An update on wound management

Let me just give you a little maxim I teach my students. Treat the whole patient, not the hole in the patient. So when you assess, you don't assess the wound itself. You assess the patient.

[Music] Welcome to The Australian Prescriber Podcast. Australian Prescriber, independent, peer-reviewed, and free.

I'm Dhineli Perera, your host for this episode, and it's a pleasure to be speaking to Associate Professor Geoff Sussman today about wound management. Geoff will not need an introduction to many listeners. He's well known across multiple health professional domains for his enthusiastic teaching and passion for wounds and their appropriate management. He's also a researcher, a clinician, and internationally regarded as an expert in the field. Geoff has put together an update in wound management, as always, with practical advice that can be immediately applied.

Geoff, welcome to the program.

It's my pleasure to be with you.

So Geoff, can you start by telling us why do we pay, or need to pay, more attention to proper wound management? Is the prevalence increasing?

This is a very good question. Unfortunately, wounds are not considered a major issue, which is far from the truth. In Australia on any given day, some 500,000 people have a non-healed chronic wound, which is very concerning, because the end result for a badly treated wound can be death, and that's something we want to avoid.

Prevalence. Unfortunately, it is getting more and more for two basic reasons. One is we have an ageing population. And if you have a look at the intergenerational report and look at the way Australia is going over the next 30 years, it's pretty scary how, within probably 10 or 15 years, a quarter of the Australian population will be over 65. The other big difference is diabetes. By 2030, we’re likely to have between 7[00] and 800 million diabetics in the world, and Australia is not immune to this. Our diabetes is going up very badly. So treating wounds correctly, quickly, you overcome the potential of complications that can lead to amputation, can lead to very serious things.

Absolutely, and I think that you're right. It's easy to overlook them because we just don't think that they are severe until they are severe. I like the idea of pre-empting that. So what's your strategy, Geoff, when you assess a wound? Do you have a mental tick box that you work through?

Let me just give you a little maxim I teach my students. Treat the whole patient, not the hole in the patient. So when you assess, you don't assess the wound itself. You assess the patient. You have to say, not that there is a wound, but why is there a wound? Is there an underlying cause that has in fact contributed to not just the development of the wound but the non-healing of the wound? Now that could be a comorbidity, like an immune disease. It might be venous disease. It might be arterial disease. It could be medication they're on. It could be their diet. There are many, many factors.

So when you assess, you assess everything, and then finally you look at the wound. But you look at the peri skin, you look at the wound itself, you look at the colour of the wound, you look at the quality of the tissue. You look at the amount of exudate, what type of exudate it is. You look for pain. You look for all of these aspects before you can then say, "I think I can diagnose this now." And once you've diagnosed exactly what the underlying aetiology of the wound is, then you can commence a treatment modality that you know will address not just the wound itself, but why the wound is there.

Right. So without that pre-assessment of what's caused it, you're saying it's kind of pointless.

Well, unfortunately, too many people just treat the wound and when in 3 or 4 weeks it’s no better, they say it's the fault of the product they've used. So they put a different product on. And when it doesn’t get better in another 2 or 3 weeks, they'll say, "Oh, that was a bad product. I'll put a different product on." What they've never, ever done is to identify why the wound is there.

I can give you many cases. I’ve had a young man a few years ago who'd had leg ulcers for 8 years, and his GP said, could I have a look at him? So I took a look at this young man who had some leg ulcers. All around was discoloration of the skin, and I looked to see what treatment he was getting. He had a cannula getting IV antibiotics, and I called the registrar and said, "Stop the antibiotics." He said, "We can't. It's infected." I said, "No, it's not." He said, "But look at all the cellulitis." "There is no cellulitis. What colour is it?" "It's purple."

"That's right. It's the violaceous halo of vasculitis. So you've been treating this patient for 8 years for an infection that he never, ever had. The problem is vasculitis." And he had Klinefelter syndrome as well. And once we got him off antibiotics, got him on to the right treatment for vasculitis, his wounds healed.

Amazing. Yeah, so it's the cause that really needs to be addressed. In your paper for Australian Prescriber, there are a couple of neat acronyms that you've mentioned in Box 2 of the article. Could you walk us through them?

These are very quick ways of doing assessments. One is TIME. Time is something we don't have enough of. Well, you look at tissue, you want the tissue to be pink, red, healthy tissue. What you don't want is yellow or black or necrotic tissue. Infection or inflammation? Unfortunately, too many people think all wounds are infected. They do swabs, but every wound will grow bugs from a swab. Does that mean every wound is infected? Categorically no. They're mostly inflamed, so you don't need antibiotics. The M is moisture. A moist wound heals better than a dry wound. So you need to have the right amount of moisture. Too little, it dries, and you form a scab. Too much, it macerates. So you have to get that balance of moisture right. And the edge. Wounds gets smaller by contraction from the edge. If the edge is dry and scaly, it won't contract. If the edge is macerated and wet, it won't contract. So that's a lovely simple acronym of assessment. Quality of the tissue, is it infection or inflammation? Is the moisture right? And is it a healthy edge?

MEASURE is another option there. So it talks about the length, the width, the depth, and how big an area of the wound there is. Take pictures. Get a gel and trace the wound because I can tell you, people think the wound's getting smaller, but when you actually compare the tracings, it isn't a smaller wound. It's bigger.

Exudate. Look, exudate is a normal part of a wound, but exudate can be clearly serous, which is perfectly fine, but it can be haemoserous. In other words, there's blood in the exudate, not a good sign. It might be purulent, in other words, green, smelly, shows the presence of infection. So understating that exudate is important.

Having just a good look at the wound itself [appearance], the tissue, is it pink and healthy? Is it red and obviously granulating, but is it yellow and sloughy? Is it black and necrotic? All important.

And pain [suffering]. We do pain very badly in wounds. So what a lot of people do is they use what's called the visual analogue scale. It's not accurate at all. But there are some very good things you use. The McGill pain index, and that goes into the type of pain. Is it burning? Tell me about the pain itself. Then you get a better idea of how significant that pain is.

Need to look at the edge. Most wounds just have a flat edge, but sometimes they're undermined, which is not a good sign. And again, with any wound management, you have to reevaluate, reassess, reevaluate. Are we doing the right thing? Is it getting better? Is it just remaining static or is it getting worse?

Beautiful. So I think for someone like yourself, Geoff, you're not thinking of these acronyms, but for people that are probably not assessing wounds on a daily basis, I liked the look of these. So moving on to dressings, inert and interactive dressing. Table One really describes all of those different types, which they can all start to sound the same when you look at the names of them.

That's why within the article, I've given a very, very comprehensive chart on the dressings, what the properties are, where we use them, what are the precautions, that really clarifies exactly what you're dealing with.

So Geoff, can you tell us a bit about acute wounds and their management? When you list out burns and tears, I immediately think of accident-prone children. What should we be aiming for?

I've particularly talked about burns and skin tears. Why? Burns are one of the most common acute wounds. Someone touches the barbecue or spills some hot water or soup or coffee. It's very, very common. Now, a burn can be very simply treated, if treated quickly and appropriately. If treated wrongly, it can have very serious consequences.

And what are skin tears? One of the areas I've worked in for many years is aged care, and I did a very big randomised controlled trial some 22, 23 years ago in Victorian nursing homes. And what we found was 1 in 3 people in nursing homes have a wound of which 50% are skin tears. And why do older people have skin tears? Because as you age, your skin deteriorates, becomes thinner, more vulnerable, and whereas the dermis and epidermis are connected, those little clips called rete pegs disappear so even minor trauma will separate the skin. Now, treated correctly a skin tear can be healed quite quickly, within a couple of weeks. Treated incorrectly, they'll become a chronic wound and will really be difficult.

But you're right about children. That's fine. Kids are going to bump themselves, they're going to cut themselves, they're going to have little minor things. The important thing is every home needs an adequate first aid kit. Now, that doesn't mean you go out and buy this great huge thing of which 90% in it is a waste of money. You need some simple products within the home, for a burn, for a cut, for a graze, the things that are likely to happen around the home.

Excellent, and we can use your chart again for that. What about chronic wounds? When does a wound become chronic?

Good question. We tend to classify chronic wound as an acute wound that after 6 weeks hasn't healed. Then it changes from being acute to being chronic. And usually where wounds are chronic, there is an underlying cause which is preventing healing.

So Geoff's article actually does dissect these four different types of chronic wounds. Do you have a quick little tip for each of them, like a hot tip that you could recommend?

Venous ulcer is caused by varicose veins, by the valves in the veins no longer working properly. The critical part of treating venous ulcers is compression, compression, compression. Get those valves working, get those veins working, get rid of that fluid and the oedema, and you will heal them.

The arterial wound's much more complicated as it's usually caused by peripheral arterial disease, where the arteries are occluded or the arteries are shrunk, or they're calcified. So that involves an intervention. You have to get blood flowing. So that's a little bit more complicated than the venous ulcer.

Diabetic foot ulcer is the real concern because virtually 1 in 4 diabetics will end up with a foot ulcer. Now, they can be treated quickly and be healed, but if they're not treated quickly, not identified, and diabetics don't identify the problem because they have a sensory neuropathy. They lose feeling in their feet. The diabetic ulcer is one that needs to be addressed quickly, because I’ve got a patient at the moment who had all his toes removed, type 2 diabetic, and the surgeon said, "This will never heal. We'll amputate your leg." Well, I've been treating him now for the last four and a half months. He's virtually healed. This was a massive wound, but with appropriate treatment, even the large wounds can be healed. That's why we have wonderful high-risk foot clinics around the country. Every diabetic should be seeing a podiatrist to check their feet regularly, but if there is a real problem, have them go to a proper wound clinic, a high-risk foot clinic, because they're the experts who will be able to cope with the diabetic ulcer and treat it appropriately and quickly.

The pressure injury, as I say, is something we see far too many of, but we see it in a lot of people, sports people get pressure injuries. Why? New pair of running shoes, a little bit too tight, rubs, causes a blister. That, in fact, is a pressure injury. It's a matter of thinking about the surface you sleep on, think about the surface you sit on, and it also depends very much on the individual. You see, if you can feel uncomfortable, you'll move because you feel uncomfortable. But if you are a quadriplegic or a paraplegic who can't feel and can't move, you've got a huge problem. And so, therefore, you have to identify patients at risk of pressure injury and intervene so that they sit on appropriate surfaces, so that their nutrition's good, and nutrition is very important for both prevention and treatment of pressure injuries, but you need to look at all of those issues.

Your section on wound infection was particularly interesting as well. Could you elaborate on one aspect, the Levine swab method, when it should be used and how to use it? And I also would like to know why we shouldn't be swabbing exudate.

I'm not a great believer in doing swabs at all because the problem with the swab is a swab will tell you what's sitting on the surface of the wound. It won't tell you if the wound's actually infected. And this is unfortunately why we see overprescribing of antibiotics in chronic wounds. Because you do a swab, it grows bugs, oh, we better get antibiotics. If I think a wound is infected, I won't do a swab. I will clean the wound. I'll take a biopsy of the wound and send the tissue to the microbiologist and ask them, "Is there something growing in the tissue?"

Now the Levine technique. What a lot people do is a Z method. In other words, you do a Z across the surface of the wound. You actually touch less than 5% of the surface. You could miss anything there. The difference is the Levine technique, you rinse the wound first with just normal saline. Then you take your swab, and you rotate it with downward pressure over at least 1 cm2 area of the wound with sufficient pressure to let fluid from within the tissue be expressed into the swab.

And there's been some good studies that compare the 2 methods, the Z method and the Levine, and you definitely get a more accurate assessment of bacteria by the Levine method. I'm not a great lover of swabs in any case, but if you're going to do it, use the Levine method, which involves getting the fluid, not the exudate, because that exudate's only got what's on the surface. Try and get any bacterial products out of the tissue. So that's why we don't swab the exudate because that's just got the normal guck that's going to be on every wound.

I am lucky enough to not have to do the swabs, but I'm sure there are many listeners out there that are involved with that. So thank you for describing that, Geoff. And finally, I wanted to ask, what would be your top two tips for best application methods of wound dressings?

The important thing in choosing a dressing is not going to the shelf and saying, "I'll take this one." You need to say, "What is the issue with this wound? Is it exudate? Is it odour? Is it pain?" And you need to choose the product with properties that will address the issue. So, you choose a product that'll address the wound issue, not the closest one on the shelf. What clinicians often say is, "Oh, it means I need to keep hundreds of products." No, you don't. You need to keep a small range of products that will address all of the major issues you're going to find with the wound.

So it's not about having variety to choose from. It's really about being quite selective with what options you have available.

Correct. And when in doubt, use a foam. Foam is probably the closest thing to the universal dressing because you can put a foam in a dry wound or wet wound, whatever, because foam is universally usable for most wounds. We often use foam not only as a primary dressing but a secondary dressing. And they make special foams that have a soft silicone surface, which means they won't stick to older people, which means when you take it off, you don't traumatise on removal. So your choice can be a very simple range of products, but ones that will address the issues.

The next thing you need to think about is, how am I going to keep that dressing on? Do not use tapes to stick dressings on older people because their skin is so fragile, when you go to take the tape off, you'll rip the skin off. So choose wisely with your product, but then choose very wisely how you'll hold it on. And there are many products available on the market that we use for retention, just to hold a dressing on without sticking. And that's very, very important.

That's great advice, Geoff. Thank you so much. That's unfortunately all the time we've got for this episode, though. I am sure we could keep talking for hours. Thanks so much for joining us today, Geoff.

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Geoff's full article is available on the Australian Prescriber website. The views of the hosts and guests on the podcast are their own and may not represent Australian Prescriber or Therapeutic Guidelines. I'm Dhineli Perera, and thanks for joining us on the Australian Prescriber Podcast.