Overview of Complex Wound Management

When you get a cut or wound, your body goes through a complicated process to heal itself. This process aims to repair any damaged tissues. However, sometimes, a wound takes a very long time to heal, and we call these long-lasting injuries as chronic or “complex” wounds. These can’t be fixed with just a bandage or the usual wound care methods because other factors are preventing the healing process.

A “complex” wound has certain characteristics. It could have been there for over three months. There might be a problem with blood flow to the wound or dead tissues in the area. The wound could be infected. Or, other health issues might be making it harder for the wound to heal.

A number of things can make it difficult for a wound to heal. Some factors are local, related to the wound itself; including how deep the wound is, whether there’s an infection, problems with blood circulation in the area, exposure to radiation, ongoing pressure on the wound, or too much moisture. Some factors are systemic, related to your overall health; including having metabolic disorders like diabetes, weakened immune system, and nutritional deficiencies.

Complex wounds are very troublesome. They not only affect your quality of life but also put a lot of strain on healthcare costs. Approximately 1 to 3% of healthcare expenses in developed countries are spent on managing complex wounds. In the United States, about $25 billion each year goes to this problem. And sadly, this number is likely to keep rising as more people struggle with chronic health issues.

Anatomy and Physiology of Complex Wound Management

The skin is the largest organ in your body. It’s made up of three main layers: the epidermis (the outer layer), the dermis (the middle layer), and the subcutis (the inner layer).

The outermost layer, known as the epidermis, has five smaller layers within it. The bottom layer, or basal layer, is made up of cells that are constantly dividing to create new skin. This layer also has cells that produce melanin which gives your skin its color and cells called Merkel cells that help with your sense of touch.

The second layer of the epidermis, called the prickle cell layer, makes up most of the epidermis. It contains cells called Langerhans cells that help your immune system fight against infections. The skin continues to get flatter as it moves towards the surface, finally forming the outermost layer, the stratum corneum.

The dermis is the middle layer of your skin. It makes up 90% of your skin’s thickness and is made mostly of collagen and elastin, which gives the skin flexibility and strength. It is also where you find blood vessels, sweat glands, sebaceous glands (which produce oil), and hair follicles. This layer is split into the ‘papillary’ and ‘reticular’ dermis.

The innermost layer of skin, the subcutis or hypodermis, is mainly composed of fat and collagen. It functions as a shock-absorber and insulator, protecting your body from trauma and helping to maintain body temperature.

Your skin has four key roles: protecting your body against harmful substances and infections, controlling body temperature, allowing your body to feel sensations like heat and cold, and helping your body to produce vitamin D.

When you get injured, the skin heals itself in stages. First, it stops the bleeding (hemostasis) by narrowing blood vessels and causing clots to form. Then, it sends a type of white blood cell called polymorphonuclear leukocytes to clean up the wound (the inflammatory phase). Around three to four days later, other cells come to help build new blood vessels and skin (the proliferative phase). About five to seven days after the injury, this healing phase begins and it can continue for around four weeks. The last step is the remodeling phase where the skin strengthens this new tissue, which can last for years. However, it’s important to note that even though healed skin is strong, it still has about 80% of the strength compared to skin that was never injured.

When a Person Should Avoid Complex Wound Management

If a person has thyroid issues or is pregnant, it’s generally not a good idea to use bandages or dressings that contain iodine.

Negative Pressure Wound Therapy, which helps heal wounds by increasing blood flow, might not be the best option if the wound might contain cancerous tissue, a fistula (an abnormal connection between organs), untreated bone infection (osteomyelitis), or dead tissue.

Using live maggots (larval therapy) to clean wounds is not advisable if the wound is close to a major internal organ, space, or blood vessel, if the wound is too dry, or if there’s a big risk of heavy bleeding.

Leech therapy, where leeches are used to promote wound healing, should be avoided if the person has poor blood flow in the arteries, a higher risk of bleeding, follows the Jehovah’s Witness faith (since they refuse blood transfusions), has a weakened immune system, is diabetic, has had allergic reactions to leeches or certain antibiotics called fluoroquinolones, or strongly dislikes the idea of using leeches.

Hyperbaric oxygen therapy, which involves breathing pure oxygen in a pressurized room to increase the oxygen levels in your blood and repair tissues, is not recommended if a person has pneumothorax (air or gas in the chest causing lung collapse), severe reactive airway disease (like asthma), or has recently undergone chemotherapy.

Who is needed to perform Complex Wound Management?

Treating complex wound problems is teamwork and is most effective when multiple healthcare professionals come together. This collective effort helps create the best conditions for a wound to heal faster and to manage any other health conditions the patient might have. Regular interactions among the team members is essential for efficient healing. This team can consist of different wound care specialists like nurses with extra training for wound care, plastic surgery nurses, and plastic surgeons. Depending on the patient’s needs, other health professionals might be involved, including a team for diabetes management, blood vessel surgeons, a lymphedema care team (for swelling issues), a nutrition expert, and a microbiologist. It’s also very important to have a pain management team and an occupational therapist, especially before the patient goes back home.

A nurse with special training for wound care should be a part of the team, especially for wounds which are not improving or getting worse after the first two weeks. It’s also important to take regular photographs of the wound to keep track of how it’s healing. In some cases, fast surgical procedures may be necessary, like for a serious skin infection called necrotizing fasciitis, or advanced reconstructive surgeries. These cases should always be discussed with a plastic surgeon.

Plastic surgery nurses can also be useful after reconstructive surgeries, like skin grafts (where a piece of healthy skin is used to repair the damaged area) or surgeries that use a piece of tissue called a flap. They can assist the other nurses when using special dressing techniques, like negative pressure therapy (a method to improve wound healing) or if maggots have been used to clean the wound. All diabetic patients with complex wounds should regularly meet with the diabetes team to keep their blood sugar and HbA1c levels (a marker of long-term blood sugar control) in check. Patients might also need to adjust their diet to support wound healing. They should be checked for poor nutrition and referred to a dietitian if necessary. Their diet usually needs more calories, especially proteins, along with more vitamins and minerals. Regular checks of albumin, prealbumin, and transferrin (proteins that can hint at how well the patient is nourished) can help to assess progress.

If a wound is infected, the patient is usually treated with an antibiotic, and the choice depends upon the hospital’s guidelines and discussion with the microbiology team to avoid overuse. Patients with lymphedema (a condition that causes swelling) should be referred to the lymphedema team for specialized care, including bandaging to reduce swelling. Blood vessel surgeons can also play a key role in certain conditions, like restoring blood flow to a limb, carrying out an amputation to control severe infection, or treating vascular diseases such as a limb with poor blood flow, or a blood clot in the deep veins.

It’s very important for patients to have pain relief to help them stick to the treatment plan and have a pain specialist involved early on can lead to better outcomes. Occupational therapists (who help with daily activities) and psychological support can be beneficial during the hospital stay and ongoing support in the community after discharge is crucial.

Preparing for Complex Wound Management

When taking care of a wound, the first step for your doctor is to gather all the necessary information about the wound and your health. They may ask about how the wound happened, your general health and diet, how long you’ve had the wound, any previous injuries or wounds in the same area, treatments you’ve been given before, and whether you have allergies to certain medications or wound dressings.

Your doctor will then examine the wound thoroughly, using a method called the TIMES framework. This is just a structured way to assess a wound and make sure nothing is overlooked. The ‘TIMES’ each stand for a different aspect of the wound that needs to be checked:

‘T’ is for the ‘Tissue type’ in the wound. This refers to what kind of tissue can be seen in the wound. This could be dead tissue, soft and moist dead skin (slough), infected tissue, new tissue (granulating), or new skin (epithelializing). They’ll also look for any foreign objects in the wound and whether bones or tendons can be seen.

‘I’ stands for ‘Infection or inflammation’. If your wound is infected, it may delay healing and lead to other complications. It’s normal for most wounds to have some bacteria in them, but an infection is generally associated with symptoms like fever, increased pain and swelling, redness, and pus. The doctor might also take a sample from the wound to check for infection, particularly if you have certain health conditions like diabetes that can make infections harder to spot. Any treatment for infection will follow local guidelines and may be discussed with specialists in infection control.

‘M’ stands for ‘Moisture balance’. Your doctor needs to make sure there is a right balance of moisture in the wound. While some moisture can help certain wounds heal, too much can allow bacteria to grow. They’ll check the level and kind of fluid coming from the wound, and may ask a team of blood vessel specialists to help choose the right dressing if there’s a risk of poor blood flow in the area.

‘E’ stands for ‘Epithelialization’, or new skin growth. If there’s no new skin growing over the wound, it might not be healing properly. Things that might stop new skin from growing can include too much new tissue, too much moisture, or infection.

And finally, ‘S’ is for ‘Surrounding skin’. The doctor will also examine the skin around the wound for any signs of further inflammation or breaks in the skin, which could indicate the wound is getting bigger.

How is Complex Wound Management performed

After a wound assessment, a plan should be put together for how to care for the wound. This plan could require help from a specialist, and should focus on a few things:

– Making sure the patient is as healthy as possible
– Controlling any infection
– Cleaning the wound
– Removing dead tissues, also known as debridement
– Managing pain
– Reducing pressure if the wound is a pressure ulcer.

For the wound to heal the best way possible, there are some conditions that the patient should meet, including having less than 200g/dl of blood sugar, more than 3 g/dl of albumin (a protein in the blood), more than 15 mg/dl of prealbumin (another type of protein in the blood), more than 1,500 lymphocytes (a type of white blood cell), a wound bed (the bottom layer of the wound) that has good blood flow, and stop smoking for a period of time.

Every wound should be handled following strict hygiene rules to avoid germs entering the wound and causing an infection. Wound cleaning is usually done with a warm saline solution (a mix of salt and water). If the wound is producing a lot of liquid or shows signs of infection, using an antiseptic solution is recommended. Removal of debris and non-viable tissue can be done in different ways, including using the body’s own enzymes (autolytic), using insects like maggots (larval therapy), using chemicals (like hydrogen peroxide or prontosan), using a machine that uses water (hydrosurgery), using surgical tools (scalpel or scissor), or with surgery.

Dressing

Wounds heal faster in a moist and clean environment. This allows growth factors (substances that help the body’s cells grow and develop) and epithelial cells (skin cells) to move to the wound bed and for the wound edges to shrink. When choosing a dressing, its ability to absorb excess fluids if the wound is oozing, hydrate (provide water) if the wound is dry, fight against infection if the wound is infected, and remove dead tissues, must be considered.

The choice of dressing should be based on the overall assessment of the patient’s health, the wound bed, and understanding the pros and cons of each type of dressing. The perfect dressing should create a moist and clean environment, prevent the wound from drying out, remove excess fluids, protect from microbes but allow gases to pass through, be free of harmful materials, fit the wound with minimal pain when applying and removing, and be cost-effective. The frequency of dressing changes varies and is usually based on the amount and nature of the wound fluid, but constant wound evaluation with each dressing change is essential to check how effective the dressing is and whether another type of dressing is needed.

There are three main categories of dressing materials. The first helps activate the body’s enzymes to treat the wound bed. The second helps manage the moisture level of the wound. The third suppresses bacterial growth. However, there is limited evidence on the effectiveness of different types of dressings. Different types of dressings include:

1. Gauze: This is a common type of dressing. It is permeable, allowing fluids to pass through, but can stick to the wound, causing trauma when removed, although it can help remove any dead tissue in the wound bed.

2. Transparent film dressing: These are thin, flexible sheets that provide a moist environment and can be used for surgical wounds or skin graft donor sites.

3. Foam dressing: This is made of a material called polyurethane and can be used in wounds that produce a moderate to high amount of fluid.

4. Hydrogel: This is a water-based polymer that can soften necrotic wound beds and dress wounds with low fluid.

5. Hydrocolloid: This type of dressing can absorb wound fluid and provide a moist healing environment.

6. Alginate: This type of dressing can absorb up to 20 times its original weight and is effective in managing high-fluorinating wounds.

Remember, the best choice of dressing depends on the specific condition of the patient and the wound.

Possible Complications of Complex Wound Management

Surgery and treatment can sometimes lead to general complications, such as bleeding, the treatment not working as planned, skin breaking down, and getting infections.

There are also specific complications associated with different treatments. For instance, with leech therapy, there are some risks. Leeches have a bacteria known as Aeromonas spp. in their mouth and digestive system that helps them digest blood, but it can be harmful to humans. This, along with a backup of blood flow, can make the body’s immune response weaker in the treated area. Therefore, to prevent infection, antibiotics may be given before the treatment. Leech therapy can also lead to prolonged bleeding, which is particularly concerning in children. Therefore, monitoring the level of hemoglobin, the protein in your blood that carries oxygen, is necessary during this treatment. Some other reported complications include allergic reactions, leeches moving to healthy tissues, and pre-renal azotemia, which is a buildup of waste products in the blood due to problems with how your kidneys filter your blood.

Hyperbaric oxygen therapy, another treatment, can also have adverse effects. Specific problems reported with this therapy include feelings of being trapped (claustrophobia), ear discomfort, and potential nerve damage due to high oxygen pressure.

What Else Should I Know About Complex Wound Management?

When it comes to healing complicated wounds, it’s vital to get the patient’s body and the wound itself in the best shape possible. One way to do this is to thoroughly clean the wound and select the right wound dressing. Additionally, it’s important to consider any other health conditions the patient might have and ensure they’re eating properly to support healing. In most cases, a variety of health professionals are involved to achieve the best results.

Pressure ulcers, sometimes known as bedsores, are injuries to the skin and underlying tissue. They often occur in people who are bedridden or in a wheelchair, particularly over areas where the bone is close to the skin, like the hips or heels. Between 3 and 15% of hospitalized patients develop these sores, which can be life-threatening for older people. Doctors divide them into four categories, from red, unbroken skin to serious tissue damage. To prevent these sores, it’s important to provide skin care, ensure good nutrition, regularly change the patient’s position, and use special mattresses to distribute pressure. Doctors usually treat these wounds by improving the patient’s general health and managing any existing infections before considering surgery.

Diabetes can cause foot problems due to nerve damage, reduced blood flow, and infection. The best approach to treating these issues usually involves a team of healthcare professionals, including a family doctor, diabetes nurse, footcare nurse, counsellor, and other specialists. Treatment includes educating the patient, monitoring blood sugar levels, carefully cleaning the wound, taking pressure off the wound, and possibly having surgery.

Venous ulcers are a type of wound that can develop as a result of varicose veins and poor blood flow, often causing significant discomfort. Treatment usually includes surgery to correct the problematic veins, using compression bandages and regular dressings for the wound. If the ulcer doesn’t heal as expected, skin grafting might be needed.

Radiated wounds occur from radiation therapy which damages cells under the skin, making it difficult for these wounds to heal. Oxygen therapy can help improve the healing environment. However, in severe cases, surgical removal of the affected area and replacement with a healthy skin flap may be necessary.

Malignant wounds are serious skin problems caused by cancer. Early diagnosis can greatly reduce the impact on the patient’s health and well-being. Biopsies and scans help with the diagnosis and determining the extent of the disease. Treatment often involves removing the tumor and possibly the nearby lymph nodes surgically.

Abdominal wound dehiscence is the splitting open of a healing abdominal wound, which can be caused by various conditions, such as trauma, infection, or stomach tumors. In some cases, the wound may be immediately closed with a skin flap. In others, a staged approach is used, beginning with a temporary wound closure, followed by improving the patient’s overall health, before final reconstruction is undertaken.

Frequently asked questions

1. What factors are preventing my wound from healing and how can we address them? 2. What is the best dressing option for my wound and why? 3. Are there any specific complications or risks associated with the treatment plan for my wound? 4. How can I optimize my overall health to support wound healing? 5. Are there any lifestyle changes or modifications I should make to promote faster healing?

Complex Wound Management can affect you by providing specialized care and treatment for wounds that are difficult to heal or have complications. This can include wounds that are large, deep, infected, or have underlying medical conditions. Complex Wound Management aims to promote healing, prevent infection, and improve overall wound outcomes, which can have a significant impact on your health and quality of life.

Complex Wound Management may be necessary for individuals who have wounds that cannot be effectively treated with traditional methods. This could include wounds that are infected, have poor blood flow, contain cancerous tissue, have abnormal connections between organs, or are close to major internal organs or blood vessels. Additionally, individuals with certain medical conditions such as thyroid issues, pregnancy, poor blood flow in the arteries, weakened immune system, diabetes, or allergies to certain treatments may require Complex Wound Management.

A person should not get Complex Wound Management if they have thyroid issues or are pregnant, if the wound might contain cancerous tissue, a fistula, untreated bone infection, or dead tissue, if the wound is close to a major internal organ, space, or blood vessel, if the wound is too dry or there's a risk of heavy bleeding, if they have poor blood flow in the arteries, a higher risk of bleeding, follow the Jehovah's Witness faith, have a weakened immune system, are diabetic, have had allergic reactions to leeches or certain antibiotics, or strongly dislike the idea of using leeches, or if they have pneumothorax, severe reactive airway disease, or have recently undergone chemotherapy.

The text does not provide specific information about the recovery time for Complex Wound Management.

To prepare for Complex Wound Management, the patient should gather all necessary information about the wound and their health, including how the wound happened, general health and diet, previous injuries or wounds in the same area, and any allergies to medications or wound dressings. The patient should also ensure they meet certain conditions for optimal wound healing, such as controlling blood sugar levels, maintaining good nutrition, and stopping smoking. It is important to work with a team of healthcare professionals, including wound care specialists, nurses, surgeons, and other relevant specialists, to create a comprehensive treatment plan and ensure regular interactions for efficient healing.

The complications of Complex Wound Management include general complications such as bleeding, treatment not working as planned, skin breakdown, and infections. Specific complications associated with different treatments include risks of leech therapy such as infection, prolonged bleeding, allergic reactions, leeches moving to healthy tissues, and pre-renal azotemia. Hyperbaric oxygen therapy can lead to feelings of being trapped, ear discomfort, and potential nerve damage.

Symptoms that require Complex Wound Management include wounds that are not healing or have become infected, wounds that are deep or have exposed bone or tendons, and wounds that are causing severe pain or discomfort. Other symptoms may include excessive drainage or bleeding from the wound, foul odor, and signs of tissue necrosis or gangrene.

The provided text does not specifically mention whether Complex Wound Management is safe in pregnancy. Therefore, it is not possible to determine the safety of Complex Wound Management in pregnancy based on the given information. It is recommended to consult with a healthcare professional for personalized advice regarding wound management during pregnancy.

Join our newsletter

Stay up to date with the latest news and promotions!

"*" indicates required fields

This field is for validation purposes and should be left unchanged.

We care about your data in our privacy policy.