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Wound Care Workup

  • Author: Brian J Daley, MD, MBA, FACS, FCCP, CNSC; Chief Editor: Zubin J Panthaki, MD, CM, FACS, FRCSC  more...
 
Updated: Mar 11, 2016
 

Laboratory Studies

The following tests may be useful to identify factors associated with wound development or those that can slow wound healing:

  • CBC count to assess for leukocytosis, anemia, and/or thrombocytopenia
  • Analysis of the patient's basic metabolic profile to look for renal insufficiency and electrolyte abnormalities
  • Determination of serum protein, albumin, prealbumin, and transferrin levels to assess the patient's nutritional status
  • Coagulation studies to evaluate for abnormalities, especially if deep wound excision is required
  • Tissue cultures of wound to determine appropriate antibiotic therapy

Additional studies that may play a role in evaluating specific wound etiologies include vascular laboratory studies (eg, plethysmography, pulse-volume recordings [PVRs]) to assess the hemodynamic significance of arterial occlusive disease.

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Imaging Studies

Plain radiography, CT, and MRI may help in looking for underlying osseous abnormalities (including osteomyelitis), proximity of the wound to hardware, or foreign bodies.

Vascular ultrasonography may be indicated to evaluate for aneurysmal disease, arterial-occlusive disease, or deep venous occlusion.

In cases in which plain radiography or MRI are not diagnostic, bone scanning may be needed to evaluate for osteomyelitis. Technetium Tc 99m–labeled WBC scanning (Ceretec) has high specificity and sensitivity for osteomyelitis. However, it requires 24 hours for completion and it lacks anatomic detail.

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Diagnostic Procedures

Perform a biopsy of every suspicious wound, but remember that biopsy results are diagnostic only if an adequate representative specimen is obtained.

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Contributor Information and Disclosures
Author

Brian J Daley, MD, MBA, FACS, FCCP, CNSC Professor and Program Director, Department of Surgery, Chief, Division of Trauma and Critical Care, University of Tennessee Health Science Center College of Medicine

Brian J Daley, MD, MBA, FACS, FCCP, CNSC is a member of the following medical societies: American Association for the Surgery of Trauma, Eastern Association for the Surgery of Trauma, Southern Surgical Association, American College of Chest Physicians, American College of Surgeons, American Medical Association, Association for Academic Surgery, Association for Surgical Education, Shock Society, Society of Critical Care Medicine, Southeastern Surgical Congress, Tennessee Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Sneha Bhat, MD Resident Physician, Department of Surgery, University of Tennessee Health Science Center College of Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Amy L Friedman, MD Professor of Surgery, Director of Transplantation, State University of New York Upstate Medical University College of Medicine, Syracuse

Amy L Friedman, MD is a member of the following medical societies: Association for Academic Surgery, International College of Surgeons, New York Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, Association of Women Surgeons, International Liver Transplantation Society, Transplantation Society, American College of Surgeons, American Medical Association, American Medical Womens Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation

Disclosure: Nothing to disclose.

Chief Editor

Zubin J Panthaki, MD, CM, FACS, FRCSC Professor of Clinical Surgery, Department of Surgery, Division of Plastic Surgery, Associate Professor Clinical Orthopedics, Department of Orthopedics, University of Miami, Leonard M Miller School of Medicine; Chief of Hand Surgery, University of Miami Hospital; Chief of Hand Surgery, Chief of Plastic Surgery, Miami Veterans Affairs Hospital

Zubin J Panthaki, MD, CM, FACS, FRCSC is a member of the following medical societies: American College of Surgeons, American Society for Surgery of the Hand, American Society of Plastic Surgeons, Canadian Society of Plastic Surgeons, American Council of Academic Plastic Surgeons, Miami Society of Plastic Surgeons, Medical Council of Canada, Canadian Military Engineers Association

Disclosure: Nothing to disclose.

Acknowledgements

Richard M Stillman, MD, FACS† Honorary Medical Staff, Northwest Medical Center; Former Chief of Staff and Medical Director, Wound Healing Center, Department of Surgery, Northwest Medical Center

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Image of advanced sacral pressure ulcer shows the effects of pressure, shearing, and moisture.
Sacral pressure ulcer before and after flap closure.
Chronic ulcer of medial aspect of right leg due to pyoderma gangrenosum.
Pressure ulcers of the lateral aspect of the right foot.
Basal cell cancer manifesting as a chronic leg ulcer.
Heel pressure ulcer.
Sacral ulcer.
Table 1. Characteristics and Uses of Wound-Dressing Materials
Category Examples Description Applications
Alginate AlgiSite, Comfeel, Curasorb, Kaltogel, Kaltostat, Sorbsan, Tegagel Alginate dressings are made of seaweed extract contains guluronic and mannuronic acids that provide tensile strength and calcium and sodium alginates, which confer an absorptive capacity. Some can leave fibers in the wound if they are not thoroughly irrigated. These dressings are secured with secondary coverage. These dressings are highly absorbent and useful for wounds have copious exudate. Alginate rope is particularly useful to pack exudative wound cavities or sinus tracts.
Hydrofiber Aquacel, Aquacel-Ag, Versiva An absorptive textile fiber pad, hydrofiber is also available as a ribbon for packing of deep wounds. This material is covered with a secondary dressing. The hydrofiber combines with wound exudate to produce a hydrophilic gel. Aquacel-Ag contains 1.2% ionic silver that has strong antimicrobial properties against many organisms, including methicillin-resistant Staphylococcus aureus and vancomycin-resistant enterococci. Hydrofiber absorbent dressings used for exudative wounds.
Debriding agents Hypergel (hypertonic saline gel), Santyl (collagenase), Accuzyme (papain urea) Various products provide some chemical or enzymatic debridement. Debriding agents are useful for necrotic wounds as an adjunct to surgical debridement.
Foam LYOfoam, Spyrosorb, Allevyn Polyurethane foam has absorptive capacity. These dressings are useful for cleaning granulating wounds with minimal exudate.
Hydrocolloid CombiDERM, Comfeel, DuoDerm CGF Extra Thin, Granuflex, Tegasorb Hydrocolloid dressings are made of microgranular suspension of natural or synthetic polymers, such as gelatin or pectin, in an adhesive matrix. The granules change from a semihydrated state to a gel as the wound exudate is absorbed. Hydrocolloid dressings are useful for dry necrotic wounds, wounds with minimal exudate and for clean granulating wounds.
Hydrogel Aquasorb, DuoDerm, Intrasite Gel, Granugel, Normlgel, Nu-Gel, Purilon Gel, KY Jelly Hydrogel dressings are water-based or glycerin-based semipermeable hydrophilic polymers; cooling properties may decrease wound pain. These gels can lose or absorb water depending upon the state of hydration of the wound. They are secured with secondary covering. These dressings are useful for dry, sloughy, necrotic wounds (eschar).
Low-adherence dressing Mepore, Skintact, Release Low-adherence dressings are made of various materials designed to remove easily without damaging underlying skin. These dressings are useful for acute minor wounds, such as skin tears, or as a final dressing for chronic wounds that have nearly healed.
Transparent film OpSite, Skintact, Release, Tegaderm, Bioclusive Transparent films are highly conformable acrylic adhesive films with no absorptive capacity and little hydrating ability. They may be vapor permeable or perforated. These dressings are useful for clean, dry wounds with minimal exudate. They also are used to secure an underlying absorptive material, to protect high-friction areas and areas that are difficult to bandage (eg, heels) and to secure intravenous catheters.
Table 2. Staging Pressure Ulcers
Stage Definition Appearance Appropriate topical treatment Average healing time (d)
I Nonblanchable erythema of intact skin Pink skin that does not resolve when pressure is relieved; discoloration; warmth; induration DuoDerm q2-3d 14
II Partial-thickness skin loss involving epidermis and/or dermis Cracking, blistering, shallow crater, abrasion Cleanse with saline; DuoDerm/Tegaderm dressing 45
III Full-thickness skin loss into subcutaneous fatty tissues or fascia Distinct ulcer margin; deep crater (in general, 2.075 mm or deeper [the thickness of a nickel]) Debride; irrigate with saline; apply DuoDerm/Tegaderm 90
IV Full-thickness skin loss with extensive tissue involvement of underlying tissues Extensive necrosis; damage to underlying supporting structures, such as muscle, bone, tendon, or joint capsule Surgically debride; irrigate with saline (possibly under pressure); apply advanced topical dressings; consider antibiotics 120
*When the overlying skin is necrotic, the staging cannot be accurate until debridement is performed.
Table 3. Support Surfaces
Class Type Principle Examples
I Simple Pressure-relieving pad or mat 3- to 5-inch foam mattress, gel overlay, egg-crate mattress
II Advanced Powered air* overlay for mattress with low air loss feature; nonpowered advanced pressure-reducing mattress replacement or powered air* floatation bed with or without low air loss feature Roho dry floatation mattress system, Pegasus Renaissance mattress
III Air fluidized Floatation by filtered air* flow pumped through porcelain beads Clinitron bed
*Long-term use of powered air devices is relatively contraindicated for patients with chronic obstructive lung disease, such as chronic bronchitis, emphysema, and asthma.
Table 4. Compression Bandages for Venous Ulcers*
Type Description Examples
Single layer Single-layer simple tubular woven nylon/elastic bandages may be imprinted with rectangles that stretch to squares when appropriate wrapping tension (30-40 mm Hg) is applied. ACE bandage, Comperm (Conco Medical), Setopress (Seton Healthcare Group)
Three layer The layers include a padding absorption layer, a compression bandage layer, and a cohesive compression bandage. Bandages may be left in place for up to 1 week depending on wound exudate. Dyna-Flex (Johnson & Johnson)
Four layer The layers include a nonwoven wound contact layer that is permeable to wound exudate and 4 overlying bandages. Bandages may be left in place for up to 1 week depending on exudate volume. Profore (Smith & Nephew)
Impregnated wrap The porous flexible occlusive dressing is composed of stretchable gauze and a nonhardening zinc oxide paste. Unna boot (ConvaTec)
*Compression wraps are contraindicated in severe arterial compromise. Some of these products are contraindicated in patients who are allergic to latex.
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