for hospital shah Alam

2. Discipline The Old Army
[Conventional Dressing]
The New Army
[Modern/Advance/Adjunctive
Dressing]
Orthopedic
Surgical
ENT
A&E
Oncology
Medical
Rehab
Pediatric
Geriatric
Primary Care
Common dressing
materials:
Gauze, gamgee, elastic
bandage, povidone,
habitane, chlorhexidine,
acetic acid, potassium
permanganate, hydrogen
peroxide, alcohol, silver
SSD, acriflavine
Examples:
i. Wound bed hydrant – hydrogel,
hydrocolloid
ii. Antimicrobial solution – PHMB,
Octenidine, Superoxidised
solution
iii. Antimicrobial primary and
secondary dressing – hydrofiber
silver, alginate, impregnated
foam
iv. Adjunctive – HBOT, topical O2
therapy, growth factor and
epidermal enhancer, NPWT

3. 3

4. QUESTION 1
In 2018 & 2019, there were many wound care conferences being held in
Malaysia (National Wound Care Conference, Southern Peninsular WCC, Global
WCC, Malacca WCC and etc.)
What were their main education content during the conference?
A. About modern wound dressing
B. About traditional and conventional dressing
C. Sometimes about wound care education
D. Wound care administration

5. QUESTION 2 – Reality Check
Taking into account that you are working at mainstream discipline (NOT in
Wound Team) in less busy hospital / clinic (i.e. general surgery, orthopaedic,
medical, klinik kesihatan); and you just attended to one of the conference;
When you came back from the conference, what is your choices / mode of
dressing that READILY AVAILABLE AND FREELY ACCESSIBLE IN YOUR
CENTRE?
A. Advance dressing (tissue engineering)
B. Modern dressing (foam, hydrogel, hydrocolloid)
C. Conventional dressing (gauze, povidone, chlorhexidine)

6. QUESTION 3
Now do you think your wound care education exposure
accurately match with your current clinical practice?
YES / NO

8. CHLORHEXIDINE
01 HYDROGEN
PEROXIDE02 KMNO4
03
PVP - IODINE
04 ACETIC ACID
05 SILVER
SULFADIAZINE06
THE OLD ARMY – What’s Common in Our
Setting?
4%, 5% 3% 1 : 1000/5000
1%0.25%, 0.5%7 - 10%
ALCOHOL
07 METHYLATED
SPIRIT08 ACRIFLAVINE
SOLUTION09 0.1%96%70%

9. 01
CHLORHEXIDI
NE
T H E O L D A R M Y
• BIGUANIDES group, C22H30Cl2N10 ,
• BACTERICIDAL (against Gram-positive and
Gram-negative organisms, facultative
anaerobes, aerobes, and yeasts). Ineffective for
polio and adenovirus
• Used in dentistry, urology, gynecology, wound
healing
• Time of onset: 30 seconds

10. • Unsure prolonged exposure for
carcinogenesis, recommended stop use after
6 months
• Anaphylactic reaction
Side Effect
Positive charge cation CHX binds with
negative charge bacteria cell wall to induce
lysis
Mechanism of Action

11. CHLORHEXIDINE 4,5%
Efficacy Cytotoxicity
• Safe for wound irrigation in low
concentration
• Not severely effect healing time
(no effect on collagen production
or tensile strength of wound)
• Increased resistant to
microbes and cytotoxicity
compared to OCT & PHMB

12. 02
HYDROGEN
PEROXIDE
T H E O L D A R M Y
• PEROXYGENS group, H2O2
• Bacteriostatic (sporicidal at 0.88 mol/L, poor
bactericidal), broad spectrum > g+ve
• Dental mouthwash, acute wound minor cuts,
cosmetic
• Reaction time: immediate

13. H202 Mode of Action
The production of free hydroxyl radicals in the Fenton
reaction is thought to be the basis of biocidal actions of
hydrogen peroxide. Free radicals eventually lead to
oxidative damage proteins and membrane lipids in vivo.
The oxidizing radical as the ferryl radical induces DNA
oxidation
T H E O L D A R M Y

14. H2O2 3%14
Efficacy Cytotoxicity
• No negative effect on wound healing
but not reduce bacterial effect
• Effervescence of hydrogen peroxide
provide some mechanical benefit in
loosening debris and necrotic tissue of
the wound
• No retardation of re-
epithelialization

15. 03
KMnO4
T H E O L D A R M Y
• Dye, manganese oxidizing effect – purple crystals
with sweet taste
• Low Bactericidal effect – broad spectrum
• Initially used to suppress vesicular stage of
eczema- dermatitis
• Reaction time: required 1hr for bactericidal effect

16. Mechanism of Action
As an astringent that suppress inflammation process
POTASSIUM PERMANGANATE
T H E O L D A R M Y

17. KMNO4 1:5000, 1:1000017
Efficacy Cytotoxicity
Effective bactericidal in 1:10000 • Fatal over 100 ml consumed
• Burns and stain the skin
• Combustible – mixture with acetic acid might explode
• Tablet should be dissolved completely – might cause
cutaneous necrosis
• Most centre has obsolete this prep d.t manganese toxicity –
nephrotoxin, hepatotoxin – should be used only on
superficial wound

18. 04
PVP - IODINE
T H E O L D A R M Y
• HALOGEN RELEASING group,
polyvinylpyrrolidone iodine, C6H9NO
• Bacteria do not develop resistance to PVP-I
• Bactericidal – broad spectrum
• Usage: antiseptic for prevention and
treatment wound infection

19. Iodine is highly reactive with surrounding and has strong oxidizing effect on functional groups of amino acids (-NH 2, -SH etc.), Nucleotides, and fatty
acids (double bond of unsaturated fatty acids). Interaction of Iodine with these groups in a cell results in disintegration of the cytoplasm, enzyme
denaturation, loss of integrity in the bacterial cell membrane and fungal cell wall

20. PVP-I 7,
10%
20
Efficacy Cytotoxicity
• Effective in reducing
bacterial load in
wound – effect not
persist - lasted for 4
days
• No inhibition in wound
re-epithelialization
• Concentration
dependent – not
suitable for burns
• Systemic toxicity

21. PVP-I 7,
10%
21
Contraindication
1. Hypersensitivity to Povidone iodine and other preparations
containing iodine
2. Thyroid disorders - goiter, hypothyroidism
3. Application to large areas of skin
4. Patient on Lithium therapy

22. 05
ACETIC ACID
T H E O L D A R M Y
• PEROXYGENS group, C2H4O2
• Bactericidal , broad spectrum esp.
pseudomonas
• Dental formulation, wound antisepsis
• Reaction time: N/A, short duration of
action about 1hr, require repeated dosing

23. Undissociated acetic acid may enhance lipid solubility allowing increased fatty acid accumulation on the cell membrane or in other cell wall
structures. As a weak acid it will inhibit carbohydrate metabolism resulting in subsequent cell death.
Acetic Acid MOA

24. ACETIC ACID 0.25, 0.5%24
Efficacy Cytotoxicity
• Efficacious against
pseudomonas, but not
significantly
• Beware of phenylketonuria due to
ketone intermediates
• No delay in epithelialization
• Does not shown to influence
tensile strength

25. 06
SILVER
SULFADIAZINE
T H E O L D A R M Y
• Topical antimicrobial – partial to full thickness burns
• Bactericidal – broad spectrum
• Evidence showed that antibiotic are more potent
therefore no more generally recommended
• C10H9AgN4O2S
• Oligodynamic effect to bacteria, fungi and algae

26. MECHANISM OF ACTION
Interact with sodium chloride containing body
fluid, silver ions released – ionized Ag+
catalyze the formation of disulfide bonds lead
to protein structural changes of bacterial wall
SILVER
SULFADIAZINE
THEOLDARMY

27. SILVER SULFADIAZINE 1%)27
Efficacy Cytotoxicity
• Insufficient evidence whether
silver-containing dressing or
topical agents promote wound
healing or prevent infection
(Cochrane R)
• Delay wound healing by sloughing
mechanism
• no more recommended to burns
wound due to altered appearance
and frequent re-application
• Not to be used along with proteases
(inhibited by silver ions)

28. PRECAUTION
OF SSD
28
• Itching and pain
• Low WBC count, allergic reaction, red
blood cell breakdown, liver inflammation
• Allergic to sulfonamides
• Not to be used less than two months
children

29. 07
ALCOHOL
T H E O L D A R M Y
• Ethyl, Isopropanol, C3H8O
• Bactericidal and fungicidal, broad
spectrum
• Most used as rubbing
• Reaction onset: immediate

30. Alcohol dehydrates cells, disrupt membranes and cause
coagulation of protein
Mechanism of Action

31. ALCOHOL, 70%31
Efficacy Cytotoxicity
• No information available for open
wound – burns effect
• Hand rubbing better than hand wash
• Depends on the type of alcohol
methyl > isopropyl > ethyl

32. 08
METHYLATED
SPIRIT
T H E O L D A R M Y
Ethanol, denatured spirit with addition of
10% methanol, CH3CH2OH

33. METHYLATED
SPIRIT
T H E O L D A R M Y
For topical umbilical cord care

34. 09
ACRIFLAVINE
SOLUTION
T H E O L D A R M Y
• DYE group, acriflavinium chloride, C14H14ClN3
• Commercial preparations are often mixtures with
proflavine
• Bacteriostatic to g+ve
• Undergo testing as antimalarial drugs, used in
biochemistry for fluorescently labeling high
molecular weight RNA, fungal infection treatment
for fish aquarium

35. ACRIFLAVINE
T H E O L D A R M Y
Proflavine acts by interchelating DNA (intercalation),
thereby disrupting DNA synthesis and leading to high
levels of mutation in the copied DNA strands. This
prevents bacterial reproduction

36. ACRIFLAVINE 0.1%36
Efficacy Cytotoxicity
• In an animal model, acriflavine
has been shown to inhibit HIF-
1, which prevents blood
vessels growing to supply
tumors with blood and
interferes with glucose uptake
and use
• Proflavine is toxic and
carcinogenic in mammals
and so it is used only as a
surface disinfectant or for
treating superficial wounds

38. PRE-QUIZ
INSTRUCTION
1. Take out your phone, ensure it
has internet connection
2. Open internet browser
3. Type in www.menti.com and use
the code appear
4. Register name+department

39. C R I T E R I A F O R T H E
S E L E C T I O N O F A N T I S E P T I C
“Natural selection is not evolution….”

40. 01
TYPE OF WOUND
Different types of wound might require
specific type of antiseptic – acute vs
chronic, burns, superficial or deep
CRITERIA FOR THE
SELECTION OF ANTISEPTIC
T H E O L D A R M Y

41. 02
03
PATIENTS CONDITION
Deformity, pain, too young and too
old age, assess to the service
CONSIDERED SENSITIVE WOUNDS
Eczema, dermatitis

42. 04
MEET THE FOLLOWING
REQUIREMENTS
1. Maintain local effectiveness
during time of exposure
2. Development of resistance
3. No risk, low risk of toxic, allergic,
anaphylactic side effects,
mutagenesis, carcinogenesis
4. Not causing pain, unpleasant
smell
5. Remain sufficient stable in the
wound
6. Germ-free

43. SPELL THE MYTH
IS NORMAL SALINE CAUSING PSEUDOMONAS GROWTH?
43

44. UTILIZATION OF
INVENTORY
Maximum utilization of dressing product and
techniques that readily available
KNOWLEDGE
Getting appropriate knowledge to ensure and
enhance clinical practice based by current
evidence
MODERN DRESSING
Selection of appropriate modern
dressing
TAKE HOME MESSAGE

45. THANK YOU
drwanzuraini@woundmedicine.co.uk
45