Chapter: Wounds and ulcerations
Article: 5 of 7
Update: Mar 10, 2021
Author(s): Ott, Hagen
After a detailed medical history and a thorough clinical examination, individual wound management including adequate local anesthesia and, if necessary, systemic analgesia are established for the patient.
As a rule, wound flushing is initially performed with physiological saline solution (NaCl 0.9%), Ringer's solution or tap water, which should, however, be obtained through a terminal sterile filter to avoid contamination (especially with Pseudomonas aeruginosa). The flushing fluid should be warmed to body temperature to reduce pain, and the wound should be carefully dried after irrigation and before reapplication of a dressing to prevent maceration.
If undesirable coatings (e.g., fibrin, blood coagulum, necrosis) remain after wound irrigation, further wound debridement may be appropriate, for which compresses previously soaked in an antiseptic are often used. These antiseptics can also be used in the further course for targeted reduction of bacteria in the area of critically colonized wounds. Rarely, patients with vascular anomalies require surgical debridement, which can be performed with curette, scalpel, or forceps. The use of these instruments is usually painful, so local anesthesia with, for example, lidocaine and prilocaine or lidocaine and bupivacaine should be used. In addition, surgical debridement often requires intensified systemic analgesia and, in individual cases, even general anesthesia.
After wound documentation and cleansing, the dressing is individually tailored to the patient under sterile conditions. The selection of the appropriate dressing material depends on numerous individual factors such as:
For a long time, classic wound care was performed with inactive textile wound dressings (e.g., gauze compresses), which served as mechanical protection and to absorb wound exudate. However, despite being combined with wound gauzes, these dressings often adhered to the wound bed, frequently resulting in pain and re-traumatization of the wound area at dressing changes. In modern wound care, interactive dressings (e.g., polyurethane foams, hydrogels, alginates) in combination with fine-mesh and sometimes silicone-coated wound spacer meshes and, more rarely, bioactive materials (e.g., autologous keratinocyte cultures) are used instead.
Hydrocolloid dressings are used for mildly to moderately exudative wounds. They contain swellable substances (e.g., gelatin, cellulose) embedded in a water-repellent layer under a semipermeable film. Therefore, they are able to absorb secretions from the wound, with the swellable substances turning into a gel that prevents the wound from drying out. Hydrocolloid dressings should not be used in the presence of wound infection.
Polyurethane foam dressings with a smooth surface and fine pores that can absorb wound secretions without sticking are often used for moderately to heavily exuding wounds. Because of their high absorption capacity, the frequency of dressing changes can be reduced and atraumatic dressing changes can be achieved. Polyurethane foam dressings are also contraindicated in wound infections. Other options for differentiated wound management can be found in the recommended literature.
At the completion of each wound care session, the patient is asked if any discomfort, such as pain, pressure sensation, or itching, is new or continues to cause impairment.
In general, patients with vascular anomalies will need to be diagnosed and treated for the exact underlying cause of a wound occurring at the affected site. Even with appropriate wound therapy, some wounds will not heal without treatment of the underlying vascular defect.