Table of Contents Introduction....2 Instructions & Objectives 2 Introduction to Electrical Stimulation. 3 Applications Lab.... 11 Case Studies..14 Supplemental Information...24 Post-Test.25 Seminar Evaluation..27 1
Introduction Clinicians involved in treating chronic wounds are faced with many challenges both clinically and financially. Studies have shown that, if used appropriately, electrical stimulation can speed wound closure through stimulation of tissue repair, increased local circulation, and decrease in microorganisms. This course, instructed and written by Jamie V. Birmingham, PT, CWS, was designed to provide the clinician with the knowledge and tools needed to determine when electrical stimulation is indicated and how to appropriately and safely develop and implement treatment programs. This home study course is intended for educational and instructional purposes only. It is the responsibility of each clinician to use their best clinical judgment and to address each patient on a case by case basis according to their individual and unique circumstances. Instructions To maximize your learning experience with this workbook and application labs, please complete the following steps in this sequence: 1. Read Taking Charge of Chronic Wounds An Introduction to Electrical Stimulation and Wound Healing text. 2. Perform electrode application labs. 3. Perform case presentations-self study. 4. Review supplementary information. 5. Complete the post-test. Fax: (407) 578-8626 Mail: 9857 Montclair Circle Apopka, FL 32703 Certificates of Completion and Continuing Education Credit Anyone scoring an 80% or higher on the post-test will be awarded a certificate of completion. If you do not successfully complete your test you will be notified and may retake it. Please call if you have any questions, and please check with your state board to determine state-specific CEU requirements and home-study eligibility. There will be no refunds for home-study courses. Objectives Upon completion of this distance learning program, the participant will be able to: Explain the principles of electrical stimulation with relation to wound care. Identify indications, contraindications, and precautions for electrical stimulation in wound care. Choose appropriate parameters of electrical stimulation given pertinent details about the patient and the wound. Demonstrate proper electrode placement techniques on simulated wounds. 2
Wound Healing Wound healing consists of a complex array of physiological events. If any of these physiological processes are impaired due to internal factors, such as impaired circulation or nutritional deficits, or external factors, such as pressure, the wound can become chronic. Although the incidence and prevalence of chronic wounds is the subject of debate, one thing is certain; treatment of chronic wounds presents tremendous challenges both clinically and financially. Guidelines In recent years, significant progress has been made towards developing guidelines for providing an optimal environment for wound healing. Eliminating causative factors and providing good local wound care (see table 1) are always essential, yet they are not always enough to heal chronic wounds. With so many wounds being complicated in nature and resistant to healing, electrical stimulation is often indicated as an adjunctive therapy to good local wound care. Studies have shown that electrical stimulation can speed wound closure through improved circulation, stimulation of cellular activity, or by providing a bactericidal effect. Confusion and Reimbursement Unfortunately, confusion and controversy has surrounded the use of electrical stimulation for wound healing for many years. This confusion is likely due to evolving payment scenarios, specifically regarding Medicare payment. In fact, in 1997, HCFA (currently CMS), announced that they would not pay for electrical stimulation for wound healing. This announcement was based on a report from and independent consulting group which stated that electrical stimulation was no more or less effective than standard care. This report directly contradicted previous and future findings of the Agency for Healthcare Policy and Research (AHCPR) who in 1993 and 1998 recommended the use of electrical stimulation to promote closure of Stage III and IV pressure ulcers in their published clinical practice guidelines. Current CMS policy (at the time of this writing, 2008), recommends and reimburses electrical stimulation for wound healing so long as the conditions meet certain criteria. For CMS coverage, wounds must have been present for 30 days with no measurable signs of healing despite good local wound care. CMS also required that wound etiology must be Stage III or IV pressure ulcer, arterial ulcer, diabetic ulcer, or venous stasis ulcer. For additional information on CMS coverage, please refer to www.cms.gov, and see Coverage and Billing Requirements for Electrical Stimulation for the Treatment of Wounds. Local Wound Care Requirements: Debridement of non-viable tissue Cleansing with normal saline or other non-toxic cleanser Choosing a dressing that keeps the wound bed moist 3
and surrounding intact skin dry Table 1 History In order to develop an understanding of the current trends and acceptable standards for electrical stimulation in wound care, it is helpful to look at the history of its development. Some of the earliest documented reports suggesting a positive relationship between electric charges and soft tissue healing involved charged gold leaf. Further clinical studies confirmed this positive relationship and began exploring various parameters and modes of application. A review of these clinical studies as well as research studies conducted on animals indicates that many varieties of applications may have been positive effects on wound healing. Variables of Electrical Stimulation The delivery of electric current to human tissue can be modulated by many variables such as waveform, polarity, frequency, intensity, electrode size, and placement. Altering any of these variables can significantly change the characteristics and effects of the current. The overall goal when applying electrical stimulation is to induce the desired physiological response (see table 2) with the minimal necessary total current. Delivering too much current can cause undesirable side effects such as skin irritation and discomfort. With so many choices, determining which combination of parameters will achieve the most comfortable and effective current has proven to be quite a challenge. Electrical stimulation is a very complex topic. In order to prevent confusion, only the parameters that are pertinent to wound healing will be covered in this course. Positive Physiological Responses to Electrical Stimulation Increased circulation Increased cellular activity Decreased pain Decreased edema Decreased bacterial burden Table 2 Waveforms The waveform describes the direction of current flow and sometimes the pulse characteristics. Direct current means that the current flows in one direction, so one electrode will be positive and the other electrode will be negative. By definition, Direct Current (DC), is the continuous unidirectional flow of charged particles (current), the direction of which is determined by the polarity selected. This flow can be interrupted; however, the period of time that the 4
current is flowing between interruptions will be more than one second in time. If the period of time between interruptions is less that one second in time, the waveform would be considered pulsed, not direct. Pulsed waveforms can be defined by describing the characteristics of one individual pulse. A pulse is made up of one or more phases, with an individual phase occurring each time the current flow returns to zero. A pulse that consists of only one phase is called monophasic, while one consisting of two phases is called biphasic. Symmetric biphasic waveforms have no net polarity, as the polarity is reversed with each phase equaling a net charge of zero. In other words, for the first phase, one electrode is positive and the other on is negative, and this reverses for the second phase. Diagram 1 gives a simplified representation of a variety of waveforms. Electrical currents having various waveforms, including continuous direct current (DC), interrupted direct current, low-voltage biphasic pulsed current, and high-voltage monophasic pulsed current (HVPC), have been shown to enhance wound healing through scientific and clinical studies. However, in terms of safety, comfort, and effectiveness, high-voltage monophasic pulsed current has emerged as the waveform of choice for many clinicians. This waveform presents as twin peaked pulses of very short duration and high peak current (>100-150 volts). Although the peak current is high, the phase duration is so short (up to 200 microseconds) that it results in a low total average current over time. Additionally, the instantaneous rise and resulting high peak intensity reduce resistance. This decreased resistance, combined with the fact that the short phase duration reduces the likelihood of stimulating nociceptive nerve fibers, results in the delivery of overall comfortable stimulation to the desired tissues. Because it is monophasic, the current flows in one direction resulting in negative polarity under one electrode and a positive polarity under the other electrode throughout the treatment. 5
Diagram 1 Continuous Direct Current (DC) Monophasic Pulsed Current Biphasic Pulsed Current High Voltage Pulsed Current Polarity Direct current (DC) and high-voltage monophasic pulsed current (HVPC) produce a polarity difference between electrodes. In other words, one electrode will be positive and the other will be negative with respect to each other. Several studies utilizing low intensities of cathodal (negative) DC have reported a decrease in the growth of various microorganismsn commonly found in chronic wounds. The exact mechanism for this decrease is not known. However, one theory is that the constant stimulation disrupts the homeostatic 6
mechanisms of these single-celled microorganisms resulting in death. Therefore, the negative pole should be chosen when microorganisms are present. The positive pole on the other hand, has been shown to facilitate cellular migration and accelerate tissue repair and therefore should be chosen during the proliferative phase (when the wound is free of microorganisms and necrotic tissue). It has frequently been reported that if wound healing reaches a plateau, alternating the polarity daily or every three days appears to re-activate the healing process. This method is thought to simulate the natural current of injury, which is the polarity changes that occur naturally in uncomplicated healing wounds. This current of injury is thought to be absent or minimized in chronic and/or dry wounds, and utilizing electrical stimulation is theorized to initiate or accelerate normal cellular activity. Direct current is also known to produce an acidic reaction at the anode (positive pole) and an alkaline reaction at the cathode (negative pole). This cathode has a softening effect and can help to speed up the debridement process through softening of necrotic tissue. Extreme caution must be used when applying direct current due to the possibility of electrochemical burns in the skin under the electrodes. A comparison of positive and negative polarity and the physiological effects of each are further outlined below (see table 3). High-voltage monophasic pulsed current (HPVC) produces very little, if any, thermal or chemical build-up under the electrodes. Although it does produce a polarity difference between electrodes and therefore will have a positive and a negative pole, it will not produce a strong acidic or alkaline reaction. As mentioned previously, in terms of safety, comfort, and effectiveness, high-voltage monophasic pulsed current has emerged as the waveform of choice for many clinicians. Direct current is NOT recommended for mainstream use due to lack of established safe parameters. Positive Attracts acids and O 2 Repels alkalines Hardens tissue Coagulates Negatives Attracts alkalines and H+ Repels acids Softens tissue Liquefies Table 3 Frequency and Duration Because studies using electrical stimulation for wound healing have not revealed clear and consistent advantages to specific parameter selection, the recommendations to follow will be based on available research, with a focus on comfort and safety. When utilizing HVPC, it could be postulated that the more current delivered to the tissues, the more effective the results are likely to be. It is also commonly accepted that the smooth buzzing sensation created by higher frequencies (greater than 50Hz) are perceived as more comfortable to the patient. Therefore, a high frequency should be used (approximately 100 pulses 7
per second). Ideally, duration of treatment should be a total of at least one hour per day. If two treatments of 30-45 minutes can be administered, this appears to be advantageous; however, given time restraints and reimbursement guidelines, this is often not feasible. Therefore, once daily treatments of one hour would be recommended. Electrode Size and Placement When treating an open wound with electrical stimulation, there are several options for electrode placement. Direct placement is recommended whenever possible, meaning that the primary electrode will be placed directly on the wound bed, and the secondary electrode will be placed on the intact skin. When utilizing direct placement, a conductive hydrogel dressing or saline soaked gauze can be used as a contact medium. Saline-soaked gauze is more likely to dry out through evaporation into the air, or absorption by the body, thereby decreasing the effectiveness of the treatment. To minimize this possibility, the gauze may need to be re-moistened during the treatment, and an occlusive covering may need to be applied to limit evaporation. A conductive hydrogel dressing may be more reliable, giving a relatively uniform and continuous current flow. It may also be appropriate to leave a conductive hydrogel dressing in place for several days, which can decrease the number of times the wound bed is disturbed and limit the negative effects such as thermally cooling the surface of the wound. Deciding between saline soaked gauze and conductive hydrogel dressing is often based on wound characteristics such as the amount of drainage. If the wound is producing moderate to heavy amounts of drainage, neither option would be able to be left on after the treatment is completed, as they would not be able to absorb the excess drainage and would therefore need to be removed and an absorptive dressing would be required until the next treatment. Therefore, saline soaked gauze would be the appropriate choice as it is less expensive, and will not likely dry out during the treatment. To place the electrode in the wound bed, you will need several more supplies. Aluminum foil with an alligator clip is an inexpensive, disposable option, in which a piece of aluminum foil is folded to a size slightly smaller than the wound bed, and attached to the alligator clip. The foil is then sandwiched between the saline soaked gauze or conductive hydrogel dressing, and this is placed directly into the wound bed. Some conductive hydrogel dressings are labeled for placement of the alligator clip directly to the dressing. In this case, the aluminum foil would be unnecessary, so long as the connection between the alligator clip and the dressing remains moist and the dressing itself remains consistently moist. Once the treatment is completed, if the dressing is being left in place, the foil can be slid out from between the two layers and disposed of. The alligator clip should be disinfected between uses on the same patient and can be used on one patient only. In other words, each patient would need their own alligator clip. If unable to be disinfected, the alligator clip would need to be disposed of. An alternative to aluminum foil with an alligator clip would be to use a standard carbon electrode that is slightly smaller than the wound bed. The 8
carbon electrode would be sandwiched between the layers of saline soaked gauze or conductive hydrogel dressing. The electrode would need to be disinfected between treatments. When using any of the above direct placement methods, the second electrode should be larger, preferably at least twice the size, than the surface area of the wound bed and should be placed 4-6 inches from the wound. Generally speaking, the density of the current increases as the electrode size decreases. In other words, the smaller the electrode will deliver a larger amount of current per square inch, thereby creating a stronger physiological response than the larger electrode. Because a physiological response is desired in the wound bed, a smaller electrode should be used there. In situations where the patient cannot tolerate direct placement, indirect placement may be utilized with the electrodes placed on intact skin adjacent to the wound. One electrode could be placed close to the wound while the other electrode is on the opposite side of the wound, a further distance away. Another option would be to bifurcate the active electrode, placing two electrodes close to the wound and one larger electrode (twice the size of the two combined active electrodes) on the opposite side, farther away. (See diagram 2) Active Electrode Inactive Electrode ------------------------------------------------------------------------------------------------------ Active Electrodes Inactive Electrode Diagram 2 Intensity When using HVPC, a comfortable, sensory level of intensity should be used, sub-threshold to muscle contraction or at the level where the patient just begins to feel the stimulation. This level is generally between 50-150 volts. If the patient has sensation in the wound bed, turn up the intensity until a comfortable 9
tingling sensation is achieved. If the patient does not have sensation in the wound bed, but does have sensation under the secondary, inactive electrode, just increase the intensity until there is a comfortable tingling sensation under that secondary electrode. If the patient has no sensation under any of the electrodes, you will turn up the intensity to between 50-150 volts, using caution to avoid adverse reactions. Indications, Contraindications, and Precautions Electrical stimulation is indicated for wounds that are not responding to good local wound care (see table 1). Although wounds of many etiologies, such as arterial, venous, neuropathic, pressure, post surgical and traumatic, may benefit from electrical stimulation, you should refer to your third party payer for guidance regarding possible limitations of coverage. The FDA lists several electrical stimulation indications that would likely have a positive impact on healing and/or quality of life, including pain, edema, and increasing local blood circulation. Some topical preparations may interfere with the flow of electrical stimulation or may contain substances that, when combined with electrical stimulation, could result in adverse reactions. Therefore, electrical stimulation should not be applied over topicals that could act as insulators, such as petroleum, or that contain substances that could cause adverse reaction, such as iodine. Because some substances can penetrate into wound tissue and/or leave residue on the surface, clinicians should consider whether the substance can be easily removed prior to applying electrical stimulation or whether the use of the substance should be discontinued all together. Electrical stimulation should not be utilized on patients who have cancer. Electrical stimulation would be contraindicated in the presence of abnormal cells, such as with malignancy. If the wound etiology is unknown, especially in chronic wounds that have been present for extended periods of time, a biopsy may be indicated to rule out the presence of abnormal cells. Electrical stimulation should not be applied in the presence of active, untreated osteomyelitis. Many texts list this condition as a contraindication due to the chance of rapid closure interfering with successful treatment of osteomyelitis. Therefore, osteomyelitis should be treated prior to beginning electrical stimulation until further research is conducted to clarify this area of use. Electrical stimulation should not be applied to areas of the body that may be overly sensitive to electrical currents. Examples are across the thorax where the current could likely effect the heart, on the anterior surface of the neck, and over the eyes. Electrical stimulation could disrupt the normal function of implanted electrical devices, such as cardiac pacemakers. Therefore the presence of any implanted electrical device should be regarded as a contraindication unless otherwise determined through manufacturer guidance. Additionally, electrical stimulation should not be applied to patients who are pregnant as the possible effects on the fetus are unknown. 10
Electrode Application Lab Read through the Preparation instructions, noting proper procedure and infection control measures. Next, apply the provided dressing/electrode as indicated in the Application instructions utilizing the provided simulated latex wound. Please note that the properties of latex are quite different than the properties of skin; adhesives should be removed from the latex wound promptly after application to prevent difficulty with removal of the dressing/electrode. Lab #1 Conductive Hydrogel Dressing Apply to Provided Latex Wound Supplies Provided Insulated alligator clip Conductive hydrogel dressing Simulated wound Additional supplies needed (optional for lab): Clean gloves Sterile normal saline (can be substituted with water for this lab) Standard gauze Disposal bag Tape Second electrode HVPC electrical stimulation device A: Preparation 1. Wash hands and apply clean gloves. 2. Remove old dressing, noting amount of drainage (was dressing saturated, beyond saturation, or too dry?) and discard per infection control guidelines. Remove soiled gloves and discard accordingly. 3. Assess wound and surrounding tissue. Note condition of surrounding skin, odor, necrotic tissue, and size of wound. 4. Wash hands and apply clean gloves. Irrigate wound with normal saline. The type of irrigation warranted will depend upon the composition of the wound. A granulating wound will require gentle irrigation, while a necrotic wound will require more forceful irrigation. 5. Dry surrounding skin with gauze, leaving the wound bed moist. B: Application 1. Apply conductive hydrogel dressing to the wound, using enough to fill the dead space, but packing lightly. Packing a wound too tightly will result in 11
internal pressure, risking further tissue loss. If the conductive hydrogel dressing provided is too large for the wound, cut off the proper amount and discard the remainder. 2. Attach insulated alligator clip and secure with tape or secondary dressing of choice. 3. Remove gloves and wash hands. 4. The second electrode should be placed 4-6 inches from the wound and should be larger than the wound bed. Lab #2 Saline-Soaked Gauze with Aluminum Foil Apply to Provided Latex Wound Supplies Provided Insulated alligator clip Standard gauze 2 x 2 Aluminum foil Sample fabricated foil electrode Simulated wound Additional supplies needed (optional for lab): Clean gloves Sterile normal saline (can be substituted with water for this lab) Standard gauze Disposal bag Tape Second electrode HVPC electrical stimulation device A: Preparation 1. Wash hands and apply clean gloves. 2. Remove old dressing, noting amount of drainage (was dressing saturated, beyond saturation, or too dry?) and discard per infection control guidelines. Remove soiled gloves and discard accordingly. 3. Assess wound and surrounding tissue. Note condition of surrounding skin, odor, necrotic tissue, and size of wound. 4. Wash hands and apply clean gloves. Irrigate wound with normal saline. The type of irrigation warranted will depend upon the composition of the wound. A granulating wound will require gentle irrigation, while a necrotic wound will require more forceful irrigation. 5. Dry surrounding skin with gauze, leaving the wound bed moist. 12
B: Application 1. Fabricate the aluminum foil electrode by folding the piece of aluminum foil into a shape slightly smaller than the wound bed. If the piece of foil provided is too large for the wound, cut off the proper amount and discard the remainder. 2. Attach insulated alligator clip to the foil electrode. 3. Saturate the gauze with saline (water can be used for this lab) and fold over the foil electrode covering it completely. Place lightly into the wound bed and secure with tape or secondary dressing of choice. Do not pack the wound too tightly. If the gauze provided is too large for the wound, cut off the proper amount and discard the remainder. 4. Remove gloves and wash hands. 5. The second electrode should be placed 4-6 inches from the wound and should be larger than the wound bed. 13
Case Presentation Self Study The following self-study will feature four wound scenarios. These will allow you to develop problem solving skills and enable you to choose appropriate treatment parameters for various types of wounds. You will also be challenged to appropriately modify your choices as the wound characteristics change. Please read the following case presentations and note your treatment choices in the spaces provided below. Instructor s notes are on the following pages. Case Presentation #1 Ms. Jones Patient: Ms. Jones Age: 67 History: Status post CVA Status: Ms. Jones is alert and oriented and has no physiological contraindications for electrical stimulation. Wound Classification/Location: Stage IV pressure ulcer on her right ischial tuberosity. Wound Measurement: 3.2 cm long x 2.8 cm wide x 1.1 cm deep with undermining of 0.8 cm at 12:00 and 1.2 cm at 2:00. Wound Composition: The wound bed is 100% moist, yellow slough and is producing moderate amounts of thick, cloudy, yellow, foul-smelling drainage. What treatment parameters would you choose for this patient? Some factors to consider before choosing parameters are: Wound shows signs and symptoms of infection (polarity) Wound bed is 100% non-viable tissue (polarity) Patient is alert and oriented (electrode placement, intensity, waveform) Waveform? Polarity? Intensity? Frequency and Duration? Electrode size and Placement? Rationale? Other Options? 14
Case Presentations Self Study Case Presentation #1 Ms. Jones Instructor s Notes What Treatment Parameters Would You Choose for This Patient? In this case, cathodal (negative) High Volt Pulsed Current (HVPC) would be the waveform of choice due to its safety, comfort and effectiveness. The active electrode will consist of aluminum foil cut and folded to fit directly in the wound bed, attached to an insulated alligator clip and sandwiched between saline-soaked gauze. Loosely fill in all areas of the wound, including undermining areas. Because this wound is producing moderate amounts of drainage, the saline gauze should not be left on the wound after treatment, as a more absorptive dressing will be required. The second electrode will be larger than the surface area of the wound bed and will be placed 4-6 inches away from the active electrode. Placement could be on the trunk (i.e. sacral area) or the upper thigh. The size difference will result in a denser amount of current under the active/wound electrode creating a sensory and physiological response, while little or no sensation of current will occur under the second electrode. The polarity of the active electrode will be negative to optimize bactericidal effects and to support debridement of non-viable tissue. Intensity should be turned up just to the point where the patient begins to feel a slight sensation at the site of the wound electrode (this is usually in the range of 50-150 volts). Frequency of application should be one hour per day up to seven days per week. This treatment regimen should continue until the wound is clean and free of infection as long as progress continues. Treatment should be re-assessed if no positive effects are seen in one week, and should be discontinued if negative effects are seen. Precautions Prior to initiating electrical stimulation treatments, the clinician should also review current treatments to be sure no topical applications or wound cleansers containing ions or petroleum are being used. These can produce adverse reactions and should be discontinued prior to initiating treatment with electrical stimulation. Other Options Conductive hydrogel dressing could be utilized, however, because of the volume of drainage, it will not be appropriate to leave on the wound after the treatment is completed and is therefore would be a slightly more costly option. I the patient was unable to tolerate direct placement, indirect placement could be utilized, with electrodes placed adjacent to the wound. Waveform? High Volt Pulsed Current (HVPC) Polarity? Cathodal (negative) 15
Intensity? Slight tingling sensation at the wound bed Frequency and Duration? One hour per day, seven days per week Electrode size and placement? Active electrode Aluminum foil electrode with alligator clip and saline-soaked gauze directly in the wound bed. Second electrode should be larger than the surface area of the wound bed and placed 4-6 inches away from the active electrode Rationale? Other Options? See above Direct placement with a conductive hydrogel dressing or indirect placement on surrounding skin. 16
Case Presentations Self Study Case Presentation #2 Ms. Jones Six Weeks Later Patient: Ms. Jones Age: 67 History: Status post CVA Status: Ms. Jones is alert and oriented and has no physiological contraindications for electrical stimulation. Wound Classification/Location: Right ischial tuberosity. Wound Measurement: Her wound now measures 3.1 cm long x 2.6 cm wide x 1.0 cm deep, with undermining of 0.8 cm at 12:00 and 1.1 cm at 2:00. Wound Composition: The wound bed is 100% clean, red granulation tissue and is producing minimal amounts of clear drainage. Patient Sensitivity: Ms. Jones has tolerated her treatments well. Should you continue with current treatment or make changes? Some factors to consider before choosing parameters are: Wound no longer shows signs and symptoms of infection There is now minimal drainage Waveform? Polarity? Intensity? Frequency and Duration? Electrode size and Placement? Rationale? Other Options? 17
Case Presentations Self Study Case Presentation #2 Ms. Jones, Six Weeks Later Instructor s Notes What Treatment Parameters Would You Choose for This Patient? At this point, treatment will continue with High-Voltage pulsed current (HVPC), however, the polarity of the active electrode will be changed to positive. Using positive polarity, HVPC is effective in accelerating wound healing. Now that the wound is only producing minimal amounts of drainage, electrode placement can be changed to conductive hydrogel dressing, which can act as both an electrode and a primary wound dressing. After delivering the electrical stimulation treatment, simply remove the insulated alligator clip, and apply a secondary dressing to secure the hydrogel in place. Check the package insert of the product you are using, however, most conductive hydrogel dressings, as with other hydrogel dressings, can be left in place for 24 to 72 hours. Frequency will be set high (100Hz) to deliver the most current per unit of time while delivering a comfortable tingling sensation, and duration will be one hour, up to seven times per week. Intensity should be increased until the patient feels a slight tingling sensation at the active electrode. The polarity of the active electrode will be positive. If the wound reaches a plateau, the polarity can be reversed daily or every three days, as this is frequently reported to re-activate the healing process. Other Options Several other options could have been considered. HVPC could have continued using the negative polarity as long as progress was being made. Electrode placement could have continued with aluminum foil cut and folded to fit directly in the wound bed, attached to an insulated alligator clip and sandwiched between saline-soaked gauze, removing the foil after treatment, leaving only the moist gauze. An additional option would be to discontinue electrical stimulation at this point. Now that the wound is free of non-viable tissue and no longer shows signs and symptoms of infection, perhaps the wound will continue to heal successfully without further electrical stimulation. Waveform? High-Voltage monophasic pulsed current Polarity? Intensity? Positive Slight tingling sensation at the wound bed. Frequency and Duration? 100Hz, one hour, up to seven times per week 18
Electrode size and placement? Conductive hydrogel dressing with insulated alligator clip directly in the wound bed. Second electrode should be larger than the surface area of the wound bed and placed 4-6 inches away from the active electrode. Rationale? Other Options? See above Continue with HVPC using negative polarity, continue with foil and saline soaked gauze, or discontinue electrical stimulation. 19
Case Presentations Self Study Case Presentation #3 Mr. Sanford Patient: Mr. Sanford Age: 72 History: Advanced dementia Status: Patient is unresponsive and unable to communicate. Wound Classification/Location: Mr. Sanford has a pressure ulcer on his right trochanter. Wound Measurement: 4.2 cm long x 2.5 cm wide x 0.5 cm deep with no undermining. Wound Composition: The wound bed is 100% granulation tissue and is producing trace amounts of drainage. Patient Sensitivity: Despite good local wound care and pressure reducing efforts, the wound has failed to improve over the last month. Mr. Sanford has no contraindications for electrical stimulation What treatment parameters would you choose for this patient? Some factors to consider before choosing parameters are: Patient is unresponsive (intensity, electrode placement) No infection (polarity) Waveform? Polarity? Intensity? Frequency and Duration? Electrode size and Placement? Rationale? Other Options? 20
Case Presentations Self Study Case Presentation #3 Mr. Sanford Instructor s Notes What Treatment Parameters Would You Choose for This Patient? Treatment would consist of HVPC for its ability to enhance wound healing using the positive polarity. Electrode placement will be a conductive hydrogel dressing with an alligator clip placed directly in the wound bed as the active electrode. The second electrode will be placed proximal on the trunk or distally on the leg. The active electrode will be positive polarity for wound healing, unless a plateau occurs and then the polarity can be reversed every day or every three days. The frequency will be set high at 100pps. Treatment time will be one hour, up to seven times per week. In this case, intensity cannot be determined by the sensation of tingling current, as the patient is unresponsive. Therefore, the intensity must be determined cautiously to avoid unnecessary discomfort to the patient. Intensity should be set between 50-150 volts, increasing slowly and carefully, watching for any signs of discomfort or muscle activity. Other Options Despite the fact that the wound does not show signs and symptoms of infection, you could begin with negative pole as active for several days for the antimicrobial effects. Some wounds may have bacterial growth or biofilm that is causing wound healing to stall, without significant reaction from the host. By beginning with the negative pole, you could decrease the microbial load. You could then continue with negative as long as progress is being made, or you could switch to positive after three days. Another option for electrode placement could be aluminum foil cut and folded to fit directly in the wound bed, attached to an insulated alligator clip and sandwiched between saline-soaked gauze. Waveform? HVPC Polarity? Positive Frequency and Duration? one hour, up to seven times per week Electrode size and placement? use a conductive hydrogel dressing with an alligator clip as the active electrode, with the second electrode placed proximal on the trunk or distally on the leg Rationale? See above Other Options? Negative polarity as active, foil and saline-soaked gauze as active electrode. 21
Case Presentations Self Study Case Presentation #4 Mr. Golden Patient: Mr. Golden Age: 52 History: Mr. Golden has a medical history of diabetes mellitus. Status: He has no other pertinent medical history and is alert and oriented. Wound Classification/Location: Mr. Golden presents with a wound on his left heel. Wound Measurement: The wound measures 2.5 cm long x 1.8 cm wide x 0.2 cm deep. Wound Composition: The wound is producing trace drainage and is free of necrotic tissue. The wound has been present for six months and has failed to improve despite good local wound care, including debridement, and pressure relief. There are no signs or symptoms of infection. Surrounding Area: Mr. Golden has sensory neuropathy in a stocking pattern from the ankle down. What treatment parameters would you choose for this patient? Some factors to consider before choosing parameters are: Sensory neuropathy at the site of the wound (intensity, electrode placement No signs or symptoms of infection (waveform, polarity) Waveform? Polarity? Intensity? Frequency and Duration? Electrode size and Placement? Rationale? Other Options? 22
Case Presentations Self Study Case Presentation #4 Mr. Golden Instructor s Notes What Treatment Parameters Would You Choose for This Patient? In this case, HVPC is used for its ability to enhance wound healing using the positive pole. Place the active electrode directly on the wound bed as before using a conductive hydrogel dressing cut to fit the wound and attach the insulated alligator clip. Due to sensory neuropathy, the intensity will need to be determined somehow other than by sensation at the site of the wound. Because the patient has sensation above the ankle, place the second electrode proximally on the leg in an area of normal sensation. Turn up the intensity until the patient feels a slight tingling sensation at the second electrode; this will be your treatment intensity. Frequency will again be high at 100Hz, polarity will be positive unless a plateau occurs, then alternating polarity every day or every three days. Treatment time will be one hour, up to seven times per week. Other Options Despite the fact that the wound does not show signs and symptoms of infection, you could begin with negative pole as active for several days for the antimicrobial effects. Some wounds may have bacterial growth or biofilm that is causing wound healing to stall, without significant reaction from the host, especially when neuropathy is present. By beginning with the negative pole, you could decrease the microbial load. You could then continue with negative as long as progress is being made, or you could switch to positive after three days. Another option for electrode placement could be aluminum foil cut and folded to fit directly in the wound bed, attached to an insulated alligator clip and sandwiched between saline-soaked gauze. Waveform? HVPC Polarity? Positive Frequency and Duration? 100Hz, one hour, up to seven times per week Electrode size and placement? place the active electrode directly on the wound bed using a conductive hydrogel dressing cut to fit the wound and attach the insulated alligator clip. Place the second electrode proximally on the leg in an area of normal sensation Rationale? See above Other Options? Negative polarity as active, foil and saline-soaked gauze as active electrode. 23
References Supplemental Information Web Sites Wound Care Information Guide http://medicaledu.com/wndguide.htm American Academy of Wound Management http://members.aol.comm/woundnet/index.html Wound Care Institute http://www.woundcare.org/ Electrical Stimulation Contact Information Mettler Electronics www.mettlerelectronics.com 24
Post Test Name: Credentials/Degree: Address: City/State/Zip: Daytime Phone: Evening Phone: E-Mail: Read the following questions and circle the most appropriate answer. Be sure to mail or fax this test to receive credit and your certificate. 1. Which of the following parameters would be appropriate for an infected wound? a. Direct Current (ua) positive polarity (anode). b. High-Voltage monophasic pulsed current positive polarity (anode) c. Direct current (ua) negative (cathode) polarity d. None Electrical stimulation is contraindicated for infected wounds 2. Which of the following is not a contraindication for electrical stimulation? a. Demand-type pacemakers b. Wound infection c. Osteomyelitis d. Cancerous wound 3. Which of the following occurs under the positive electrode (anode)? a. attracts acid b. attracts alkalines c. softens tissue d. a. and c. 4. Electrical stimulation should be indicated: a. in chronic wounds not responding to conservative treatment. b. on all wounds. c. on Stage IV pressure ulcers only. d. only on wounds with vascular etiology. 5. Which of the following is not as essential element for good wound care? a. debridement of necrotic tissue b. keeping the wound bed dry c. eliminating / alleviating causative factors d. providing a dressing that keeps the wound bed moist and surrounding skin dry 25
Post-Test, Cont. 6. When using electrical stimulation to accelerate wound healing, if cessation in healing occurs, you should: a. discontinue treatment b. change the polarity every five minutes during treatment c. increase the intensity d. change the polarity daily or every three days 7. When applying electrical stimulation for wound healing, the intensity should be set: a. at the level where a slight muscle twitch is observed. b. as high as the patient can tolerate. c. at the level where the patient just begins to feel a slight tingling sensation. d. at the level where a strong muscle contraction is observed. 8. Which of the following produces a polarity difference between electrodes? a. High-Voltage monophasic pulsed current b. Low-Voltage symmetric biphasic current c. Direct current d. a. and c. 9. In most situations, the active/wound electrode should be: a. larger than the second electrode. b. smaller than the second electrode. c. the same size as the second electrode. d. the only electrode used. 10. Ideally, electrical stimulation should be applied directly to the wound bed. Which of the following would be an appropriate active/wound electrode? a. conductive hydrogel dressing b. petroleum-impregnated gauze dressing c. saline-soaked gauze d. all of the above e. a. and c. 26
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