• Framework: Use TIME (Tissue assessment, Infection/inflammation, Moisture balance, Edges).

• Key Elements: 

  • Etiology: *** Always address underlying etiology 

    • Trauma, infection, vascular, frail, pressure, edema, Diabetes, etc.  

    • Assess the whole patient!

    • Consider vascular studies, labs, imaging, specialists, etc. 

      • ABI’s are critical for lower extremity wounds. 

    • ** Always consider there could be more than one etiology contributing to wound

  • Tissue type 

    • Bad: necrotic/black, slough/yellow

    • Good: granulation/red, epithelial/pink

  • Exudate 

    • Type: Serous, sanguinous, purulent, etc. 

    • Amount: none, minimal, moderate, heavy

  • Infection/bioburden signs (or biofilm suspicion)

    • Consider PCR testing: biofilm is not seen by the naked eye.

  • Periwound condition: intact, macerated, erythematous

  • Wound edges: rolled, flat, adhered to wound bed

  • Measure measure measure

    • size, depth, undermining, tunneling, sinus tract etc

  • Pain

  • Bonus: wound bed temperature does affect wound healing.  Optimal temp is above 91.4

• Goal: Determine healability and select modalities to create a moist, clean wound bed. Promote granular tissue formation and epithelial wound advancement

Preferred (non-cytotoxic, safe for routine use):

1. Preferred: Hypochlorous acid (HOCl) solutions: Broad antimicrobial, biofilm disruption, anti-inflammatory; low cytotoxicity. 

   1. Examples: Vashe®, Puracyn®, Microcyn®, Anasept®. Ideal for chronic and/or infected wounds

2. Normal saline (0.9% NaCl): Universal, isotonic, no harm to cells.

3. Chemical debridement/biofilm removal: Surfactant-based (with/without PHMB or betaine).

   1. Examples: Prontosan®, Prophase™.

4. Heavy bioburden: Diluted Dakin’s (0.025% sodium hypochlorite)

   1. Use with Caution / Short-Term Only: disrupts healthy tissue

5. Eschar: Providone-iodine

Select method based on wound type, patient tolerance, and setting.

• Autolytic: Moisture-retentive dressings (hydrogels/hydrocolloids) – gentle, patient-friendly.

• Enzymatic: Collagenase ointment (e.g., Santyl®) – selective for necrotic tissue.

• Mechanical: 

  • Gauze debridement

  • Surgical scrub brush

• Specialty only:

  • Sharp: By trained clinician at bedside

  • Ultrasonic mist (non-contact, point-of-care)

  • Surgical: OR only

Use only with clinical signs (not prophylactic long-term; reassess in 1–2 weeks).

• Hydrogels: for dry/necrotic wounds

• TAO: only if signs of or high risk for infection

• Mupirocin: for staph A or strep B skin infections

• Gentamicin: pseudomonas (consider oral abx if infection is deeper than superficial

• Medical-grade honey: Autolytic debridement, odor control, antimicrobial. Example: MEDIHONEY®.

• Cadexomer iodine: Absorbs exudate + slow iodine release. Examples: IODOSORB®, IODOFLEX®.

• PHMB: Low resistance, effective vs. bacteria/yeast/fungi. Often in dressings or combined cleansers. Other: DACC (hydrophobic bacteria-binding) for physical bacterial removal.

• Silver based dressings such as silver alginate or topical silver gels such as Silvasorb