Wound management training 1: Types of deep tissue healing

GMH 2007 • Wounds heal by one of 2 ways:

– regeneration, which only occurs in the epidermis
– repair, which occurs in any tissue deeper than the epidermis

• Wounds that regenerate tend to require little or no

intervention

• Deeper wounds that heal by repair can suffer

interruptions or complications

• Being able to identify healing by first (primary) intention

or second intention allows for more realistic assessment
and planning

T.Ellis – Director, WoundHeal Australia,

July - 2007

TYPES OF DEEP TISSUE HEALING 1: Types of deep tissue healing

st nd rd
Characteristic 1 Intention 2 Intention 3 Intention • Healing by first intention:
Wound Edges Approximated Not approximated Initially not • Healing by first (primary) intention is
approximated
uncomplicated healing where:
Infection Absent Frequently present Frequently present
– wound edges are joined together
– there is no tissue deficit to fill
Granulation Small amount Large amount Larger amount than in
healing by 1st intention; – no infection
less than healing by 2nd
intention – the scar tissue formed is relatively small
Small Large Larger than healing by
– union of the wound edges occurs in a timely manner
Scar
1st intention; smaller though the actual time taken to heal depends on the
than healing by 2nd
intention
person’s condition

Healing time Short Long/delayed Longer than healing by

1st intention; less than
• Initial union of wound edges would take place
healing by 2nd intention over 7-10 days, though the maturation stage of
Example Surgical wound Venous (leg) ulcer Surgical wound post healing could take up to 2 years.
perforated appendix

1: Types of deep tissue healing

• Healing by Second intention:
• Healing by second intention occurs when there is a
tissue deficit
• The body must fill and contract the wound area in order
to restore tissue integrity
• The body produces granulation tissue in order to
establish scar tissue
• Wounds healing by second intention will always have
more granulation tissue in relation to size than a wound
healing by first intention
• Healing time is longer because of the additional need for
tissue growth

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 2: Overview of healing -
four stage model
• Healing is a feature of the immune system
• When wounding occurs the body devotes an enormous
amount of energy to repairing the damage so that normal
body defenses are restored
• Healing generally occurs in an orderly fashion and
features bleeding, inflammation, growth of new tissue
and scar maturation
• Wounds that don’t heal in an orderly fashion represent a
significant burden on the person and may require
specific intervention to facilitate tissue growth and repair

Healing by second intention over a period of 10 weeks

• In order to determine the correct care you must be able
respond to the changes in tissue as wounds heal

2: Overview of healing -
four stage model
• Skin, muscle and other tissue types are highly organized
in their original state
• When wounding occurs the healing process replaces
that highly organized tissue with “filler” tissue or scar
• Whilst scar tissue is very important in restoring integrity,
it is never as strong, functional or visibly the same as the
tissue it replaces
• The new tissue is relatively disorganized compared to
the tissue it replaces and will require ongoing protection
to ensure its maintenance
• There are a large number of co-factors that interplay to Tissue in its original state is organised and
produce new tissue and any interruption to the supply or functional – like this picket fence!
function of these factors will result in less than adequate
scarring

Tissue integrity (the fence!) is restored using materials that

When damage occurs, organisation and can offer similar function to the original but are not as well
function are lost – repair is required! organised or capable of performing exactly the same way.

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 2: Overview of healing - 2: Overview of healing -
four stage model four stage model
• Stage 1: Wounding – bleeding (0 hours to day1)
• Stage 1: Wounding – bleeding (0 hours to day1)

Key events:

Damage to tissue occurs

Decrease in tissue / organ function

Haemorrhage

Clot forms

High risk of bacterial and foreign body

contamination
Wound occurs due to trauma
Extent of wounding impacts on other Note: bleeding indicates wound
has penetrated through to (at
stages least) the dermis
Bleeding occurs following Diagram showing blood clot in
trauma: wound area:
Wound is plugged by clot wound is sealed off from further
that forms as bleeding slows contamination at this point

2: Overview of healing - 2: Overview of healing -

four stage model four stage model
• Stage 2: Inflammation - clearing the wound (days 1 - 3) • Stage 2: Inflammation - clearing the wound (days 1 - 3)

Key events:

Blood vessel constriction (stops bleeding)

Release of substances by cells that cause blood vessel dilation - increase in size
(largely responsible for the redness surrounding wound and the swelling in
tissue)

White blood cells enter the wound area and clear debris and microbes

White blood cells send chemical signals that attract other specialised cells to the
wound area

Process most active 12 - 72 hours following injury (acute wounds)

Inflammation after injury – essential for healing Inflammation extends into deeper tissue

2: Overview of healing - 2: Overview of healing -

four stage model four stage model
Inflammation: clearing the wound continued…

An infected wound showing inflammation induced by bacteria –

same process, different reason White blood cells enter wound area and begin to clear dead tissue and microbes

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 2: Overview of healing -
four stage model
Inflammation: clearing the wound continued…
The inflammatory stage helps the body to clear unnecessary dead tissue as well as microbes from
the wound. If dead tissue and high numbers of bacteria remain in a wound, the process of
inflammation will continue and sometimes causes wounds to “stall” in the inflammatory stage. The
pictures above show how the body clears dead tissue from a wound during the inflammatory stage.
These pictures were taken about six weeks apart demonstrating how long the process can
sometimes take.
2: Overview of healing -
four stage model
• Stage 3: Proliferative stage – growing new tissue (days 3 – 24)
Blood vessels are cleared and new vessels grow into and from the wound; white
cells continue to clear debris; oxygen levels in the wound begin to improve;
redness and swelling reduces;
2: Overview of healing -
four stage model
• Stage 3: Proliferative stage – growing new tissue (days 3 – 24)
Key events: epithelialisation (days 6 – 24)
Tissue matrix provides substrate for migration of epithelial cells
Epithelial cells derived from edges of wound, hair follicle remnants,
glandular remnants
Requires moisture and occurs under scab if one exists
Tissue is pink-white in appearance despite the original skin colour
This is because there is no melanin in the new tissue at this point
New tissue begins to lose its red “see through” appearance
Inflammation largely subsided, the wound area is filled with new tissue (granulation) and
Wound surface area and volume begin to decrease significantly due to
resurfacing (epithelialisation) begins. Note that the wound is beginning to contract now
contraction – up to 80% of closure is due to contraction
2: Overview of healing -
four stage model
Stage 3: Proliferative stage – growing new tissue (days 3 – 24)
Key events: granulation tissue formation (days 3 – 24)
Macrophages and neutrophils (white blood cells) are involved in the
transition from inflammatory to proliferative stage
New cells migrate through wound and begin to divide and produce new
tissue
Specialised cells called fibroblasts begin to increase the production of
collagen which provides the scaffold for new tissue to grow on whilst
adding strength to new tissue
Blood vessels begin to grow from within the wound forming new
capillaries and then join to original capillaries outside the wound area
allowing blood to flow through the wound area and increasing the
amount of oxygen in the wound
2: Overview of healing -
four stage model
Stage 3: Proliferative stage – growing new tissue (days 3 – 24)
Newly formed granulation tissue ready for epithelialisation;
granulation tissue is very fragile and bleeds easily if disturbed by
trauma, for example during dressing changes
2: Overview of healing -
four stage model
• Stage 3: Proliferative stage – growing new tissue (days 3 – 24)
that new tissue is growing. Contraction is the main process by which wounds close
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 2: Overview of healing - 2: Overview of healing -
four stage model four stage model
• Stage 4: Maturation stage – tissue remodeling (24 days – 2 years)
• Stage 4: Maturation stage – tissue remodeling (24 days – 2 years)

Key events:

Epithelial (new tissue) lining becomes multi-layered – less “see through”

Cell growth balanced by cell death

Collagen production balanced by activity of collagenase (an enzyme that breaks
down collagen); if this does not occur properly, scars can be “lumpy” rather than
flat and smooth
Scar continues to form and strengthen, continues contraction
Scar will gradually shrink over time and will eventually be quite pale in colour
rather than the pink colour of newly formed scar An epithelialised wound that is now maturing. This wound is superficial so “scar”
will disappear entirely. In larger, deeper wounds however the scar will remain
In darker skin, the scar will always remain paler then the skin it replaces visible and undergo changes over a 2 year period.

2: Overview of healing -
four stage model Treating laceration
• Stage 4: Maturation stage – tissue remodeling (24 days – 2 years)
• The key to correct treatment is ASSESSMENT

• Factors to assess: depth, trauma, haemorrhage,

wound edges, contamination, pain or loss of
sensation, location

• Administer first aid – refer after assessment…

Maturation phase now complete and only pink,

visible surface scar remains

First Aid First Aid

• Arrest haemorrhage – pressure and elevation • When bleeding has slowed – assess depth

• Expectations: bleeding should slow or cease after 2 or 3

minutes • Grade 1 – epidermal
• Grade 2 – dermal
• If bleeding continues, especially pulsing, maintain
pressure and contact emergency assistance – i.e. • Grade 3 – Subcutaneous tissue (fat)
ambulance • Grade 4 – muscle through to bone

• Where possible – use sterile items in contact with

wounds, ensuring hands are clean and gloves are worn • Grade 3 and 4 should be referred for suturing
(Standard Universal precautions)

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 First aid
• When bleeding has slowed – cleanse
• Aim is to remove debris: running tap water
is effective; antiseptics can be used after
this but evidence suggests this may not be
of any significant benefit
• Ensure loose debris is completely
removed as foreign bodies delay healing
Observation
• Further bleeding
• Redness, pain, heat, swelling, loss of
sensation or increasing pain (all may
indicate infection of deeper nerve damage)
• Patients should be referred for medical
treatment if any of the above occurs
Superficial burn
Deep Partial thickness burn
Treatment - dressings
• Immobilise – up to 3 days ideal: may require splinting/rest
– this will allow clot, granulation, adhesion to progress –
especially in deeper wounds
• Non-stick dressings: foams are ideal as they will absorb
and adhere
• Film backed non-stick dressings like Opsite surgical or
Tegasorb etc can also be used
• Use water-proof dressings to facilitate care
Burn Wound management
• Burn wounds fall into 3 categories:
1. Superficial
– confined to epidermis; characterised by redness/inflammation;
acute pain; hyperaemic area is blanchable; healing in 3-7
days; no scarring
2. Partial thickness
– Dermal (Superficial partial thickness): confined to epidermis
and upper dermis; characterised by redness/inflammation;
acute pain; blistering; blanchable hyperaemia; healing in 3
weeks; possible scarring
– Deep dermal (Partial thickness): destruction of epidermis and
almost all dermis; mottled appearance; sluggish capillary
return at best; may be non-blanching; pain will vary according
to depth of destruction; scarring likely to be hypertrophic;
healing > 3 weeks; REFERRAL for excision grafting etc
Partial thickness burn
Partial Thickness
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 Burn Wound Management
3. Full thickness
– Destruction of epidermis, dermis and may extend to adipose, muscle
tendon and bone; wound can vary in colour from deep red to grey to
white; leathery to touch; generally insensate; TERTIARY REFERRAL
for resuscitation, excision, grafting, scar management
Burn Wound Management
• 1st aid: For thermal and most chemical burn wounds - cool and
protect; cool running water; can be up to 20 minutes; observe for
hypothermia

• All partial and full thickness burn wounds occurring on hands,
feet, face, throat/neck, genitalia, over joint areas or circumferential
burns should be referred to tertiary centres for assessment and
intensive management where necessary
• Cement or lime burns: do not wet as this actually activates the
substances and caused more injury – allow powder to dry, brush off
and then use water to flush
• 5% TBSA in children and 10% in adults can be managed at local
level if superficial or partial thickness only; greater than this area
should be referred on for assessment at tertiary centre

• Superficial or partial thickness burn wounds that fail to progress in 4

weeks should also be referred to a tertiary centre

Burn Wound Management

Superficial and PT dressings
• Treatment: Superficial and Superficial partial thickness
• Assess tissue – if blistered, cool 20 mins’, cover with soft
dressing (foam or Aquaclear) bandage and refer –
especially over jointed areas

• Dressings:
• Aquaclear (Hartmann) – cooling formed gel sheet
• Film dressings
• Hydrocolloids

• Antimicrobial dressings:
• Acticoat 3 and Acticoat absorbent
• Aquacel Ag
• Contreet Ag – hydrocolloid or foam
• Atrauman Ag
• SSD cream – use is now diminishing, especially in burns units

Partial Thickness
Partial Thickness - refer

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Pseudo-eschar forming

Common dressing categories

Rules…
Categories of dressings and
their use •
•
Dressings do not heal wounds, people do!
Dressing choice relates to assessment outcomes – assessment and
accurate diagnosis are the most important aspects of wound
management
• Dressings are tools of the trade ONLY
• Dressing categories have specific purposes

?=
• There is no one answer for every person’s wound
• Dressings carry instructions for use – these should be followed!
• Dressing regimes should not be constantly changed
• Dressings should keep wounds: warm, moist, non-toxic
• Products should have some evidence to support their use: Evidence
based practice
• Eggs, vegemite, most honey, sugar, vinegar etc should be fed to the
Tal Ellis
patient – not put on their wounds
Lecturer, Nursing, School of Nursing and Midwifery, University of South Australia
Director, WoundHeal Australia Pty Ltd

Categories of dressings Categories of dressings

• Film membranes:
• Foams:
– Properties -
– Properties -
• adhering polyurethane film • non adherent foam sheets or fillers
• vapor permeable • (some adherent foams on market)
• conformable • vapour permeable
• waterproof • maintain moist environment
• some waterproofed
• maintain moist
• highly absorbent
environment
• primary or secondary
• non-absorbent
• primary or secondary

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Categories of dressings
• Hydrogels:
– Properties -
• polyethylene glycol;
polymeric; hydrophilic
• amorphous or sheet like
• absorbent
• hydrating - ie provide
moisture
• amorphous variety fill space
• sheets can conform
• primary
Categories of dressings
• Hydrocolloids:
– Properties -
• Carboxymethylcellulose
• wide variety of forms - sheets, paste,
islands, woven
• maintain moist environment
• vapor permeable
• conformability depends on form
• absorbent - forms gel
• primary and secondary

Categories of dressings Categories of dressings

• Combinant
• Alginates – eg: hydrocolloid + alginate
– Properties - • Hypertonic Saline
• derived from brown seaweed • Retention
• hydrophilic
• Parrafin gauze
• calcium/sodium ion exchange
• haemostatic, absorbent
• Cotton/gauze/non adherent
• gel forming, conforming • Enzymes
• multiple presentation - sheet, rope, • Nanocrystalline Silver
mixed
• primary or secondary (if combined • Growth factor impreganted
with hydrocolloid) (future)

Acticoat Ionic/nanocrystalline silver

• Silver has been used for centuries as an
antiseptic agent
• Lost favour with the advent of antibiotics
• Regained favour as bacterial resistance
became a problem
• Many differing presentations and
manufacturers of dressings using silver as
the active agent

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 Aquacel Ag
Aquacel Ag - ConvaTec

• Hydrofibre dressing impregnated with

ionic silver
• Has excellent antibacterial properties
• Has excellent exudate handling
characteristics
• Useful on heavily colonised or infected
wounds
• Best used on moderate to heavy
exudating wounds

Acticoat – Smith and Nephew

• Nanocrystalline silver
• Similar antibacterial properties to Aquacel
Ag – possibly better delivery of silver to
the wound bed
• Presented in both low absorbent and high
absorbent forms
• Has been used extensively in burns
treatment
• Useful in deep/exudating wounds – eg
PU’s

Acticoat Acticoat absorbent

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 Contreet - Coloplast
Contreet’s three-way mode of
action:

• Antibacterial effect of silver

through hydroactivated technology,
Acticoat producing a sustained release of
silver in the wound bed and in the
dressing.

• Barrier against external bacteria

and fluids reducing the risk of cross
contamination

• Superior exudate management

and moist wound healing

(Coloplast website)

Atrauman
• New product from Hartmann

• Contact layer –like Paraffin gauze

• Contains silver delivered in ionic

form – i.e. active

Can be left in place and only

secondary dressing changed

Conclusion Digital imaging and assessment tools

• The digital revolution provides us with excellent Visitrak (Smith and Nephew)
resources for imaging, assessment and recording

• Skill and training valuable as technology is useless

unless properly used

• Images belong to institution – permission required from

client and institution for use outside clinical environment

• Not an embedded standard for assessment

• Fundamentals of assessment will remain the key to good

record keeping

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Using Visitrac… Visitrac
• Produced by Smith and Nephew

• Manual recording of wound data which can then be

entered via Vistrac Capture to maintain a computer
based record

• Cost $700 plus tracing sheets and depth gauges (both

are ongoing costs)

• Very useful where computer facilities are hard to access

as data can be used to record in non-digital form (i.e.
patient record)

• Instant/on-the-spot assessment data

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AMWIS and Visitrak - Summary

Alfred/Medseed wound imaging system – AMWIS

provides detailed assessment and reporting via web – very
detailed, can be slow to use

Visitrak – manual tracing but can be combined with

Visitrak capture to provide assessment and pictorial records
– not as detailed, still takes some time, requires additional
equipment, on-the-spot measurement

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