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Toolkit

Pressure Injury Toolkit For Spinal Cord Injury and Spina Bifida

Beyond the wound - Bringing best practice to the bedside

Wound management

Follow principles of optimal wound management

Optimal wound bed preparation includes (TIME)32:

  • Tissue management (including removal of non-viable tissue)
  • Infection and inflammation control
  • Moisture balance, and
  • Epithelial edge advancement

Cleanse the wound

  • Use normal saline, sterile water, lukewarm tap water (water suitable for drinking) or pH-balanced wound cleansers as per the (i) manufacturer’s recommendation and (ii) your organisation’s wound cleansing policy.11
  • For wounds with suspected or confirmed infection, suspected high levels of bacterial colonisation or debris, consider using cleansing solutions with antimicrobials.32
  • Conservative sharp wound debridement in accordance with your organisation’s wound debridement policy may be required if there is a moderate amount of nonviable tissue present. It is performed by a suitably qualified wound care professional and usually involves local anaesthesia.
  • Surgical debridement is performed in consultation with or by the tertiary SCI service and plastic surgeons

Dress the wound

The results of a comprehensive wound assessment are used to determine the most appropriate wound dressing.

Select a dressing based on the32:

  • Ability to maintain a moist wound bed
  • Nature and volume of wound exudate
  • Need to address bacterial bioburden
  • Condition of the tissue in the wound bed
  • Condition of peri wound skin
  • Wound size, depth and location
  • Presence of tunnelling and/or undermining
  • Goals of the person

Considerations:

  • Remove dressing gently with adhesive removal swab to avoid skin damage.
  • Consider appropriate adhesive (such as silicon borders) to protect the skin.
  • Assess the person’s pain and need for pain relief prior to dressing changes.

Children with SCI or SB

When recommending dressings, consider the child’s pressure management plan to ensure wound management is practical and does not interfere with strategies to maintain play, movement, socialisation and schooling where possible.

Investigate products that are available in smaller sizes and that protect fragile skin.

Check products for precautions, for example, cadexomer iodine ointments and impregnated dressings should not be used with children.11

Manage complications

  • Hypergranulation:
    Hypergranulation (over-granulation of tissue which extends above the base layer of the wound) delays healing. Multiple management strategies have been described, although unclear which is most effective. Treatments may include silver nitrate, sharp debridement and secondary dressings that control moisture (such as hypertonic saline) and provide compression11,20
  • Superficial infection3211:
    • Consider cleansing using a non-toxic topical antiseptic agent of appropriate strength for a limited time.
    • Remove biofilm using antiseptics in conjunction with maintenance debridement (by an appropriately qualified professional).
    • Consider the use of antimicrobial dressings such as silver sulfadiazine for a time limited period or medical-grade honey.
    • Prevent contamination of the wound through careful skin cleansing processes and the selection of dressings to prevent exposure to faecal matter.
    • Optimise systemic factors by improving nutrition, managing blood pressure and cholesterol and recommending cessation of smoking.
  • Deep infection
    • Remove infected bone and or devitalised tissue near or surrounding infected area, draining any abscesses or pus.
    • Commence appropriate intravenous antibiotics.
  • Osteomyelitis (OM):
    • The wound is unlikely to achieve permanent healing if osteomyelitis has not been adequately treated.
    • Negative Pressure Wound Therapy (NPWT) is not recommended in people with untreated osteomyelitis. It may be used in consultation with the tertiary SCI service if OM has been addressed in accordance with the organisation’s NPWT policy.
    • A prolonged course of antibiotics based on bacterial sensitivities from bone biopsy will be required, initially intravenous followed by suitable oral antibiotics.32
    • Antibiotic therapy should be monitored by the GP in consultation with an Infectious Disease specialist.

Remove pressure

A person with SCI or SB will have absent or reduced sensation below their level of injury and not be able to feel (or completely feel) the pressure, friction or shear contributing to the wound. It is important to remove all mechanical forces impacting on the wound.

Depending on the location of the wound, removing pressure may mean the person cannot sit in their wheelchair and management may involve periods of bed rest. If it is recommended that the person should not use their wheelchair, all health professionals should schedule their appointments with this in mind. It may be difficult to confirm whether the wound is under pressure when the person is sitting in their wheelchair therefore consultation with an occupational therapist or seating therapist is recommended.

See Address Causative and Contributing Factors: Mechanical Factors in this Toolkit.

Monitor

Monitor for Red Flags, such as signs of deep wound infection, and reassess the wound regularly using a Validated Tool to evaluate the management plan.

Adjunctive therapies

Additional research is required to determine the effectiveness of various adjunctive therapies such as electrical stimulation for people with SCI. For up to date information, consult the most recent National Pressure Ulcer Advisory Board Guidelines and the SCIRE Project website.

If used, other treatment motilities should be used in addition to standard wound management. The success of adjunctive therapies may rely on the extent to which contributing factors have been addressed.