Wound Care Workup

  • Author: Richard M Stillman, MD, FACS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Apr 6, 2010
 

Laboratory Studies

  • Tests that sometimes are useful in identifying underlying factors that can slow wound healing include the following:
    • CBC to assess for leukocytosis, anemia, and 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 coagulation abnormalities, especially if deep wound excision is required
    • Tissue cultures of wound to determine appropriate antibiotic therapy
  • Laboratory studies that may play a role in evaluating specific wound etiologies include vascular laboratory studies (eg, plethysmography, pulse-volume recordings [PVRs]) to check the hemodynamic significance of arterial occlusive disease.
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Imaging Studies

  • Imaging studies that may play a role in evaluating certain wound etiologies.
    • Plain radiography, CT, and MRI may help in looking for underlying osseous abnormalities, proximity of the wound to hardware, or foreign bodies.
    • Vascular ultrasonography may be indicated to evaluate for aneurysmal disease or deep venous occlusion.
    • Bone scanning may be needed to look for possible osteomyelitis. Technetium-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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Proceed to Treatment & Management
 
 
Contributor Information and Disclosures
Author

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

Richard M Stillman, MD, FACS is a member of the following medical societies: American College of Angiology, American College of Surgeons, Association for Academic Surgery, and Society of University Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

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

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

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Senior Pharmacy Editor, eMedicine

Disclosure: eMedicine Salary Employment

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: American College of Surgeons, American Medical Association, American Medical Women's Association, American Society for Artificial Internal Organs, American Society of Transplant Surgeons, American Society of Transplantation, Association for Academic Surgery, Association of Women Surgeons, International College of Surgeons, International Liver Transplantation Society, New York Academy of Sciences, Pennsylvania Medical Society, Philadelphia County Medical Society, Society of Critical Care Medicine, and Transplantation Society

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA  Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract

Disclosure: AMGEN Royalty Consulting; ARdelyx Ownership interest Board membership

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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
AlginateAlgiSite, Comfeel, Curasorb, Kaltogel, Kaltostat, Sorbsan, TegagelAlginate 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.
HydrofiberAquacel, Aquacel-Ag, VersivaAn 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 agentsHypergel (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.
FoamLYOfoam, Spyrosorb, AllevynPolyurethane foam has absorptive capacity.These dressings are useful for cleaning granulating wounds with minimal exudate.
HydrocolloidCombiDERM, Comfeel, DuoDerm CGF Extra Thin, Granuflex, TegasorbHydrocolloid 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.
HydrogelAquasorb, DuoDerm, Intrasite Gel, Granugel, Normlgel, Nu-Gel, Purilon Gel, KY JellyHydrogel 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 dressingMepore, Skintact, ReleaseLow-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 filmOpSite, Skintact, Release, Tegaderm, BioclusiveTransparent 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)
INonblanchable erythema of intact skinPink skin that does not resolve when pressure is relieved; discoloration; warmth; indurationDuoDerm q2-3d14
IIPartial-thickness skin loss involving epidermis and/or dermisCracking, blistering, shallow crater, abrasionCleanse with saline; DuoDerm/Tegaderm dressing45
IIIFull-thickness skin loss into subcutaneous fatty tissues or fasciaDistinct ulcer margin; deep crater (in general, 2.075 mm or deeper [the thickness of a nickel])Debride; irrigate with saline; apply DuoDerm/Tegaderm90
IVFull-thickness skin loss with extensive tissue involvement of underlying tissuesExtensive necrosis; damage to underlying supporting structures, such as muscle, bone, tendon, or joint capsuleSurgically debride; irrigate with saline (possibly under pressure); apply advanced topical dressings; consider antibiotics120
*When the overlying skin is necrotic, the staging cannot be accurate until debridement is performed.
Table 3. Support Surfaces
Class Type Principle Examples
ISimplePressure-relieving pad or mat3- to 5-inch foam mattress, gel overlay, egg-crate mattress
IIAdvancedPowered 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
IIIAir fluidizedFloatation by filtered air* flow pumped through porcelain beadsClinitron 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 layerSingle-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 layerThe 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 layerThe 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 wrapThe 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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