CW

one needs to know some more details before trying to answer your query

firstly how and why did it occur --> is it a decubitus ulcer i.e. a pressure sore?
does he have sensation in the region?

is he ambulatory or bed-ridden?

can he move in bed?

without knowing all this the only generalized suggestion I can make is about the possible role of Hyperbaric Oxygen Therapy if there is no contra-indication to using it in this particular case.
unsigned

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What kind of infection did he have? It sounds to me like he might have some osteomeylitis. A bone scan of his ischial bones might tell you if he has some infection in the bone. If he does then the wound will NOT heal until the infection is gone. There are generally two ways to heal that kind of infetion. 1) six weeks of IV antibiodics or 2) surgically removing the infected bone area.
RachRN

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Have you looked into osteomyelitis or infection in the bone? This will definitely delay healing until it has been treated.
Sheryl

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I suggest you find a wound specialist in your area. Try looking at  www.aawm.org or www.wocn.org to find board certified specialists of various disciplines. It's impossible to make good recommendations without a full assessment first.
Renee C., MSPT, MPH, CWS

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It would be good to have a little more information about your husband but without knowing:

1. Most importantly, is he keeping the pressure off the area to allow for healing? Without compliance on your husband's part to keep the pressure OFF this area, you will not get healing.

2. Has his nutritional health been evaluated, i.e. prealbumin, albumin levels?

3. Has the infection been adequately addressed?

I would recommend that he go to a good wound care center for help - call your area hospital and ask to speak to their ET nurse (if they have one) for suggestions where to obtain good wound care. I wish you the best.

Becky

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I have seen where if you place a small strip of something like algisite, not packed, in that type of a wound with a secondary dressing such as simply a 4x4 and change it daily it will resolve.MM,lpn

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How much pressure is on the area? He may need to spend 22 out of 24 hours in bed to keep the pressure to a minimum and allow the wound to heal. However, that is unrealistic for most people. Have an Occupational Therapist check his seating (I assume he is in a wheelchair) and his cushion to make sure it is appropriate. Wheelchair push ups every 15 minutes will also help relieve pressure. You don't give much description of the wound. Make sure it is clean and covered by a dressing that will absorb moisture but not dry it out. If it is infected or heavily contaminated, you may need an antibiotic or antiinfective agent, but not peroxide, iodine, betadine, etc., that will damage healing tissue.

Nancy B. RN CWCN

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Please mention if he is a paraplegic. One of the local flaps can be safely used to close the wound.

Dr.V.Alamelu

Plastic Surgeon

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Have the Doctors suggested skin graft/ flap???

Tim Biggs PTA

Unsigned (depth)

For example your charting might read :

"Sacral wound noted length: 2.5 cm, width: 2.3 cm, visible depth: 0.5cm however noted eschar in center of wound consisting of 30% of wound bed true depth unknown until debridement complete."

This way you are charting depth prior to debridement (if done) and the depth of the wound after debridement isn't such a shock to the facility or family.
Tina (LVN/ Tx nurse)

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You can't stage a wound that has a necrotic base. You can certainly  measure it, though. Just remember that it will get bigger before it gets smaller, as it is debrided and cleans up. The base will lower as it gets towards healthy tissue.
Renee C., MSPT, MPH, CWS

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No, the depth of the wound cannot be
measured if there is slough or eschar...unless
the slough is loose and cheesy- like which can be
removed with irrigation or in dressing change and reveals a red wound bed after removal of this material...or the amount of slough is down to a thin film on the wound base. It may help to refer him to NPUAP site where they include guidelines on staging and mention "depth."
Maria C., PT, CWS

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I measure depth on wounds with eschar or slough, but in the wound description I specify that there is non-viable tissue on the wound bed. You cannot STAGE a pressure sore that has debris covering the floor of the wound unless of course you can see tendons, muscle, or bone somewhere and therefore know it is a stage 4.
Vicki F, MSPT, CWS

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A wound with eschar or blackness can not be staged. YOU can measure the depth of the wound that you have but you should carefully document that the wound is ".4cm deep with black eschar in the center and yellow slough at the edges" or something like that so that you "qualify" the fact that you have a measurement, but it's not a "true" measurement.

Rachael Nottingham, RN, BSN

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I was also taught that the depth is undetermined if there is slough or eschar present. How can you measure depth if the bottom of the wound cannot be seen.

Ronna Mincey-Meece RN
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You are not able to measure the depth of a wound when necrotic tissue is present.
Amy Pastor RN CWS

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I can't see how you can acurately measure depth if you cannot get to the wound base. It would be either StageIII or unstageable. MM,LPN,Wound care nurse

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Hi: Good question. The way I have learned is: If a wound is 80-100 % it's not stageable. Slough can be considered moist eschar and the same principle
can apply. However if the wound is 2.0 cm and the wound bed is covered with a thin layer of slough--You could possible stage this as a 3 .
Best Regards,

Jamie B. Pinnock, RN

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You cannot tell how deep the wound bed is until the slough tissue is debrided. The depth of the wound would be measured to the level of the slough. I currently have a lady with an ulcer on the coccyx. The slough tissue is now removed and the ulcer measures about 1 inch deep, whereas, prior to slough removal the ulcer measured about half an inch in depth.

Nancy B. RN CWCN

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No, you cannot measure wound depth because you cannot visualize the wound bed depth. Hope this helps

unsigned

I'd rather see Neosporin on it than leave it open to dry. Dry wounds
don't heal as well.
Renee C., MSPT, MPH, CWS

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Hi Julie, wound care now adheres to the "moist wound care" theory of keeping the wound clean and moist to promote healing. The antibiotic ointment is a good idea although I would hope he is also washing it daily with a mild soap and warm water (i.e. in the shower) before applying the ointment. Using NSS is always a good idea but not absolutely necessary. Hope this helps. Becky, PT

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cleanliness is a pre-requisit to healing

it would be advisable to ask him to have a head wash daily with his usual soap, no special medicated soap after which he could apply any non-irritant cream or powder such as mupirocin, nadoxin, silversulphadiazine powder. long-term continuous use of neosporin is not advicable because of the risk of complications. these could be applied over the strapping if the strapping is necessary

unsigned

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Julie,
The presence of hair follicles actually helps healing,
but it depends on how deep the wound is. The hair
follicles has epidermal cells which help resurface
the wound. If it is deep however and a clean cut,
it should heal well by just the approximation of
the edges alone and securing with steri strips.
You may need to shave off hair around the wound
to really short if you think you can manage
keeping debris from the wound (maybe up to 2 inches from the wound edges. This will just make it
easier to manage the wound and keep cleaner.
Saline or sterile water is best to use to irrigate.
Sometimes, when the wound does not look
clean, it may be necessary to use peroxide, but NOT to flush but maybe pat the surrounding area and
the incision line with gauze slightly wet with
peroxide. If a part of the wound is gaping, I
wouldn't use peroxide but use sterile water only. You don't need to apply an antibiotic cream unless
keeping the wound clean is an issue. Look out
for a healing ridge which the wound should have
by as early as the second week. This will let you know the wound is filling in. I would protect it with gauze though.
If it has necrotic tissue (slough or eschar), I'd consult
someone about using a pulsevac to debride.
Good luck,
Maria C. PT

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Whirlpool is an often overused treatment, but it is difficult to say if it is unnecessary in your case since I cannot see the wound. If the wound still as necrotic tissue, it needs to be cleaned up. However, there are other ways of doing it, possibly, besides whirlpools. Whirlpools are often not the best for extremities that have compromised blood supply.
An alternative might be pulsed lavage, which is a "water jet"-like set up to clean the wound.

Your best bet would be to find a wound specialist to go to. Make him/her explain to you what is going on in terms that are understandable. Find a CWS at www.aawm.org.

Vicki, MSPT, CWS

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Dear Robin,
I suggest consulting a wound care specialist.
It seems from the location of the wounds (most
distal portion- toes), that this is a circulatory problem.
He already had vascular surgery.
The whirlpool may need to be put on hold. Tissues
which are starved of good circulation may not do
well with application of direct heat. There is
"proximal heating" which is warming up the leg
from a high portion (as on the knees) so there is no direct warming of the affected parts, there is still warming but at "slower rate," (kind of like when you warm up frostbite, you warm this up slow), and there are other ways to increase circulation through properly monitored exercises. Some exercises also help a person develop "collateral circulation," (smaller vessels are sprouted to aid circulation). Has he had an ABI or any vascular study? There are therapy modalities which can help too, even perhaps hyperbaric oxygen. There is also
"Anodyne therapy," which I recommend you look into as well. All of these of course, you need to consult a wound care specialist to see the wound and do further assessment. I hope your husband can also consider reducing caffeine intake and smoking if he is
doing any of these. They cause vasoconstriction, so
vessel diameter is smaller, hence wounds do not get good circulation.
Good luck,
Maria C., PT, CWS

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Robin,
Also, if there is odor, ask about culturing
the wound or doing biopsy to rule out
the presence of infection which can be serious.
Wounds on the feet are a common starting point
for osteomyelitis (infection of the bone). This needs
to be checked. Is he diabetic also?
Again, whirlpool may need to be put on hold,
due to direct heating involved. Also,
immediately after whirlpool, wound begins to
cool down. Wounds cooled down will not have
any cell activity for 2-3 hours sometimes.
Whirlpool is now more used for debriding if
there's a lot of necrotic (dead) tissue. There
are alternative forms of debridement which might
work better for your husband...Again, consult a wound specialist
in your area.
Good luck again,
Maria C. PT, CWS

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Hi Robin, without having more information it is hard to determine whether or not whirlpool is the correct treatment for your husband at this time. Almost all treatments have their correct time and place in wound care but whirlpool's use is very limited. I would probably recommend the use of eletrical stimulation rather than whirlpool. Has your husband been evaluated by a Physical Therapist with knowledge of wound care? There are multiple avenues to explore and it sounds as though the wound care facility you are using is somewhat limited with their approach. Hopefully your husband does not smoke because this is very detrimental to the blood flow to the legs. Also, good nutrition is essential to wound healing so if this has not been checked (i.e. bloodwork to determine levels of protein) it needs to be along with removal of all necrotic tissue in the wound bed and treatment of any infection. Check with the PT department in the VA hospital to see if they can direct you to more effective treatment. If not, try your local hospitals for advice. Sometimes we have to go outside the insurance circle for help and I know this can be expensive, but perhaps a payment plan could be worked out with the provider should you find a good one that is not within the VA system. I wish you the very best. Becky, PT

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hyperbaric oxygen therapy may be of some help provided there is no contraindication for its use.

aloe vera local application has shown good results when used for frostbite cases. perhaps it could be of some help in this case.
unsigned

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Assuming the revascularization was successful, you must now determine what else is delaying wound healing. Is the pressure on the heels been relieved? Does he have any co-exising medical conditions that will delay healing, such as diabetes, and if he does, is that disease under control? What is the condition of the wound bed? Does it look healthy or infected? Maybe you may need to see a podiatrist that specializes in wound care.

Nancy B. RN CWCN