996
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Skin Care Prevention Guidelines
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Implement the following for Patients At Risk of skin breakdown:
1. Assess patient daily for reddened areas or any alterations in skin over bony
prominences, feet, heels,between skin folds, contracted extremities, etc.
2. Reposition patient at least every 2 hrs while in bed. When sitting in a wheelchair,
repositioning should occur every 1 hour and the patient taught to shift weight at least
every 15 minutes.
3. Use positioning devices (pillow, foam wedges) to maintain 30° lateral position and
separation of bony prominences.
4. Elevate calves on pillows or positioning devices to relieve heel pressure.
5. Place pressure reducing mattress on bed
6. Place pressure reducing cushion in chair.
7. Utilize draw/transfer sheet for positioning and turning. (Do not drag heels)
8. Elevate knee latch prior to head elevation.
9. Maintain head elevation as low as possible.
10. For incontinence: Cleanse skin with ph-balanced/soapless cleanser and follow with
moisturizer and moisture barrier ointment.
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Skin Care Prevention Guidelines (continued)
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11. For incontinence: Consider use of briefs, pads, or external catheters. Initiate bowel and
bladder program.
12. For incontinence: Assess for fluid/fiber requirement for constipation or diarrhea.
13. Assess nutritional status and dietary history. Obtain dietary consult.
14. Monitor lab values for nutritional deficit:
Hemoglobin <12mg/dl Total Lymphocyte Count <1800mm3
Serum Albumin <3.5 mg/dl Total Protein <6.0 mg/dl
15. Weigh patient. Monitor for significant weight loss,( 5% loss in one month or 10% in six
months)
16. Assess need for vitamin/mineral supplements: Multivitamin with Minerals
17. Educate patient and family regarding pressure ulcers.
18. Review plan of care with patient and family.
19. Update with care plan with prevention interventions. Initiate changes as needed.
20. Document in notes a summary of interventions and compliance, improvement, or decline.
21. Document body assessment findings weekly.
www.woundconsultant.com
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Nutrients Necessary For Wound Healing
• Proteins
– Function
• Wound Repair
• Clotting factor production
• White blood cell production
• Cell-mediated phagocytosis
• Fibroblast proliferation
• Neo vascularization
• Collagen synthesis
• Epithelial cell proliferation
• Wound remodeling
– Results of Deficiency
• Poor Healing , Edema, Lymphopenia, Impaired cellular immunity
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Nutrients Necessary For Wound Healing
(continued)
• Albumin-Controls osmotic equilibrium . Results of deficiencyhypoalbuminemia which promotes generalized edema, thereby slowing
oxygen diffusion and metabolic transport mechanisms from the capillaries
and cell membrane.
• Carbohydrates-Supply cellular energy and Spare protein. Results of
deficiency- Body uses visceral and muscle proteins for energy .
• Fats-Supply cellular energy, Supply essential fatty acids, Cell membrane
manufacture and Prostaglandin production. Results of deficiency-Inhibited
tissue repair.
• Vitamin A-Necessary for collagen synthesis and epithelialization. Result of
deficiency is poor healing
• Vitamin C-necessary for membrane integrity. Result of deficiency is poor
healing and capillary fragility
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Nutrients Necessary For Wound Healing
(continued)
• Vitamin K- Necessary for Coagulation. Result of Deficiency, Increased risk of
hemorrhage and hematoma.
• Pyridoxine, riboflavin and thiamine- Necessary for Antibody and WBC
formation. Cofactors in cellular development. Promote enzyme activity.
Result of Deficiency , Decreased resistance to infection
• Copper- Necessary for Collagen cross linkage. Result of Deficiency –
Decreased collagen synthesis.
• Iron- Necessary for collagen synthesis enhances leukocytic bacterial activity.
Result of deficiency- Anemia, impaired tensile strength and impaired collagen
cross linkage.
• Zinc- Necessary for cell proliferation and cofactor for enzymes. Result of
Deficiency – Slow Healing and Alteration in taste
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Wound Care Dressing Categories
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Calcium Alginates ( Algisite, Silve sorb, Sorbsan)
Description:
– Non-woven mass of calcium-sodium alginate fibers that form moisture retentive
gel on contact with wound fluid; non occlusive, derived from brown seaweed –
rope or flat dressing form
– Requires secondary dressing cover
Indications:
– Partial to full thickness wounds with moderate to heavy exudates
– Autolytic debridement of yellow slough in deep wounds with uneven wound beds
– Odor control
Disadvantages
– Are not recommended for wounds with light exudate or dry eschar
– If wound bed dry, the dressing will not form gel and may adhere to granulation
tissue causing trauma
Reminders
– Irrigate wound between dressing changes
– Do not use in dry wound
– It is inappropriate to moisten this product before using
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Wound Care Dressing Categories
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Category
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Description
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Gauze
– Absorbent, 100% meshed cotton fabric, available in pads, strips, and rolls, of either tightly or
loosely woven material.
– Used as primary and secondary dressing.
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Indications
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Superficial and cavity wounds
Wounds with moderate to heavy drainage
Filler for packing dead space in large wounds
Mechanical debridement of slough – (wet to dry)
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Disadvantages
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Reminders
– Some products may shed, leaving lint in wound bed
– Permeable to moisture and bacteria leading to risk of contamination
– If wound becomes too dry, removal will cause trauma to wound bed
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Wound Care Dressing Categories
• Categories
– Hydrocolloids (Replicare, Duoderm)
• Description
– Occlusive wafer dressing, containing hydrophilic colloidal particles
(pectin, gelatin, elastomers) in an adhesive compound laminated onto a
flexible water resistant outer layer Used as secondary dressing.
• Indcations
– Autolytic debridement of minimal to moderate amount of
slough/necrosis
– Prevent secondary infection from contamination
– Maintain moist wound surface
– Provide limited to moderate absorption
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Wound Care Dressing Categories
• Disadvantages
– Occlusive properties can promote infection in high risk patients
(anaerobic infection)
– May dislodge with shearing or friction
– Dislodges with heavy exudates
– May tear fragile surrounding skin when removed
– Unpleasant odor upon removal
• Reminders
– Should not be used on infected wounds.
– Change every 3 – 5 days
– Do not use with fungal lesions, herpetic lesions, wounds with deep
tunnels, tracts and undermining
– Apply wafer 1-2 inches larger than wound
– May secure edges with tape
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Wound Care Dressing Categories
• Category
– Hydrogels (Solosite, Intrasite gel and hydrogel wound
dressing)
• Description
– Semi-permeable hydrophilic polymers composed primarily of
water or glycerin; available in gel, sheets, or impregnated
gauze form
– Requires a secondary dressing
• Indications
– Support autolytic debridement due to moisturizing effects
– Maintain moist wound surface
– Pain relief in radiation-damaged tissue and superficial burns
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Wound Care Dressing Categories
• Disadvantages
– Not indicated for heavily draining wounds
– May contribute to periwound maceration
– Not indicated for the management of chickenpox and
shingles lesions, and 3rd degree burns
• Reminders
– Sheet form is most appropriate for partial thickness wounds,
should be cut to fit the wound, change every other day
– Gel form frequency is once or twice a day
– Do not use sheet form if wound is clinically infected
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Wound Care Dressing Categories
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Category
– Transparent Films (Tegaderm, opsite)
Description
– Adhesive, transparent polyurethans and polyethylene films, semi permeable
membrane dressing that is waterproof yet permit oxygen and water vapor to cross
the barrier while remaining impermeable to bacteria and contaminates. Used as a
secondary dressing.
Indications
– Supports autolytic debridement. Maintain moist wound surface.
– Provides protection from friction, shear, microbes and chemicals
– Allow visualization of the wound
– Used as cover dressing
Disadvantages
– Does not adhere well in moist areas
– The Adhesive may cause stripping of the surrounding skin
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Transparent Films Continued
• Disadvantages
– Not recommended for exudative wounds
– Contributes to peri-wound maceration
– Contraindicated with infected wounds
• Reminders
– Need approximately 2 inch border on intact skin
– Skin must be clean, some manufacturers recommend defatting skin with
alcohol and using a sealant prior to application
– Frequency change is every 3 days
– A build up of exudates is indicative of autolytic debridement and a normal
occurrence, change if exudate is beyond wound borders
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Topical Ointments
• Antibiotic Ointment - Chemical agents that eliminate living
organisms pathogenic to the host; broad-spectrum antibacterials
are useful for mixed infections (frequently more than one
pathogen is present and quick identification is difficult) Avoid
long-term usage of antibacterials, to prevent the development of
resistance. Check for allergies.
– Bacitracin – effective against gram positive cocci and bacilli
– Gentamicin - effective against gram negative organisms including E.Coli,
and Pseudomonas
– Bactroban – effective against staph aureus, MRSA, beta hemolytic
streptococcus,
– Neomycin Sulfate – effective against most gram-negative organisms
except Pseudomonas
– Polymyxin B – effective against Pseudomonas and other aerobic gram
negative bacilli
– Neosporin/Triple A – is a combination of Polymyxin B, Bacitracin Zinc,
and Neomycin sulfate, and
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– Polysporin – is a combination of Polymyxin B and Bacitracin Zinc
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Topical Ointments cont’d
• Medihoney - Promotes a moist environment
conducive to healing; Highly absorbent, for
excellent exudate management; Cleanses and
debrides due to its high osmolarity; Helps to
lower the wound pH, for an optimal wound
healing environment. Non-toxic, natural, and
safe. Available in alginate, colloid, and tube
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Topical Ointments cont’d
• Polysporin Powder – antibacterial powder containing Polymyxin B sulfate
and zinc Bacitracin, effective against gram-positive cocci and bacilli, Neisseria,
Haemophilus influenza, Pseudomonas and other aerobic gram-negative bacilli
but not against proteus and serratia species.
– Sensitization can occur after long term usage.
• Silvadene Ointment - Silver Sulfadiazine; has broad spectrum antibacterial
spectrum including staphylococcus aureus, E. coli, Pseudomonas aeruginosa,
Proteus mirabilis, candida albicans
– available by prescription only
– Hepatic and renal impairment
• Enzymatic debrider (Santyl Ointment) - A proteolytic enzyme that
debrides necrotic tissue from wounds without destroying healthy granulation
tissue; use once a day; collagen specific; manufactured by Healthpoint
– available by prescription only.
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Topical Ointments cont’d
• Xenaderm Ointment – topical ointment containing balsam
peru, trypsin, and castor oil. Balsam peru is a capillary bed
stimulant with a mild bactericidal action, trypsin assists in
debridement of necrotic tissue, and castor oil reduces premature
epithelial desiccation.
– Utilized twice daily & prn for treatment of stage 2 wounds, denuded or
excoriated tissue, works as a moisture barrier/protective coating of skin.
Used with or without a secondary dressing.
– Do not apply to fresh arterial clots
– a temporary stinging may occur at application
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Wound Stages and Treatments
• Stage I lesions may not require dressing
• Stage II, III and IV Lesions
– With a clean granulating wound bed (minimal drainage)
• Apply hydrocolloid dressing (Replicare), or hydrocellular
foam dressing (Allevyn Thin) Change every 3 days and
prn.
– Wound with moderate to heavy drainage
• Pack with calcium alginate dressing (Aligisite M)
• Cover with: Hydrocellular foam dressing (Allevyn
adhesive, Allevyn Plus Adhesive)
• Change every 3-5 days and prn
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Question
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Wound Stages and Treatments
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– Wound with moderate to heavy drainage (Continued)
You may also cover with:
– Composite border dressing
• Cov-R-Site, Cov-R-Site Plus
• Change more frequently every 1-2 days and prn
If tunneling is present
– Pack Tunnel loosely to fill space
Minimal to no drainage
– Gauze dressing soaked with hydrogel
• Soak sterile gauze with Solosite
• Moderate to heavy drainage
– Calcium aliginate dressing :
• AlgiSite M Rope Dressing
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Wound Stages and Treatments
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Assess for signs of infection; if signs of infection are present
– Apply silver antimicrobial dressing
• Acticoat, Acticoat Rope
Cover with a secondary dressing
– Allevyn Adhesive, Allevyn Plus Adhesive
• Change every 3 days and prn until infection resolved
If silver antimicrobial dressing contraindicated apply
– Metronidazole paste 1% applied to wound or
– Metronidazole tabs 250 mg (crush into a fine powder unlike to 500 mg
dose): crush 1-2 tabs and apply to wound. Cover with composite border
dressing :
– Cov-R-Site, Cov-R-Site Plus
• Change daily until odor and exudate controlled
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Skin and Skin Structure Infections
• The skin is the body’s natural barrier or defense
mechanism
– Skin infections are the most common type of
infection
– Skin infections may involve any or all layers of the
skin, muscle or fascia
– Skin infections may be rapidly spreading and may
lead to sepsis or other serious infections
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Presentation of Skin Infections
• Due to various types of skin infections, presentation
will be specific to the type of infection. Typically the
area will be erythematous, tender, warm and swollen
– The following conditions increase the risk of
infection
• Increased concentration of bacteria on the skin
• Excessive moisture of the skin
• Occlusion of blood supply to an area of the skin
• Availability of bacterial nutrients
• Damage of the skin, allowing bacteria to penetrate
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Definition/Description
• Primary: Usually caused by one bacterial species (normal skin
flora) to an area of normal skin (e.g,, cellulitis, pyoderma).
• Secondary: Usually polymicrobic and occurs at an area of
previously damaged skin (e. g diabetic foot infections, decubitus
ulcers)
• Fungating tumor or ulcerated wound: A malignant cutaneous
wound that proliferates into and through the epidermis. The
presentation is typically a fungus or cauliflower-like appearance,
and commonly has a foul odor. The odor is typically caused by
aerobic (pseudomonas, proteus, klebsiella ) or anaerobic
(Bacteriodes fragilis) bacteria or necrotic tissue
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Pharmacologic Therapy
• Duration of therapy for the treatment of skin/skin
structure infection is limited to 14-21 days. The patient
should be reassessed for appropriateness of therapy at
that time for either continuation of current regimen or
switching to alternate therapy.
• The choice of an antibiotic can be narrowed down by
C+S data.
• Alcohol and alcohol-containing medications should be
avoided in all patients prescribed metronidazole
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Treatment Algorithms for Skin
Infections
• Does the patient have a fungating tumor or a foul smelling
wound
– If Yes, next see if the patient has a contraindication to
metronidazole
– If No
• Treat with Metronidazole 250-500 mg po/IV tid to qid
for 7-14 days
• Or Metronidazole Paste 1% apply to affected area daily to
bid for 7-14 days
• Or Metronidazole tabs 250 mg (1-2 tabs) crushed and
applied to wound daily-bid for 7-14 days
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Treatment Algorithms for Skin
Infections cont’d
• If response is incomplete
– Repeat course of therapy
– Or Clindamycin 300 mg po qid for 7-14 days
– Or consider aerobic bacteria etiology (pseudomonas,
Proteus, Klebsiella)
– May use either a 1st or 2nd line agent based on
clinical information
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Question
• DM is a 73 year old male with stage III CKD with his first
episode of a foul smelling stage three wound on his coccyx.
Since DM is in considerable pain he can barely tolerate wound
dressings and he admits to consuming a couple of drinks too
many on the weekends. What systemic antibiotic would be
appropriate to treat DM’s skin infection.
• A) Metronidazole 250-500 mg po/IV tid to qid for 7-14 days
• B) Clindamycin 300 mg po qid for 7-14 days
• C) Amox/Clav potassium 250-500 po q8h or 875 mg po q12h
for 7-14 days
• D) Do nothing and observe the wound
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Treatment Algorithms for Skin
Infections cont’d
• If the patient has a fungating tumor or foul
smelling wound and does have a clinical
contraindication to metronidazole
– Clindamycin 300 mg po qid for 7-14 days
• Good-many gram positive anaerobes
• Moderate Staphyloccus aureus including some MRSA,
Streptococcus pyogenes, Gram negative anaerobes and
Chlamydia trachomatis,
• Clindamycin has more variable activity than vancomycin
against such pathogens as MRSA and S. pyogenes
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Treatment Algorithms for Skin
Infections cont’d
• If response is incomplete, subsequent to clindamycin
therapy
• Repeat course
– Or
• Amox/Clav potassium 250-500 po q8h or 875 mg po q12h for 7-14 days
• Unasyn 1.5 g IV q6h or Zosyn 3.375 grams IV q6h if pseudomonal coverage
is required.
• Cefuroxime Axetil 250-500 po bid for 7-14 days
• Cefpodoxime 400 mg po q12h for 7-14 days if npo may use ceftriaxone 1-2
gram iv q24 hours for 7-14 days . If pseudomonal coverage is needed ,
ceftazidime 1 gram iv q8 for 10-14 days
• Ciprofloxacin 250-500 mg po/iv (200-400 mg)q12h for 7-14 days
• Levofloxacin 500 mg po/iv daily for 7-14 days
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Treatment Algorithms for Skin
Infections cont’d
• If the patient does not have a fungating tumor or foul smelling wound.
(considered uncomplicated skin infection)
– Amoxicillin 250-500 mg po tid for 7-14 days
– Dicloxacillin 250- 500 mg po qid for 7-14 days
– Penicillin VK 250-500 mg po qid for 7-14 days
– Cephalexin 250-500 mg po qid for 7- 14 days
– Ancef 1 gram iv q8 for 7-14 days (assuming normal renal function)
• If the patient is penicillin allergic
– Erthromycin 500 mg iv/po bid for 7-14 days
– Tigecycline 50 mg iv q12h for 14 days (of note tigecycline has poor
anaerobic coverage). Tigecycline has good activity against atypicals,
enterococci (including VRE) staphylococci (including MRSA), S.
pnumoniae, S.pyogenes.
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Question
• MJ is a 58 year old dehydrated woman with stage IV metastatic
breast cancer who comes to your ER with a fungating tumor of
the right breast which is bleeding. What would be your treatment
of choice for MJ?
• A) Tigecycline 50 mg iv q12h for 14 days
• B) Amox/Clav potassium 250-500 po q8h or 875 mg po q12h for 7-14 days
• C) Epinephrine 0.1% (1:1000) Soak gauze with epinephrine and hold dressing
with pressure over bleeding area(s) until bleeding stops
• D) Oral Aminocaproic Acid 5 grams for the 1st dose then 1 gram every hr for
eight hours or until the bleeding the stops.
• E) Have the tumour surgically removed
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Treatment Algorithms for Skin
Infections cont’d
• If response is incomplete, subsequent to previous therapy
involving Penicillins, 1st generation cepahlosporins and
antistaphalococcal penicillins
• Repeat course
– Or
• Amox/Clav potassium 250-500 po q8h or 875 mg po q12h for 7-14 days
• Unasyn 1.5 g IV q6h or Zosyn 3.375 grams IV q6h if pseudomonal coverage
is required
• Cefuroxime Axetil 250-500 po bid for 7-14 days
• Cefpodoxime 400 mg po q12h for 7-14 days if npo may use ceftriaxone 1-2
gram iv q24 hours for 7-14 days . If pseudomonal coverage is needed ,
ceftazidime 1 gram iv q8 for 10-14 days
• Ciprofloxacin 250-500 mg po/iv (200-400 mg)q12h for 7-14 days
• Levofloxacin 500 mg po/iv daily for 7-14 days
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Bleeding associated with
Fungating Tumors
Definitions/Descriptions and
Treatment Strategies
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Diagram of a Fungating Tumor
specifically a Rhabdomyosarcoma
by Dr.Chua, Dr. Premsenthil, Dr. Premsenthil1 & Dr. Tan Suzet2
1 Oncology Specialist, Kuching General Hospital
2 Head of Radiology, Kuching General Hospital
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Definition/Description
• A fungating tumor or ulcerated wound is a malignant, cutaneous
wound that proliferates into and through the epidermis. It
typically has a fungus-or cauliflower- like appearance and has a
foul odor. The odor is typically caused by either aerobic or
anaerobic bacteria, or it may be due to necrotic tissue. Fungating
tumors occur in 5% to 10% of patients with metastatic cancer
and skin involvement, and are most common during the last 6
months of life
• Cancers that are most often associated with fungating tumors
include breast, lung, head and neck, oral cavity, stomach, kidney,
bladder, uterus, cervix, vagina, vulva, ovary, colon, lymphoma
and skin
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Common symptoms associated with
fungating tumors
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Pain
Odor
Bleeding
Purulent exudates
Pruritus
Infection
If the patient is concurrently taking warfarin, NSAIDs, or
antiplatelet medications, these therapies should be withheld until
bleeding from the wound resolved
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Pharmacologic Therapy (Strategies
for managing bleeding)
• Silver Sulfadiazine cream 1%
– Apply to affected area(s) daily or bid. May be used for capillary bleeding
• Epinephrine 0.1% (1:1000) Soak gauze with epinephrine and hold dressing
with pressure over bleeding area(s) until bleeding stops. Epinephrine is a
potent vasoconstrictor. If used to manage local bleeding, must monitor for
signs of wound/tissue ischemia
• Aminocaproic Acid Injection( 250 mg/ml): Soak gauze 2x2 in 5 ml of
aminocaproic acid. Unfold the 2x2 to create 4x4 gauze and place guaze over
bleeding area. Repeat up to four times a day for 7-10 days.
• Clinical notes: In some instances, case reports are the only evidence that
exists to support the use of these products. However, many clinicians have
experience with these therapies and are comfortable with their use
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Systemic Therapy
• Aminocaproic Acid tablets/solution
– 5 grams po x 1 dose initially, followed one hour later with 1-1.5 gram
dose po tid-qid until bleeding stops; continue therapy for 7 days there
after (maximum dose: 30 grams/day).
– Clinical notes:
• Dosage forms include 500 mg tablets and 1.25 grams/5 ml syrup.
• Common side effects include nausea, vomiting, diarrhea, rash,
dizziness, headache and weakness
• Serious adverse effects include bradycardia, hypotension, myopathy,
rhabdomyolysis, renal failure and thrombosis
• Renal dysfunction or oliguria: dose should be reduced by 15-25%
55
Related Symptoms and Keys to
Symptom Management
• Pain- should always be assessed in patient prior to wound dressing changes or
interventions necessary for wound care management. Sometimes giving a
patient an immediate release opiate up to 30 minutes prior to a scheduled
wound dressing change may alleviate the pain and trauma associated with the
intervention.
• Anxiety- Often times patients are anxious in anticipation of a wound dressing
change. Pending on the physical location of the wound and degree of pain
there is also some degree of embarrassment patients experience. Sometimes
premedication with lorazepam or midazolam (also up to 30 minutes prior to
dressing changes) may facilitate the process for nurse, physician and patient.
• Always assess a patient’s pain and anxiety prior to any type of wound
intervention and manipulation.
56
Questions
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References
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2.
3.
4.
5.
6.
7.
8.
9.
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Ladin DA. Understanding dressing . Clin Plast Surg. Jul 1998; 25 (3) 433-41
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Goldberg MT,Tomaselli NL. Management of pressure ulcers and fungating tumors.
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