Thank you so much. So I'm going to get started. I have no financial disclosures related to the content of this presentation. I am going to discuss a few wound care products. I'm not endorsing any of them, and I have no financial relationships with any of them. I do have a few other disclosures, just to mention, though. I burned myself on the grill a few times, got burned by some girls in high school, still recovering from that. My fraternity pledge class was called the Rug Burns, true story. My house actually burned when I was 11 years old, also true. And I once had some really great sideburns. So you could say that I was maybe born to be a burn doctor. So anyway, I do trauma acute care, but about 40% of my practice is burn surgery, and I've been doing it for about eight years now. So it's kind of an area that's near and dear to my heart. So I was really honored when I was asked to participate with this symposium. So first of all, let's talk about skin. What does it do? Well, it does many, many things, as has already been alluded to, and this is, I think, a fantastic symposium to talk about it, because it is the largest organ system, and it's the only organ system that you don't really need a CT scan to examine. You have to look at it with your eyes. So it's a barrier against external factors, regulates our body temperature, helps us maintain fluid balance, that amazing homeostasis, enables tactile sensation. It also contours and cushions our body, and it makes us look good. You can see this guy here with his exposed muscles. Without his skin, he's not nearly as handsome as he would be with skin on. So it does a lot for us. I'll just briefly talk about the skin layers. I hate to be repetitive. We've got the epidermis, it's the thin top layer. This is the protective barrier, generates new skin cells, and it provides the skin tone. The dermis, though, this is really where the rubber meets the road. This is the majority of the thickness of the skin. It contains the collagen and elastin, provides skin strength, produces sweat and oil, and it maintains the blood supplies. This is probably the most important layer. And then, of course, you have the hypodermis. This is subcutaneous tissue. This cushions the muscle and the bone. It's insulation. It contains the nerves and blood vessels. It's also very variable in depth, and it depends upon the patient's body habitus and also the anatomic location. You're going to have quite a bit more of this, for example, in the abdomen compared to, say, on the foot. Skin also changes as we get older. This should be not surprising to any of us if we've managed both pediatric patients and older patients. So dermis gets thinner about 7% per decade. And as we get older, we also have lower epidermal turnover. We have less vascularity, decreased collagen matrix, and decreased fibroblast and macrophages, which of course are instrumental in wound healing. So what this really means is that as we get older, our skin is thinner. It's more susceptible to injury. And also, more importantly, wound healing takes longer as we get older as well. And this is something that I think we always need to take into consideration whenever we are managing a wound. The 20-year-old with a big wound is going to heal differently than the 80-year-old with the exact same wound. So let's talk about the effects of skin loss on physiology. And these are all things we need to think about whenever we're managing a patient with a big wound. So first of all, fluid status. This is particularly important. So as we mentioned earlier, skin is important with maintaining homeostasis. So if you have a large wound, you're likely going to have a large fluid loss to go along with it. And this needs to be accounted for. So this means that if you're managing that patient's fluids, they're probably going to require a higher maintenance rate. They're not going to accumulate as much interstitial fluid because they basically have this evaporative process going on that a lot of that fluid is going to get removed. And we've noticed even that some patients with really large wounds, especially some of the bigger wounds we've managed, they may not even form pleural effusions. And that's simply because that fluid that you're giving them, instead of collecting in the pleural space, it goes on the bed sheets. The IOs may not be accurate. And for this reason, you may have to utilize the hemodynamics and the urine output and other factors in order to really manage the patient's fluids. Temperature management is also particularly important. These patients with big wounds, they have a hypermetabolic response. So if it's a large wound, it's a large heat sink. It's basically just extracting that thermal energy from the patient. And this heat loss results in hypermetabolism. So this means that both in the intensive care unit, you have to monitor the patient's body temperature closely. You have to increase the room temperature. You can do active warming. But also in the operating room. So when you take these patients to the OR, temperature is particularly important. It has to be monitored very, very closely. This is something that I've gotten in the habit of doing for every case. Not only do we increase the room temperature, but I'll ask the anesthesiologist at the start of the case, what is our starting temperature? I'll write it on the board. And I will usually set a cutoff and say, as long as we stay above X, then we're going to keep going. But if we get below X, I want to know about it. This is especially important if you have an anesthesiologist who maybe doesn't do big wounds or doesn't do burns regularly. They may not be as familiar with this. And every op report I do, I have my starting temperature and my ending temperature documented. So these large areas with patients exposed to these basically means that you're going to have increased heat loss. So an increased OR temp, this is another way to do it. But if you do increase your OR temperature, it's been known to increase syncopal events in medical students. This has actually been shown scientifically. And I had this happen to me just a few weeks ago. Nutrition is also very important. Nutritional needs in a patient with a big wound increase by anywhere from 10% to 50%. And this means that you need to do an early nutritional assessment. You got to make sure that you initiate the diet early and monitor intake. We actually, in our center, we will continue tube feeds up until the moment of surgery. And there's even some literature to suggest that you can continue throughout the operation as well. And so this is the kind of case where, I know this was mentioned by one of the speakers earlier, but if you have an anesthesiologist who's insisting on, oh, got to be NPO eight hours before surgery, you got to say, no, not really. If you have a protected airway, patient's intubated, we can continue and even go through the operation. Because the nutrition is actually more important. If they're not intubated, you can increase the portions. You know, we'll do double portions, increase the protein intake. You can also supplement with tube feeds. This can be done overnight. And if they are intubated, you want to get the indirect cryolometry. We call it the metabolic part. This is typically done, you want to do it about weekly just to readjust your tube feeds. And it's not uncommon. You know, when I'm in our trauma ICU, you know, tube feeding rates, 55 an hour, 16 hour. In the burn unit, I've seen tube feed rates at 120 an hour. It's not uncommon. So the patient's nutritional needs will be significantly higher. What about pain management? Well, this stuff hurts. This is a very particularly important part of managing patients with big wounds. So large wounds, they are painful. There's a significant release of inflammatory mediators, hyperalgesia is common. There's increased patient anxiety. With the pain response, you'll be managing the anxiety as well. And this involves both pharmacologic pain management and then also weaning those pain medicines once the wound heals. So how do we do this? Well, we do it through multimodal therapy. And this is kind of a, it's the pain pyramid. So first of all, we do scheduled non-opioids, which would be like acetaminophen and NSAIDs. Also we can do adjuncts like gabapentin. We also utilized local anesthetics. So if a patient has an extremity wound, this is a perfect opportunity for a local nerve block, especially if the patient's getting a dressing change or going to the operating room. And then after that, use opioids. And this typically is going to involve a scheduled long acting, such as like an MS-Contin. Then you have an on-demand oral like oxycodone, followed by, then when they undergo dressing changes, we'll do a pre-medication before it, and then you have a PRN during it. So pain management is very, very important for these patients. Physical therapy, get them up and moving. So this is one of those comfort level things where often patients that have big wounds, we kind of defer to letting them lay there. We really need to make sure that if possible, they can get up. They will benefit from mobility. It'll improve their long-term functional outcomes. This may require additional pain management, but a large wound doesn't mean the patient needs to be in bed all the time. We had a burn patient a few years ago who was a 70% flame burn, and he had exposed tibias, and he was able to walk. Obviously he wasn't walking with exposed tibias, they were dressed. But the point is that he was actually able to walk with exposed tibias. So just a big wound by itself does not mean that they have to lay in bed all the time. Also treat the underlying cause. Most wounds, there's a previous wounding insult. So if it's like a trauma, you know, or a burn, but some wounds may have a chronic underlying cause. You know, these would be things like calciflaxis. We've seen purpura fulminans from COVID-19 or venous stasis. So you want to make sure that you've evaluated what the original cause is, and we're doing whatever we can to treat it. If it's an extremity, assess the vascular supply, and if it's unclear etiology, get a skin biopsy and try to find out more. Now we'll talk briefly about the wound management. So the mainstay of surgical management of any wound is debridement, which was mentioned earlier. And this is a perfect example of to cut is to cure. So with any wound, it doesn't matter whether it's a burn or whether it's neck fash or what have you, we want it to breed down to healthy tissue, and we're going to look for tissue perfusion. This would be, this is the same regardless of what the etiology is. And this is something that we often look for, is I like to look for thrombus vessels. This is actually a pavement burn that we see quite commonly in Las Vegas. And what we will often do is we will cut through the burn tissue and we will see these, which are these thrombus vessels there. And that indicates that that skin blood supply has actually been knocked off. And even though it sort of looks viable now, it's actually not going to be viable in a few days. So this is a full thickness burn. After the wound is excised, it's got to be cleaned thoroughly. So what we will usually do is after we're down to healthy tissue, we will irrigate thoroughly with, we can use these big three liter bags of normal saline, hooked up to Sisto tubing. That tends to work really, really well. Bleeding is important to stop, and we use all of our typical tools for controlling surgical bleeding. Stitches, cautery. But if you have those like big surface areas of bleeding, that's where we'll use epinephrine silk lap sponges. Also thrombin spray is fantastic. And if it's an extremity, you can wrap with elastic. So there's all kinds of different tricks to control bleeding in the operating room. But it's really important to, after the debridement, make sure that the wound is clean, irrigated, and you want to try to get rid of all the dead tissue as possible. Now what about non-healing wounds? So I've kind of implied that you always want to get down to good healing tissue. But what if you excise the patient down to good healing tissue, and you examine it afterwards. So you want to see bleeding, perfusion, granulation. But let's say you look at it in a day or two, and you see more necrosis, sloughing, and exudate. In that case, you may need to re-excise, and again, fix the underlying comorbidities. And previously, I really enjoyed that mnemonic that one of the speakers mentioned. I've actually not seen that before, but that's fantastic. I'm going to take that home. But you want to fix the underlying comorbidities. But this next slide is a perfect example. So if you do multiple excisions, and there's just no healing, that's when you want to consider palliative care. And this next slide shows an example of a patient who, this is after about this patient's fourth excision. And this started out as a wound that was about the size of a dessert plate. It was a morbidly obese woman who had an injection in her abdomen at another hospital, developed skin necrosis, and was sent to us. So it started out as an excision about that big, didn't heal, ended up getting bigger, bigger, bigger. And we finally found that all we were doing is creating a bigger hole. And all that was happening was we were excising down to what we thought was healthy tissue, and then things just weren't healing. And unfortunately, this patient did eventually pass away from other causes. But it's a perfect example of you have to monitor for healing, make sure that the patient's actually getting better. And if not, then it's time to consider palliation. So now what? You got the wound excised. Now, the goal is wound closure one way or another. And so a couple of questions to ask is whether the hospital that you're at can handle this. So this includes wound care resources and comfort level of the individuals involved. Is this wound over some special areas, such as joints, big vessels, bones, and so on? It's important to engage other specialists. This may involve plastic surgeons who can do flap reconstruction or a burn center, if you have one at your hospital or if you need to transfer them out. These are all things to consider. So different closure strategies, you know, primary closure is the easiest. This is what you're going to do at the first operation. But in general, if you're at this talk, you're here to hear about wounds that you can't close primarily. Secondary intention is ideal for wounds that are smaller and deeper and well vascularized. This is where you just let it close on its own through granulation. Tertiary closure, you'll take them back after debridement to do a closure in the operating room. But if the wound is too big to close, this is where you're going to want to generate an actual wound bed and do skin grafting later. Wound care, it's big business, lots of money every year, $32 billion for Medicare or Wound. I'm going to talk about a couple of these real briefly because I know I'm starting to run short on time. But I'm not going to go too much into these biosynthetic dressings, but these are ideal for partial thickness wounds that can be applied and left in place. I know some of the other speakers already talked about some of these, but these are some of the ones that we use, Superthel, Puricol, and Algacyte. Not necessarily endorsing any of them in particular, but we use them all for different purposes. Wound vacs are fantastic. They are simple and effective. They can be placed and remain in place for anywhere from two to five days. They apply negative pressure and remove fluid. This enhances formation of granulation tissue and enhances surface blood flow. May not be possible if you have a wound in a sensitive area or where it's really, really large. But I would urge caution if you want to examine the wound daily. So if it's a wound that you're not sure is getting better, it's probably better to avoid the wound vac for a day or two, wait until you're pretty sure it's getting better, then apply the wound vac because then it will accelerate your healing. And this is just a couple photographs of us using them. On the left here, this is a patient with bilateral AKAs and big, big wounds from burns. And then on the right, this is a patient with a buttock burn that we were managing. Skin substitutes. Well, it depends on the situation. If it's a small wound, probably not necessary. If it's a large wound, especially one that's a little bit more superficial, definitely may be a benefit. Advantages for this are fluid balance, temperature regulation, pain management. It also restores function and better mobility, and it covers up structures, including tendons and nerves. So cadaveric allograft, this is the one that we use quite a bit. This is one of the more common ones. This is basically cadaver skin. It's exactly what it sounds like. It's skin from a dead person. Pros are it's easy to apply, thaws quickly, doesn't get infected too easily, it's pretty durable, decreases your fluid loss, helps with pain control, and it's a good test for a skin graft. If it adheres well, then you have a pretty good idea that a skin graft is going to work. On the negative side, though, not all hospitals will carry it, and if you leave it on too long, it will integrate, and this can be really short for kids. I've placed it on kids with wounds, and by day four, it's starting to integrate. Adults it will take longer. You have more time. This kind of goes back to the wound healing differences on ages, but this is a good possibility. This is what it looks like when you place it. It's meshed, and so we place it down there, and it adheres. This serves as a temporary covering. Cadaver skin, similar to human cadaver skin. I'm not sure if it's available anymore, but I know that we used to use it quite a bit. One major difference is that it comes in rolls, so it's these long strips, but it works very similarly. It doesn't tend to integrate quite as well, but it offers a lot of the same benefits. Dermal substitutes, there's lots of different varieties. These are the main ones that we use, including Norbisorb, Integra, and Primatrix. Each one of them has their own pro and con. I'm going to talk about a couple of them. Primatrix, this is a fetal bovine acellular dermal matrix. This is really good for really big wounds that are full thickness. It's quick to apply, and it's designed to integrate into the patient. This is actually what it looks like when you first put it on on the left, and then after it's starting to integrate, after about four or five days on the right. This is what you want to end up with. It's a nice wound with fully integrated Primatrix. You can see the matrix mesh there, where it's fully integrated. It's a wound that's basically getting ready for skin grafting. Norbisorb, similar. It's a biodegradable temporizing matrix. This is really good for smaller, large burns. You can use it for variable depth burns. It's easy to apply. Infection risk is pretty low. It works okay on hands and feet, whereas Primatrix, not so good for hands and feet. It takes a little bit longer to integrate, but you've got to watch out for fluid getting trapped underneath it. That's one of the advantages of Primatrix, is that fluid just seeps right out, whereas with Norbisorb, fluid can actually get trapped underneath. This is what it looks like when you first apply it. We've gotten in the habit of pie crusting that actually lets the fluid come out. This is what it looks like after it's been on for about two to three weeks. This is where it's getting ready for skin grafting. Basically, what you do is you peel that top layer off, then you have a nice wound bed underneath ready for skin grafting. Integra, this has been around a long time. It's a product for the ages, but it still works great. It's really good for smaller, more sensitive areas. It's really important to get good tissue contact with these. Similar to Norbisorb, you have to monitor for fluid collection underneath, and it can facilitate rehepatilization in small wounds. On the downside, the infection risk is a bit higher. You have to be really, really mindful of this, so it's not good in difficult areas. It works really well on hands and feet. That's really where we use it quite a bit. This is what it looks like after it's applied, and you can see the integration underneath. In summary, in general, we want to maximize and manage the nutrition, control the patient's pain, especially the dressing changes, anticipate and manage the fluid loss, watch out for and manage hypothermia. There's many, many different wound coverage options. I just really scratched the surface, and consult subspecialists when it's difficult, and the end goal is a closed wound. Thank you very much. Thank you.

wound care

management of large wounds

skin

physiology

surgical management of wounds