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I have seen wonderful results with Iodosorb by Health Point. unsigned

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Hi,
My name is Marcia , Wound Specialist for a large home heath company. I have come across a wound dressing that is working wonders for some of my patients. It is called Xcell Wound Dressing. It is meant for wounds that do not respond to silver products and is highly effective on a wide variety of aerobic and anaerobic organisms, fungus and yeast. I would be glad to send you information or you can contact your representative from Medline. Good luck!

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Acticoat actually per the last table I've seen, delivered the most amount of silver. Acticoat now has the absorbent type which works well with some more heavily exudating wounds for which might also find the need for antimicrobial agent. Aquacel
Ag does have th advantage of minimizing macerating and irritating periwound areas because of the direction of absorption is always vertically. I suggest you apply a dimethicone ointment around the
periwound area to minimize irritation and maceration then use Acticoat absorbent with the pseudomonas infection.
Maria Dulce Carunungan, DPT, CWS

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I have had success with using acetic acid wet to dry for a week to 10 days, then going back to the previous dressing. The lady I have now, I have been cleansing with acetic acid, the rinsing well with normal saline, then using aquacel. It has kept this wound from going into a full blown problem.

Patti, WCC

unsigned

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Dear Joseph:

As a forensic expert I can tell you that the amount of time varies even among 80 year olds with low risk factors. It all depends on how long there is continuous pressure. However, assuming that the patient is never turned, the pressurized area will break down as follows:

Stage I - 2-8 hours;
Stage II - 8-24 hours;
Stage III - 24-48 hours;
Stage IV - 48-72 hours;

I am certain though that you will get a variety of opinions as to time, but they won't that far apart.

With regard to "3X5.5 blister with dark fluid", the blister denotes a thermal injury that would occur from friction by dragging the patient on the sheet rather than lifting. In my opinion, you won't usually find blisters from pressure alone. As to length of time, it only takes a few seconds to injur the skin from a friction rub. I hope this is helpful.

Regards,

Thomas A. Sharon, R.N., M.P.H.

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Based on my knowledge, wounds develop based on many factors and can’t be time lined. Each situation is unique-- depending on factors surrounding the individual. I have never read in any literature that a stage 1 wound will definitely develop into a stage 2 in 1 week, if a certain condition exists. One thing is certain- if appropriate assessment of the patient holistically is not done, and if intervention/prevention measures are not taken wounds will continue to breakdown. In terms of time- wounds are generally discussed physiologically. If there is any information in regards to the timeliness of wounds please inform me also. Thank you. j.b.pinnock@att.net.

Jamie Pinnock RN, CWCN

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Hi Joseph,
Have you contacted the AAWM. I am not sure if they have specific time lines for each stage of a PU, however, they would be a great resource. Let me know if you need there contact info.
Marta PT, CWS

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I am a direct service L.P.N. and find this book useful. Hope it will help you in your work.
www.smith-nephew.com The little Green Book, a practical guide to wound
management. A----Z.
BEE

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I am not quite sure you might get your question answered. There are many patient factors involved in susceptibility to developing a pressure ulcer, or how fast they progress to the next stage. Once an area of skin is subjected to pressures greater than capillary closing pressure of 32 mmHG, it will not take
long to start the breakdown process. Those with poor nutritional status, cardiovascular issues, respiratory issues, collagen problems, hypoactivity are most susceptible. A healthier person who develops
a pressure ulcer would heal and not progress further if he has good nutrition, is active, with non of these comorbidities. It won't take long for a sickly, debilitated individual to progress from stage
to stage. I would be interested to see if there are studies as (like study with subjects who are homogenous, with the same nutritional status, age, level of activity, etc.). You might look for
this criteria if you might run across several different ones.
Maria Carunungan, DPT, CWS

If it is at all extensive, I would immediately consult a surgeon and have it debrided. Otherwise I would leave it alone & wrap if there is just a little
drainage, possibly by putting a 4x4 elastogel and wrap (if they are not ambulatory). These are tricky situations. Once opened, you really have to
deal with them by surgery. If stable, leave alone.

Deborah Harris, BSN, JD, RN, CWCS
Louisville, KY

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If the eschar is dry, hard and intact on heels or toes, you leave them intact, keep them dry and relieve pressure. If they become fluctuant, (soft, boggy, draining) then you must debride them. Of course if you can find someone to do a selective sharp debridement it will be the quickest. You're next option is to have it crosshatched by a professional and then use an enzymatic debrider. At the very least protect the edges, use an enzyme, hydrogel gauze and an absorbant dressing like
foam. It will probably drain quite a bit and need to be changed BID.

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Dear Marcia:

Try to obtain access to electromagnetic therapy by Diapulse Corporation of America. It is covered by Medicare Part B (G0329) and it increases blood flow to ischemic areas and promotes healing even in patients with PVD. In conjunction with the Diapulse, the physician may want to debride the eschar, culture the wound and prescribe appropriate antibiotics.

Regards,

Thomas A. Sharon, R.N., M.P.H.

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A wound cannot heal until the eschar is removed. You can try Panafil or Accuzyme, these are enzymatic debrider, to remove the eschar. If the eschar is very large you may want to have a physical therapist remove it or get a surgeon's consult. I have had great success using panafil and accuzyme and once eschar is removed switching to a different med. C.B. LPTA

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If open and draining you have to mechanicall (takes a while) or surgically debride the eschar before you can attack the problem of healing. Is osteo involved?
Cheryl Wound Care Nurse

Leah

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Accuzyme by Health Point is a chemical debriding agent that I have been using with success on eschar. unsigned

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Hello,

Opinions vary on the way to handle these wounds. From my experience, and from wound specialists I have heard speak, if the black eschar is dry and “stable” (not mushy, not with perimeter induration or redness indicating probable infection underneath) and especially if the patient has arterial insufficiency, I leave them alone and try to keep them from trauma. Many times these wounds will never heal, but will not worsen, and the idea is that with the poor blood flow and all the other factors inhibiting healing that these patients usually have (diabetes, neuropathy, …) you don’t want to open up a wound if you don’t have to. I have seen many stable heel ulcers eventually peel off like a huge callous though, and heal. Also, sometimes black, dry-gangrenous toes will autoamputate on their own time. So the answer is that each patient is a unique case, with many things to consider.

Vicki, MSPT, CWS
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Hi Marcia,
The AHCPR Clinical Practice guidelines id a wonderful resourse. Their 800# for a free copy is:
800-358-9295. If the eschar is intact the best treatment is to just eliminate the pressure. I like a variety of the pressure relief boots, but if you have a compliant pt---just elevating the heel off the bed with a pillow placed under the calf works wonderfully.
Once the eschar is no longer intact it is necessary to
debride the eschar.
Donna Cameron RN WCC
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Marcia, you don't say if the eschar is on the heels or not, but if it is and the eschar is tight leave it alone. It does serve as a protective layer. It the eschar is loose it can be trimmed by the appropriate person and it you have drainage it may be infected. If it is infected it must be debrided by a physician. Any time you have a heel with eschar you need to keep it dry and use a protective protect like 3M or skin prep daily. You always also need to assess the patient for pain in the area and they should be wearing heel lift boots not shoes or slippers. If the eschar is anywhere else on the foot escher must be debrided for the wound to start healing.
darlene BSN Rn

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Marcia, if the eschar on the feet is intact and benign, the rule is to leave them alone. If they change and open, drain, etc. then they must be treated. But I, personally, would check the person’s vascular status before opening up any wound that may not be able to heal. Sue, CWS

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I would be more inclined to agree with the doc that said 24-72 hours. I have seen a 4cm fluid filled (clear fluid) turn up basically overnight. Expecially when the person is already physically compromised. Dark fluid I would not really be sure about. MM

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Dear Terri

In my experience, the time it takes with continuous uniterrupted pressure for breakdown to occur is as follows:

Stage I - 2-8 hours;
Stage II - 8-24 hours;
Stage III - 24-48 hours;
Stage IV - 48-72 hours.

However, as I mentioned to Joseph of the Health Department, who is asking the same question, the presence of a blister usually denotes the occurence of a friction rub thermal injury which usually happens when the patient is not lifted sufficiently to prevent dragging. In that case the blister could have been present only moments before the surveyor arrived.

Thomas

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These blisters can "pop up" in a matter of hours, from most of my experience the darker blisters have had some sort of trauma causing the tissue under the blister to bleed, hence the darker color. In the elderly the trauma can be something as simple as putting an ill fitting shoe on the person, same as a healthy person getting a new pair of shoes that doesn't fit right. But because we are healthy we feel that the shoe is uncomfortable and pad the area or take off the shoe. Elderly people typically have lost a most of the sensation in there feet or will describe the feeling as being "too tight", and next thing you know you have a deep purple blister.
Tina L.V.N. (wound care nurse)

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This is a good question. I have never considered time factor in development of wounds in this manner. I don’t think I have read anything in regards. In my opinion, the development of a wound depends upon many factors to include the persons overall health, mobility etc, prevention measures? Two people may have a stage 1—no break in skin—1 person may develop a blister the other may maintain skin integrity. Prevention of progression is the key- by examination of all factors that may affect development of a wound nd identifying this to the individual. Education is the essentia. You did not mention the capacity in which you work, but I suggest getting a professional consult if necessary. A consultant may help you to take a look at what you have and to develop prevention protocols etc.

Jamie Pinnock RN, CWCN

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A pressure ulcer can very quickly progress from stage 1 (non-blanchable erythema or redness, relieved with relief of pressure) to a stage 2 (like
a bad sunburn and skin may be broken or intact, or with a blister). The fluid in a blister is usually the color of urine but will turn darker as the ulcer progresses toward the next stage when pressure is not relieved. It is 24 to 72 hours... 24 if the pressure is not relieved and stays above the capillary closing pressure of 32 mmHg. 72 hours, if pressure is reduced but not relieved. The ulcer should
be immediately noticeable as it begins to develop, that is, if a patient is adequately assessed. If the patient is in a health facility, an ulcer progressing
is suggestive of inadequate care.
Maria Carunungan,DPT, CWS
 

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Would not think so because an ostomie is not a wound. Unless of course the surrounding tissue has become irritated. Miller

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Dear Pam:

I think not. Ostomies are surgical constructs that have a specific function. Therefore, the assessment takes on a greater dimension than assessing a wound. The assessment procedure differs depending on what type of ostomy you are refering to. In general there are several components to any such assessment:
skin edges and surrounding skin for integrity;
ostomy fucntion;
patient's emotional and social responses to the alterations in body image and function;
level of care required to maintain function and prevent complications;
ability of patient and or significant others to provide daily maintenance.
Regards,

Thomas A. Sharon, R.N., M.P.H.

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I am a direct service L.P.N. and hope Algorith---- Canadian Ostomy
Assessment Guide will be of help to you. Sponsored through Convatec.
Division of Bristol-Myers Squibb Canada Inc., 1998.
BEE

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Hi Mr. Hoenig:

I can only imagine how frustrating this must be for your loved one and your family. It is good that you are seeking information to help make an informed decision. Based on the information you gave, I would suggest conservative treatment, unless the treating M.D. deems it detrimental to perform an invasive procedure. Usually for limbs that do not have adequate blood flow- keeping the wounds dry is best- because moisture can promote infection. Infection prevention is one of the goals of conservative treatment. There is a wound care product by the name of Granulex that in my experience have worked well to provide good topical therapy for wounds on limbs with poor blood supply. It is manufactured by Bertek Pharmaceuticals and is a Prescriptive item. Granulex is expensive, but in my humble opinion it is worth the expense for conservative treatment. Managed care often covers most cost of the prescription. I would also suggest you talk with your father’s M.D. about signs of infection and pain control if it is an issue for your father. You can check out info on Granulex by visiting www.bertek.com and then click on Granulex. Have your father’s M.D. look over info—he can also request that a Rep from the company contact him if needed. Hope this helps.
Jamie Pinnock, RN, CWCN

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Without a good blood supply his wounds will never heal. A skin graft would be a waste of time. It would never take without a good supply of blood. The obvious choices are stint, bypass or angioplasty. Don't let them amputate until you have exhausted all other options. 80% of people who have amputations die within one year of amputation.
E. Clos R.N. Wound Care Specialist

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Kenneth,
how frusterating this must be for you and your family. I am wondering about the general health of your father. Of course, it is unrealistic to try to heal a diry wound, so cleaning and debridement are a must. Providing adequate blood flow in the most efficient way possible is a must, because a wound cannot heal without nutrition and oxygen. If this is a pressure ulcer, removal of most if not all of the pressure, the cause, is also must. With underlying CHF, edema management is a must, to allow healing. I would love to help you problem solve and think through some ideas. Feel free to contact me at mkostler@vcn.com.

Marta PT, CWS, CLT

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Hi I am not a health care professional but I do know about maggot therapy as I am on the board of directors for the BTER Foundation who's mission is to educate, do research and funding for patients who cannot afford MDT. I myself am a diabetic who had "POOR" circulation and a chronic non-healing ulcer (Stage IV) with osteomyelitis. I had tried for two years using IV antibiotics and quite a few treatments without success. Of course amputation was highly recommended. Out of sheer desperation I begged to have my doctors try maggot therapy. these are sterilized maggots, raised and sold just for medical purposes. They worked when nothing else could. My feet are totally healed and have been for three years. Unless a life is in immediate danger I see no reason not to try them. They are inexpensive and noninvasive, and all natural. Please consider and check out our website for more information.
BTER Foundation Home Page

Thanks,
Pam Mitchell