M:EMPHIS pathway for malignant wounds

• Assess volume and appearance as change may indicate infection.
• Protect surrounding skin with barrier in highly exuding wounds.
• Consider using a nonadherent contact layer below to reduce trauma.
• Use superabsorbent secondary dressing (refer to local formulary)
• Consider referral to dietician if exudate is excessive.
• Refer to Exudate Pathway for full guidance if available in your health board.

• If cause of odour is devitalised tissue then aid autolytic debridement using antimicrobial/DACC products as per local formulary e.g. flaminal, honey etc.
• Consider activated charcoal or Cinesteam dressings as adjunct to above products. Place odour control dressing over absorbent dressing in wet wounds as some will be ineffective when wet.
• Irrigate or use soaked gauze on wound with PHMB* cleanser e.g. prontosan at dressing changes.
• Commence metronidazole antibiotic wound gel if exudate levels are low (7 days treatment) If high exudate then commence Flaminal® Forte or other formulary antimicrobial.
• Increase dressing changes if necessary and consider fitted garments to secure products.
• Consider essential oils as per your local complementary therapy team guidance (Hospice)

• Consider need to cleanse. Only when necessary to remove excess exudate and debris.
• Choose dressings that minimise trauma and pain during application and removal. Consider use of adhesive removers.
• Consider strategies to support pain reduction, refer to local analgesia guidelines.
• Evaluate need for pharmacological and nonpharmacological strategies to minimise wound related pain.
• Swab wound if suspected infection is the cause of the pain.
• Refer to pain specialist nurse, GP or palliative care team as necessary for further advice.

• Bleeding:
  • Light: apply pressure for 10-15 mins with moist non-adherent dressing and apply alginate/ haemostatic dressing.
  • Heavy: apply pressure to wound. Utilise other haemostatic agents—see M:EMPHIS Guideline— seek urgent advice if no management plan already in place.
• Severe end of life bleeding anticipated/suspected:
  • Ensure patient and family aware of possibility of large catastrophic bleed.
  • Give emergency contact numbers to family/carers.
  • Supply dark sheets/ towels/gloves/aprons/plastic sheet/clinical waste bags.
  • Ensure benzodiazepine, adrenaline and calcium alginate dressings are in patient’s home

(see Consensus Document for further details)

If wound is locally or clinically infected, an antimicrobial/DACC dressing is advised.

• For dry/low exudate— Flaminal® Hydro, honey based dressings, or ointment. Or other local formulary antimicrobial/DACC metronidazole gel can be considered for short term use (maximum 7 days)
• For moderate/high exudate—Flaminal® Forte or silver based hydrofibre dressings, or local formulary antimicrobial/DACC.
• Use of wound cleansers/ soaks at dressing changes with PHMB* can be useful such as prontosan.

If clinical signs of infection (increased pain, exudate, fever etc):

• Obtain wound swab.
• Consider antibiotics (only if patient is unwell and pending swab result)

Maceration:

• Consider increasing dressing changes.
• Protect surrounding skin with a barrier film.
• Select an appropriate absorbent secondary dressing.

Excoriation

• Consider cause i.e. exudate, skin stripping, allergy.
• Protect surrounding skin with a barrier film or if required treat with local formulary product e.g. Flamigel®.
• Select alternative dressing if allergy suspected.
• Consider topical steroid (diminishing regime)
• Use adhesive remover if skin stripping is the cause.

Itching

• Consider cause—exudate, allergy, endogenous.
• Reverse cause where possible.
• Consider topical steroid.
• Consider oral antihistamines.
• Seek further advice if needed.

Assess psychological and social impact

• Regularly evaluate the psychological and social well-being of the patient during every visit using a holistic approach.
• Take into account the emotional needs of family members and caregivers alongside those of the patient.

Key considerations:

Recommend counselling or support services such as Macmillan, Marie Curie, or other organisations offering social assistance for patients, families, and caregivers.

Refer to NICE guidelines for additional information and recommendations.

Promote supported selfcare, where suitable, to enhance patient empowerment and autonomy.