Wound Email - May 30, 2007

Wound Care Information Network

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May 30, 2007

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Previous email questions & their replies are listed below. Remember, replies have not been validated for accuracy or truthfulness.

I am looking for a check off list that would help us determine if a wound is avoidable or unavoidable. I appreciate your help Sincerely Judy Scofield, LPN	Hello, I don’t know of such a checklist, mostly due to liability reasons/setting yourself up for a lawsuit. At our facility, we do the Braden assessment on all admitted patients, and if the score demonstrates an increased risk for skin breakdown, we implement pressure reduction such as pressure-relief wheelchair cushions, low-air-loss mattresses, turning schedule, bridging heels,etc. Even with our protocol, you have to be careful with documentation. For instance, we have to make sure we document that we are following through with our pressure relief measures after ordering them. Vicki, PT, DPT, CWS
I am interested in knowing if you are familiar with any dressings which help with patients who bleed from intermittently from cancer lesions. We have a patient who is having more frequent episodes of intermittent bleeding from her abdomen and groin area. May I get a cost and product information. Karen Truitt, RN, BSN	I think a stomahesive powder is very good for the bleeding cancer lesion. Flora, RN,ET --- I cared for a cancer patient with bleeding lesions on the outside of her neck. I was to apply jelonet (paraffin gauze) onto the bleeding areas and dress with protective dressing after. It did work well. All the best. Direct Service Nurse. BEE L.P.N.
Hello Please can you tell me if MDT can be used on a patient with dry gangrene. My elderly father has gangrene in both feet, he is not a diabetic but has had problems with his circulation for some years. So far he has had 3 toes removed from his left foot but is not likely to have any further surgery because of his age (96). I wrote to his doctor requesting that he consider MDT but he wrote back and told me he would not be following up on my request because dad has dry gangrene and the treatment is not appropriate. Is this correct? Nothing that I have read about the treatment has indicated that this is the case. I don't know much about gangrene but dad has some pretty nasty sores which certainly don't look dry to me and his feet smell like something that died a week ago and he is in constant pain. Regards Colleen Macgowan	Now, I am unsure if this practice is recognized now; but one client, I was to apply betadine sol’n to the toe lesions and placed 2 by 2 dressings between the toes. This was done daily and it kept the lesions dry. If necessary, p.o. antibiotics would be ordered. BEE LPN --- Dear Colleen, Dry gangrene is normally left alone or painted with betadine....however, dry gangrene can become wet gangrene in which case the MD needs to see him. If your Dad is medicare...have a home health agency come out and a podiatrist....medicare pays for both. I am a home health nurse, and I have patients whom have dry gangrene all the time. Preventing an infection is the key. Pat Seemann RN BSN WCC --- Colleen, you father's case sounds complicated and each case is very individualized. I think that any questions of MDT (maggot debridement therapy) should be directed to the expert in this field "Dr. Ronald Sherman" who is also an infectious disease doctor. The web site is BTERFoundation.org Here you can find out more about MDT and all areas of bio-therapeutics. I hope all goes well with your father. Pam Mitchell Patient Advocate BTER Foundation --- Your question is very good and I applaud you for seeking more information. MDT (maggot debridement therapy) can be done on a wound with dry gangrene but there are some very good reasons why you would not want to do this. When someone has poor circulation and their healing potential is poor (due to age, circulation, nutrition, and other medial complications) we make every effort to keep the dry black cap intact. It serves to protect the area and keep bacteria out. When someone has good healing potential we debride that gangrenous tissue so the under surface can heal with out his obstruction. The only time it would be in your fathers best interest to debride (whether with maggots or other method) is if there starts to be drainage leaking out from behind the dry cap or if there is a fluid build up behind the tissue making it fluctuate like a water bed. Sound like your doctor is giving good advise. Good luck! Michelle, PT, CWS --- If his wounds are not dry, then he doesn’t have dry gangrene. Dry gangrene should be dry, and hard as a rock. If an area of necrotic tissue is soft and damp, it is in danger of harboring bacteria and becoming a real problem. Find a wound specialist in your area that will talk to you and answer your questions. Vicki, PT, DPT, CWS
My wound has been diagnosed with MRSA again and now also P.Arginosa. Dr. wants to put in a pic line & treat with antibiotics. Fourth time with MRSA. Will I ever be free of MRSA????? All I want is to be able to swim like I used to!! All this started from a spider bite 7/29/1999!! Feeling hopeless! J Oertwig	Let me tell you from personal experience that a PICC line and iv antibiotics is the only way. Maybe mine was alittle different, but after an auto accident with perforated bowel and MRSA in my hip joint I was on Flagyl and Zypvox for 4 months and oral Flagyl for another 2. I'm MRSA free and swim when I want. Judy --- Where is your wound located? Another question, how was the culture obtained? Was the culture a biopsy or quantitative or swab? How the culture was obtained is very important to determine if it is an acurate result. Is it really MRSA? Yes MRSA can be treated and resolved. How long have you had this wound, and is it healing? I can't offer a lot of help without more information. R DeLaney LPN, CWS, ACCWS --- Nothing makes me crazier than overtreating a wound that isn't infected....but merely colonized. I would need much more information about the wound, but I have many patients that test positive for MRSA and pseudamonas and I treat it with silver products or 1/4 strength dakins and it heals just fine. Spider bites can be a pain and they keep opening up after you heal them. I have done continuous irrigation with vancomycin solution to a spider bite that had tracked....that worked well. Pat Seemann RN BSN WCC --- Hi, I am not a medical professional but I have an opinion on what may help. MDT (Maggot debridement therapy) works on MRSA infections with great success. I had MRSA and other infections in my diabetic ulcers and maggots healed them up quickly and totally. When nothing else could. (Including five different antibiotics and three different pic lines)Please check out our web site for further information and how to order medicinal maggots. You can also contact me through the site if you have any questions from a former patients perspective. Good luck, Pam Mitchell Patient Advocate BTERFoundation.org --- I understand that UVC light can be used to treat MRSA. Also heard that Dr. Andrew Bolton in the UK just published an article on using maggots to treat MRSA with astounding success in just a few weeks. Laurie M. Rappl, PT, CWS --- Consider adding a potent topical antimicrobial dressing to the wound(s) such as Acticoat. It is bactericidal against the most aggressive strains of MRSA (it has been tested and found effective against 188 strains of MRSA). It is also effective against pseudomonas. If your wounds are dry or draining only lightly, moisten the dressing with water to get the full effect (rather than saline). More information: www.acticoat.com. Good luck to you. Lee Ann --- Hello, I have treated lots of spider bites. They can be tough. I have the best results with them when I can do daily pulsed lavage with suction (a method of cleaning wounds sort of like a water pic), and use silver dressings on them while the MD has the patient on antibiotics. The lavage removes dead tissue and decreases the bacterial “load” in the wound, and the silver is antimicrobial also. Find a wound specialist in your area who can help. Vicki, PT, DPT, CWS --- I don't know where your wound is located but we have had several battles in our nursing home with chronic MRSA wounds. I know that this isn't a normal treatment but I believe I would try Dakins solution until healed. (1/4 strength -rinsing wound BID. If wound is large, after rinsing in Dakins, use a saline dampened Kerlix gauze impregnated with TRIAD by Colorplast paste to pack.) Ask your physician to order Zyvox orally. The Zyvox is great for MRSA - better than Vanco but also comes with a hefty price tag. However - the treatment is systemic and topical. If the wound keeps opening - it may be in the bone. This treatment has worked for us, hopefully it will help you. Cindy RN WCC
I'm interested in finding out how one would go about treating a postpartum vulva and perineal wound originating from surface sutures. Now almost 16 weeks after birth, while the wound has closed, a small area of the vulva above perineum area remains red, as if irritated, despite all sutures having dissolved. The perineum, which has also healed, remains taut and brittle. A 5 day application of Canesten Cream advised by GP has not helped either area. Any suggestions? unsigned	sorry, no replies
I gave birth on Jan 31st and experienced a first degree tear (very minor) of about one inch in my vagina. My doctor stitched the wound with Monocryl sutures, which don't absorb completely until 120 days. After 18 days the top layer of stitches extruded in large pieces--my vagina was very inflamed and I clearly was reacting to the suture material, but in spite of this the wound was healing well with no evidence of infection so my doctor waited before snipping the stitches out at about four weeks, and snipping out two knots at week five. The top layer of the wound was closed and healing at this point, and has healed very well. Unfortunately there is about a half inch of suture material sewn in the layer underneath this top layer which was never removed. I have been suffering incredible pain and inflammation below the surface of the wound as my body has tried to dissolve the suture and heal.I have had no signs of infection. Now, at 12 weeks, an ultrasound shows no signs of obvious suture material or other "foreign" things, but does reveal an incredible amount of inflammation. The pain has decreased, and now I feel mostlly soreness and itchiness in the lower layer of the laceration, but I am still in a serious amount of discomfort. My question is: will this wound heal properly after having reacted to this suture for so long??? Thank you so much, Rosemary	It sounds like you may need to have a more aggressive treatment for the inflammation itself as it appears to have gone form an acute problem to a chronic one. Perhaps a steroid for a week to stop the inflammation process instead of waiting and hoping for the best. You might try an NSAID yourself and see if you get any relief. Yvonne Asay LPN
We have recently taken a CE course where it stated that granulation tissue was present in a stage II wound. Can this be true? I didn't think that a stage II wound would granulated, but rather just epithelialize. Please respond. Thank you! Angie Sostad RN,CWOCN Good Samaritan Hospital, Kearney -Nebraska	Granulation tissue is "scar tissue", which is seen in full thickness tissue destruction. A stage II pressure ulcer is not full thickness destruction, therefore heals by regeneration of epithelium. I would like to have some of the information from the CE program you went to. There is a lot of confusion among nursing when different things are being taught, and we certainly do not need more confusion. My email is rdamt7@yahoo.com. R DeLaney LPN, CWS, ACCWS --- Stage II pressure ulcers are partial thickness wounds, which do not heal by granulation (unlike stage 3’s and 4’s which are full thickness wounds). Lee Ann
I have been diagnosed with polycythemia. I recently have had complications with my feet and developed a clot in my great toe. Due to poor micro vascular perfusion of my great toe I developed 2 painful ulcers on my great toe. I am using aspirin, have had an arterial Doppler which was clearly negative for any large vessel obstructions. Both the ulcers were very painful, red and had minimal discharge. The pain is decreased and really only hurts when I walk on them too much. They seem to be healing but get to a plateau where they have increased pain and sensitivity and look like they may be getting a little bigger again. I have been soaking them in tepid Epsom salt baths for approx. 15 minutes 2 x daily and during the day when I am walking on them and working I have been putting polysporin/ozonol on them and covering them with a bandage. I am going to try the silver dressings this week. I leave them uncovered at night when I am sleeping. There is no exudates from them and the toe will go from pale and white to purple and red very quickly. I was wondering if there were any products that you knew of that may help speed up the healing process and promote a moister environment for the healing process. I can not use anything that increases heat to the area as this actually hurts and makes the ulcers worse. I would appreciate a response to these questions. Thank You, Dawn Young, R.P.N., C.H.N.	A couple of ideas/ suggestion I can offer. Please discuss these with your medial provider or wound care specialist. I am concerned about the self care you have performed to date. Epsom salt soaks are discouraged as they dry the skin by pulling fluid from your body to the concentrated salt solution and expose you to bacteria. Sleeping without dressing on also does not maintain a moist healing environment and exposes your wounds to contamination. To increase your circulation you could see a physical therapist who does wound care. They would have access to electrical stimulation or possibly Anodyne to increase your micro circulation. Then you should have on a dressing (silver is great) that is appropriate for your drainage level. Wounds should stay moist and covered to protect form contamination. Another possible treatment that I have had a lot of success with is Xenaderm Ointment. it s a prescription medication (a 60 gram tube is roughly $60-80 but will last 2-3 months for a couple of toe tips). There are 3 components to this medication. One is intended for debriding a wound but it is so gentle and mild, I consider this to be more effective in keeping a wound free of dead tissue. The second component is simply a protective barrier so a cover dressing is not needed to kept contamination out. The last ( and most important) component is Balsam Peru. This is a vasodilaor that can cause an increase in local circulation by 50%. You can do this yourself and you don't need bulky dressings that make your shoes to small. its highly effective an smells good. But you do need to apply twice a day, many insurances will not cover the cost of the Xenaderm and you should expect it to take 2-4 months (bear in mind I have never seen your wounds and do not know you full medical history...) Please consult someone well versed in current wound care treatment strategies. Michelle, PT, CWS --- We have had experience with patients presenting with polycythemia and also ulcers on their feet from the disease. We used a good old fashioned UNNA boot to heal. It worked quickly as well. God bless!! Cindy R. RN WCC

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