What are the steps for classifying and managing wounds?

Wound Classification and Management

Wound management should follow a structured approach that includes prompt assessment, classification, and appropriate interventions to optimize wound healing and prevent complications. 1

Initial Wound Assessment

Physical Examination

• Measure and document wound size (length, width, depth), extent of surrounding inflammation, and quality/quantity of drainage including color and odor 1
• Use a sterile, blunt metal probe to assess depth, detect foreign bodies, identify soft-tissue abscesses, communications with joint cavities or tendon sheaths, and check for palpable bone (probe-to-bone test) 1
• Evaluate for signs of infection: presence of purulent secretions (pus) or at least 2 cardinal manifestations of inflammation (redness, warmth, swelling/induration, pain/tenderness) 1
• Assess arterial perfusion to determine if revascularization is needed, especially for lower extremity wounds 1

Classification Systems

Several validated classification systems can guide wound management:

1. T.I.M.E. Framework 1:

   • Tissue debridement (sharp, enzymatic, autolytic, biological)
   • Infection/inflammation control
   • Moisture balance
   • Epithelial advancement/wound edge preparation

2. NERDS/STONES Assessment for chronic wounds 1:

   • NERDS: Nonhealing, Exudate, Red friable tissue, Debris, Smell (superficial infection)
   • STONES: Size increasing, Temperature elevation, Os (probe to bone), New breakdown, Erythema/Edema, Exudate, Smell (deep infection)

3. Wound Severity Classification (for specific wound types):

   • For diabetic foot infections: mild, moderate, severe based on depth, extent, and systemic manifestations 1
   • For pressure injuries: Stages I-IV, unstageable, and deep tissue injury 1
   • For traumatic wounds: WSES classification for specific organ injuries 1

Wound Management Algorithm

Step 1: Debridement

• Remove hyperkeratosis (callus), necrotic tissue, and slough from the wound base 1
• Debridement reduces pressure at callused sites, removes colonizing bacteria, facilitates collection of appropriate specimens for culture, and permits examination for deep-tissue involvement 1
• Warn patients that bleeding is likely and the wound will appear larger after debridement 1

Step 2: Infection Assessment and Management

• Obtain appropriate cultures before initiating antibiotic therapy when infection is suspected 1
• Collect tissue samples rather than superficial swabs when possible, as they provide more accurate culture results 1
• For infected wounds, especially in diabetic patients, prompt management with appropriate antibiotics and surgical intervention is recommended 1
• Consider imaging (ultrasound, CT, MRI) to detect deep soft-tissue abscesses, sinus tracts, or bone involvement 1

Step 3: Wound Bed Preparation

• Apply appropriate dressings to maintain a moist wound environment while controlling drainage and exudate 1
• Consider pH management (target pH 4-6) using appropriate antimicrobial agents 1
• For infected wounds with biofilm, use antimicrobial dressings containing iodine, medical-grade honey, silver, or EDTA 1

Step 4: Addressing Underlying Factors

• Assess and manage vascular supply - perform Doppler arterial pressure measurements, ankle-brachial index (ABI), or transcutaneous oxygen pressure (TcpO₂) as needed 1
• Evaluate for peripheral neuropathy using 10-g monofilament testing 1
• Implement pressure offloading for pressure injuries or diabetic foot ulcers 1
• Optimize systemic factors: glycemic control, smoking cessation, nutrition, cardiovascular risk factors 1

Step 5: Advanced Therapies (if standard care fails)

• Consider negative pressure wound therapy (NPWT) for complex wounds after revascularization or minor amputation 1
• Evaluate need for hyperbaric oxygen therapy for non-healing diabetic foot ulcers after revascularization 1
• Consider biological therapies (growth factors, skin substitutes) for wounds that don't progress with standard care 1

Step 6: Monitoring and Reassessment

• Regularly reassess the wound to evaluate healing progress 1
• Document changes in wound size, appearance, drainage, and surrounding tissue 1
• Adjust treatment plan based on wound healing trajectory 1

Special Considerations

Diabetic Foot Wounds

• Evaluate at three levels: the patient as a whole, the affected limb/foot, and the infected wound 1
• Assess for osteomyelitis using probe-to-bone test and appropriate imaging 1
• Consider multidisciplinary care team approach for optimal management 1

Pressure Injuries

• When complete healing is not possible, focus on: Stabilizing the wound, Preventing new wounds, Eliminating odor, Controlling pain, Infection prevention, Advanced dressings, and Lessening dressing changes (S-P-E-C-I-A-L approach) 1
• Evaluate need for surgical intervention for stage IV pressure injuries with osteomyelitis 1

Traumatic Wounds

• Classify based on wound depth, contamination level, and hemodynamic status 1
• Consider appropriate surgical intervention versus non-operative management based on classification 1

Common Pitfalls and Caveats

• Relying solely on wound appearance without considering systemic factors can lead to treatment failure 1
• Culturing clinically uninfected wounds is unnecessary and may lead to inappropriate antibiotic use 1
• Failure to address underlying causes (vascular insufficiency, pressure, neuropathy) will result in poor healing outcomes 1
• Neglecting regular reassessment and adjustment of the treatment plan can delay healing 1
• Overlooking the importance of nutrition, glycemic control, and smoking cessation can significantly impair wound healing 1