What are the standard wound care orders for an open skin wound with purulent drainage and mild eschar?

From the Guidelines

Standard wound care for an open skin wound with purulent drainage and mild eschar should include daily cleansing with clean water or saline, debridement of necrotic tissue as needed, and dressing with a sterile, inert dressing to control excessive exudate and maintain a warm, moist environment. The goal of wound care is to promote healing while managing infection and preventing further complications. According to the IWGDF guidance on use of interventions to enhance the healing of chronic ulcers of the foot in diabetes 1, clean ulcers regularly with clean water or saline, and debride them when possible to remove debris from the wound surface.

When selecting dressings, consider the amount of exudate, comfort, and cost, as recommended by the IWGDF guidance 1. For example:

• For dry or necrotic wounds, use a continuously moistened saline gauze or hydrogels to facilitate autolysis 1.
• For exudative wounds, use alginates, hydrocolloids, or foams to absorb exudate and facilitate autolysis 1. However, do not use antimicrobial dressings with the goal of improving wound healing or preventing secondary infection, as recommended by the IWGDF guidance 1.

Debridement is a crucial step in wound care, and sharp debridement is preferred to other techniques, as it is more definitive and controllable 1. Debridement should be repeated as often as needed if nonviable tissue continues to form.

In addition to wound care, consider systemic antibiotics if there are signs of spreading infection, and maintain a moist wound environment to promote healing while managing excess exudate. Nutritional support with adequate protein, vitamins A and C, and zinc can also enhance healing. Offload pressure from the wound area if applicable, and monitor for signs of worsening infection, increasing eschar, or delayed healing, which may indicate the need for more aggressive debridement or culture-guided antibiotic therapy.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Collagenase Santyl◊ Ointment should be applied once daily (or more frequently if the dressing becomes soiled, as from incontinence). When clinically indicated, crosshatching thick eschar with a #10 blade allows Collagenase Santyl◊ Ointment more surface contact with necrotic debris It is also desirable to remove, with forceps and scissors, as much loosened detritus as can be done readily Use Collagenase Santyl◊ Ointment in the following manner: 1 - Prior to application the wound should be cleansed of debris and digested material by gently rubbing with a gauze pad saturated with normal saline solution, or with the desired cleansing agent compatible with Collagenase Santyl◊ Ointment (See PRECAUTIONS ), followed by a normal saline solution rinse

• Standard wound care orders for an open skin wound with purulent drainage and mild eschar include:
  • Cleansing the wound with normal saline solution or a compatible cleansing agent
  • Removing loosened detritus with forceps and scissors
  • Applying Collagenase Santyl◊ Ointment once daily, or more frequently if the dressing becomes soiled
  • Considering crosshatching thick eschar with a #10 blade to allow for more surface contact with necrotic debris
  • Using an appropriate topical antibiotic powder when infection is present, prior to applying Collagenase Santyl◊ Ointment 2

From the Research

Standard Wound Care Orders for Open Skin Wound with Purulent Drainage and Mild Eschar

• The management of open skin wounds with purulent drainage and mild eschar involves the use of topical agents and dressings to promote healing and prevent infection 3, 4, 5.
• Silver sulfadiazine is a commonly used topical agent for wound care, due to its antibacterial properties 3, 4.
• However, the use of silver sulfadiazine has been shown to slow healing in burns, and alternative agents such as nanocrystalline silver, octenidine, and polyhexanide may be more effective 5.
• Negative-pressure wound therapy (NPWT) with silver-impregnated dressings has been shown to be effective in reducing bacterial load and promoting healing in contaminated wounds 6.
• The use of collagenase ointment, which facilitates eschar separation, has been shown to be equivalent to silver sulfadiazine in terms of outcomes, but may be more expensive 3.
• Early laminar excision, which involves the removal of devitalized tissue, has been shown to improve control of burn wound sepsis when combined with silver sulfadiazine dressings 4.

Topical Agents and Dressings

• Silver sulfadiazine: antibacterial properties, but may slow healing in burns 3, 4, 5.
• Collagenase ointment: facilitates eschar separation, equivalent to silver sulfadiazine in terms of outcomes, but may be more expensive 3.
• Nanocrystalline silver: effective in reducing bacterial load and promoting healing in contaminated wounds 5, 6.
• Octenidine and polyhexanide: alternative agents that may be more effective than silver sulfadiazine in burns 5.

Wound Care Techniques

• Negative-pressure wound therapy (NPWT): effective in reducing bacterial load and promoting healing in contaminated wounds 6.
• Early laminar excision: improves control of burn wound sepsis when combined with silver sulfadiazine dressings 4.
• Debridement: removal of devitalized tissue, essential for promoting healing and preventing infection 3, 4.