Navi

Also looking for something called MIRE.

Thanks
Frank

KellyMarinedog@aol.com

Robin

Ed

Priscilla

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Priscilla,

I have two article regarding the use of phenytoin in wound healing. Both from pharmacy journals. One is a case report of a patient with massive
grade IV pressure ulcer that was unresponsive to conventional treatment and the other was a comparison of phenytoin with two other standard treatments for patients with stage II decubitus ulcers. I can send you copies if you would like. Please email melissa.naylor@med.va.gov

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have used dilantin for treatment of wounds. Since dilantin has a side affect of hypergranulation (seen in the gums of dilantin users) it is used to promote granulation of tissue in wounds. We used it on a hospice patient with 3 stage 3 wounds and they actually healed before she passed away. I haven't seen the documentation but I have seen the results.

Application technique: We used mepitel, it is a silicone mesh (decrease pain due to exposed nerve endings and prevent destruction of microscopic granulation) directly over the wound. Dilantin powder was sprayed onto the wound bid. Using the mesh you don't cleanse the wound unless there was copius amounts of drainage. You just rinse off the mesh and then replace onto wound.

unsigned
 

JB

Jen

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Hello Jen,

I have had some experience with long-standing wounds in an alcoholic before. The main problem that I have read about and heard about with alcoholics is that their nutrition is so terrible, and this results in overall physiologic disturbances as well as simply starving the wound of adequate building materials. I don't right off hand have any references for you though! Sorry.

Vicki F. MSPT, CWS

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I would suggest to get ABI's done bilateral and if it shows no arterial compromise and truly is a venous ulcer, we have found a compression wrap/profore dressings have been successful. We have had long-term leg ulcers( 6 years), healed in about 6 months using this dressing.
TL

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Check you patient for history of Diabete,
Was the patient ever in Vietnam?
Check of exposure to chemcals such as Agent Orange or similar type chemicals.
Has the patient worked in construction?
Check on exposure to chemicals or hazards.
Do not be so ready to blame or cite alcohol for wound problems search deeper and more intestity on other causes.

Robert

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This sounds very scary to me. I would take this person to a wound specialits immediately. The current treatment does not sound appropriate and the odor you are smelling may very well be just as you described "rotten meat". I urge you to seek further medical attention now! Good luck.

JW

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MMM... I can't tell you not to follow the advise of her physician, but if you feel as if something is wrong there is nothing wrong with seeking a second opinion...if you feel as if she needs to be evaluated take her to the emergency room...I would also suggest her going to a wound specialist or clinic.

JP

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Beth,
I know that in wounds that are very wet and draining that colonization ( excessive bacterial growth) and subsequent infection are significantly increased. Usually in my practice - patients with large amount of edema and drainage start with frequent dressing changes with unna boot- ie qod- usually after a couple of dressing changes the drainage is significant reduce and the frequency could be backed off. Excessive drainage and odor are sign of infection. Also it is very important that blood sugars are controlled or the risk of infection is increased. You are right to be concerned!. Also is a compression dressing ( coban) being used with the unna boot.
Jerri D, RN, CWCN, COCN

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I don't know if this is any help but if I were you I would first want to establish whether cultures had been done or not and do one if not, if infection is present she needs the dressing changed at least every three days if she is being treated with a systemic anti-biotic, otherwise daily,
the chances of this wound improving under the present conditions is nil while there is pitting odema especially, because she obviously had arterial disease (diabetic origin) it will be difficult to improve the odema (compression bandaging won't be an option) and maybe antidiuretics if they haven't been tried already might be useful. Diabetic ulcers are among the hardest to heal and it seems to me that your aim should be to keep the wound clean and free from infection as healing is unlikely, it seems to be a maintenance situation. The idea of charcoal dressings as you will know is to reduce odour but to leave it for two weeks seems incredible. Ask the doctor what his rationale is - I would be very interested in what he replies.
Also how long has he been treating this wound and what improvement has there been so far ?
Hope this is some help
Maria M RN

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Hello Beth,

Definitely ask questions, and find a new doctor who will talk to you and take better care of this problem!! In my opinion, Unna boots are overused and changed too infrequently, especially if this one is getting soaked like you describe! An alternative to Unnas are the newer 4-layer bandaging systems for vascular insufficiency. Only someone who can see the wound will be able to guide you on a different path, but I would get another opinion.

Vicki F., MSPT, CWS

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I would seriously consider changing doctors, or at least getting a second medical opinion.

By the sounds of it, the wound is infected. There is a strong possibility the smell be due to the dressing not being changed.

I would strongly advice the nursing staff take the dressing down and cleanse the wound, despite what the doctor orders.

Either way, unless something is done, there is every chance of your relative could develop further complications.

Martin

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You need to find a new doctor quickly!

unsigned

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I would suggest contacting one of the wound care companies such as Convatec who already have simular studies and can provide you with a lot of data including dollars and cents info.

JP

Rachael

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Rachael-I am doing the same thing for primary full depth wounds. I am just starting and would love to hear your findings.
Florence
 

You can put all the topicals you want on a venous ulcer, but if you don't get to the cause of the problem, you won't have much success. First, make sure the arterial supply is good, though an ankle-brachial index or non-invasive arterial study. Once that is cleared, they need to use compression. The multi-layer compression wraps work well, especially if someone isn't super active. Since he has had antibiotics forever, of one type or another, I would definitely culture. He probably has resistant organisms now. See also the responses to Barbara above. She had a similar question. Renee C., MSPT,MPH, CWS

Diane, It sound like to me you nursing home patients needs Arglaes Film. This a antimicrobial barrier film dressing that releases silver into the wound bed. The dressing change would be to cleans the wound with saline, then apply a calcium alginate to the wound bed. This will absorb drainage. Cover with the Arglaes. This is a seven day dressing. If there is a very large amount of drainage holds can be cut in the Arglaes to allow some of the drainage to pass but not enough to dry out the wound. If using the holds, cover with gauze dressing and change the gauzes as needed leaving the Arglaes in place for the seven days. Arglaes will decrease the infection in the wound and allow for autolysis of any necrotic tissue that may be present in the wound. We have used this same treatment in our hospital and have had great results. Sherri, RN

Diane- I have had a couple of patient recently that I have venous ulceration that they have had 6-7 years. I would first ask - What is the patient circulatory status. If he has good pulses and warm feet with good capillary refill , then this patient would be appropriate for a compression dressing such as profore by smith and nephew ,surepress by convatec, or unna boot etc. I have had lots of success using the Aquacel Ag by Convatec to the wound bed and then the compression dressing over that. The Silver decreases the bioburden while the aquacel provides for absorption. Hope this was helpful, Jerri Drain, RN, CWCN, COCN

Hello Diane,   I believe Silvadene is much overused in wound care, and it sounds like that may be true here. For venous insufficiency, compression wraps are something to try, and the newer systems like Profore are nice because they provide compression but don't (if applied properly) restrict arterial flow into the limb even when the legs are elevated, like in bed at night. I would go to a wound clinic if you can, and ask questions.   Vicki F., MSPT, CWS

Diane, First of all if a wound has a protein destroying orgainism growing then the wound will never heal due to the fact that the organism eats the new cells that are forming. First of all see what your facility policy is for obtaining wound cultures. If your facility does not have a standing policy then ask the physician for the order. You will need both anerobic and aerobic cultures. If the cultures are negative then a treatment that has worked for me is good cleansing with sterile NS, application of hydogel with colligan( made by Holster) cover with a Nugel wafer and secure, change the dressing every 72 hours. Since the Nugel wafer is clear then this allows you to assess the wound daily without removing the dressing. Also address the patients dietary and vitamin needs. Increase protein intake if not contraindicated and it is recommended to have them on Z-gen, which is a complex vitamin with Zinc Sulfate which is great for increasing healing ratio, Vitamins E, A, and C is also recommended. Good luck and let us know how things turn out. A wound care facility is also a good idea. They can do amazing things.......Jan

Compression bandaging is the best therapy for venous leg ulcers after confirming the patients ABPI to exclude arterial disease.You may find it useful to obtain a book by Moya Morrison and Christine Moffat called A Colour Guide To The Assessment And Management
of Leg Ulcers.Published by Mosby 1995
 

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That small opening present for so long sounds like it might be a drain hole for a bone infection. He should have some type of study (MRI, bone scan) to see if there is one. If so, then several weeks of antibiotics should help, and it will probably heal at that point.

Regarding the pool, and covering it. It should not be left open to air. That increases the risk of infection, and it heals better when kept moist, not
dried out. If he wants to go into the pool, then it should be covered with an waterproof dressing, such as a film or hydrocolloid. I don't know what kind of dressing you're using, but talk with the doctor to see what kind of dressing you could use on top to make it safe to go in the water. If he goes in without the barrier, then he increases his risk of infection and could get dirty water deep into his wound, and any germs from his leg could get into the water.

Renee C., MSPT, MPH, CWS
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Pam

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GOOD MORNING, PAM, I am not a certified wound care RN, (my job is Infection Control) but I am very interested in wound care, and I acquired that "job" because of my desire to see good wound care in our patients...now for your need... Have you ever been told about the Aquacel Ag (Aquacel with Silver - made by Convatec) for wound care? It works very well for long-term wounds...You put it in the wound bed (especially if there is any yellow slough noted) and pack the rest of the wound cavity with a Kerlix AMD dressing (made by Tyco Kendall). The Aquacel Ag is changed every 3 days but the Kerlix AMD is changed everyday. I have just completed a one-month long treatment plan with a patient who was an assault victim on April 1, 2003, and there is a deep, Stage IV on the coccyx...you would not believe the difference this treatment made. I was so excited to be able to transfer him to a long-term care facility near us that does good wound care. Let me know if you need any other information. I'll be glad to help with anything.

Louise, RN

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Pam
The VAC could maybe work for you

You can look up information about in at KCI's web site

VAC stands for Vacuum Assisted Closure. THis works on all kinds of wounds.
Jerri Drain, RN, CWCN, COCN
 

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depending on the size of these wounds sound like you would benefit from a wound Vac system. The wound Vac plays several roles in wound healing one of the most important is it stimulates the tissues to draw from the body all the necessary elements for healing, improves circulation to the area and removes extra exudate. Talk to your physician and see if you are a candidate. Good Luck......Jan

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 Pam,
I'm guessing you have ulcers that aren't healing. I've handled bed sores before and daily exposure to UVR(ultraviolet radiation)machine, after cleansing and before dressing, has proven to be effective in drying up the wound. If you have no access to this, try exposing your wound site to the sunlight in the morning...it would help kill harmful bacterias and stimulate wound healing. Do this for at least 10min. daily.This has no side effects so it won't hurt if you try it.

Blenda, PT

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I live with a C4 quad who developed the same problem. Pressure relief here is essential. When you are in bed try positioning your legs apart to open that area, especially at night when you are asleep, during the longest period of pressure relief time you have available. Sounds like you are also dealing with a fungal problem that needs something more than a topical cream. Check with your doctor about trying Diflucan. Shaklee makes a great product called Optiflora that helps to increase the good bacteria in your colon to fight the overgrowth of yeast. You can read about it at www.shaklee.net/yvonne. Hope this helps, Yvonne

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Are you referring to "Dakins solution"? Not much one can do with a non compliant patient. However, I'm sure I don't have to remind you to document, document, document. Since this person has no family to help in your situation and this wound does jeoparidize her health, how about Adult Protective Services? You don't mention this patients mental capacity to make decisions, etc. Has a wound specialits seen this patient?

JW

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Have you thought about fibracol dressing? We have had good luck with it with some of our residents. Cleanse with Carraklenz, apply Allcare to surrounding tissues and then place the fibracol to the wound base and cover with a light dressing. This may help.
April RN

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Hello Kahne,

First off, if the pt has no infection, I would stop the Dakins. It is terrible on granulation tissue! Second, if a patient is that non-compliant, my agency would have to discharge him/her after offering as much help as possible and social services to try to get the pt assistance.

Vicki F, MSPT, CWS

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Consult an angiologist and have a doppler test it
could be that the root of your problem stems from
venous hypertension.
Janine

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Mary,
Hi! I am a physical therapist and work with an orthopedic surgeon. I'm concerned about what happened to your leg. Have you gotten an x-ray of your shin? Based from your history, it is possible you might have had a fracture of your tibia (shin bone) that's why the bruise hasn't healed at all. If not, you might have torn some leg muscle. Assess yourself if you have an inability or difficulty to move your foot up and down or sideways. I also think you might have some circulatory problem since you stated your condition and cutting down on your weight might help. Make sure though that you really don't have diabetes co'z in some cases, diabetes along with hypertension makes it hard for wounds to heal. Or better yet, go see a good orthopedic doctor, it will save you more money than you think you will by not going to. Trust me.

blenda