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CHRONIC WOUNDS

CHRONIC WOUNDS. Based on a presentation by Dr. David Thomas at the AMDA Convention. Four Kinds of Chronic Wounds. Pressure Ulcer ( PU ) Diabetic Ulcer ( DU ) Venous Ulcer ( VU ) Arterial Ulcer ( AU ). Chronic Ulcer Types. Etiology is different Treatment is different

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CHRONIC WOUNDS

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  1. CHRONIC WOUNDS Based on a presentation by Dr. David Thomas at the AMDA Convention

  2. Four Kinds of Chronic Wounds • Pressure Ulcer (PU) • Diabetic Ulcer (DU) • Venous Ulcer (VU) • Arterial Ulcer (AU)

  3. Chronic Ulcer Types • Etiology is different • Treatment is different • Outcome is different • Gestalt is different

  4. Differential Diagnosis

  5. Diagnostic Approach • Wound over bony prominence (PU,DU) • DM with neuropathy, recurrent trauma, surrounding callus (DU) • PVD, wet or dry gangrene (AU) • Signs of venous stasis/calf or ankle (VU) • Other causes possible, but rare

  6. Pain in Chronic Ulcers • DU: no or diminished pain, sensation • VU: little pain, intact sensation • PU: intermittent pain • AU: constant pain

  7. Pressure Ulcers • Visible evidence of pathological interruption of blood flow to dermal tissues • Chief cause: sustained pressure • Most commonly over sacrum, hip

  8. Pressure Ulcers:What Works • Must relieve pressure or it won’t heal. • Must use moist dressing or it won’t heal.

  9. Types of Moist Dressings • Wet to wet: cheapest • Hydrocolloid: for dirty areas • Hydrogel/ Foam/ Alginates/ Biomembranes/ Collagen • Thin Film Polymers: tear off top layer of cells

  10. Problems • Most doctors treat few pressure ulcers. • Very few good studies; none for most treatments. • Treatment modalities for pressure ulcers are considered devices: only safety, NOT efficacy, must be proved.

  11. Zinc paste Antacid Gold leaf Aluminum foil Topical insulin Ultrasound Lasers Arginine Dry dressings Paraffin Treatments Proven NOT to Work

  12. Treatments with No Data • Magnet therapy • Honey/ Sugar • “Skin equivalents”

  13. Treatments With Very Flawed Data • Vitamin C • Patient’s serum mixed with proprietary gel • Vacuum therapy • Electrical stimulation • Topical Phenytoin • Cytokine growth factors

  14. Other Effective Treatments • Sheng-ji-san (SJS) • Whirlpool • Any kind of pressure relieving bed • Debridement of necrotic tissue: surgical (required if infected), autolytic, enzymatic

  15. Pearls from Dr. Thomas • Hydrocolloid dressings are impervious to urine and feces but cannot change dressing. • Heel ulcers have a very thin layer of tissue underneath: debridement exposes bone. Debride only if tissue is infected; otherwise form crust with betadyne and use boots.

  16. Pressure Ulcer Guidelines • Address nutrition • Promote granulation tissue • Promote epithelialization • Prevent contamination

  17. Dressings • Stage I: Thin film polymer • Stage II: Moist gauze (wet-to-wet) or hydrocolloid • Stage III/ IV with dead space/ exudate: hydrogel, wet-to-wet, or hydrocolloid with synthetic absorption dressing below. • Stage III/ IV with necrosis: debride, then treat as III/ IV above.

  18. Nursing Home Pearl • Home health nursing and nursing home care plans of ulcers tend to call for improved nutrition and healing; if pressure ulcers have occurred because the patient is dying/ not eating, make sure the care plan reflects that (for liability and survey purposes).

  19. Venous Stasis Ulcers • An area of discontinuity of the epidermis, persisting for 4 weeks or more, occurring as a result of venous hypertension and calf muscle pump insufficiency. • Must exclude arterial disease, neuropathy, diabetes, rheumatoid arthritis, hemoglobinopathies, and carcinoma. • Biopsy if long-standing or looks weird.

  20. Diagnosis of Venous Ulcers • Location on the calf • Bronzing (lipodermatosclerosis) • Exclusion of arterial insufficiency by bounding DP pulses, or ABI > 0.8 • Tend to be slow-healing (~90% heal by one year), irregular, and associated with edema and sloughing

  21. Treatment of VU:What Works • Must compress the calf, or it won’t heal • However, arterial insufficiency is an absolute contraindication to compression therapy • Must carefully assess for arterial flow

  22. Compression Options for VU • ACE wrap: useful for removing edema • Unna boot: works via muscle contraction against the hard shell; will not work in a nonambulatory patient • Venous support hose: comes 25 to 35 mmHg, but 35 needed to work • All compression must be wrapped tight enough to be effective

  23. Infection in VU • All VU’s are colonized • No evidence that colonization impairs healing, though may interfere with a graft • Don’t culture VU’s!

  24. Recognition of Infectionin VU’s • Fever • Increased pain • Increased skin erythema • Lymphangitis • Ulcer rapidly becomes larger • If infected, treat with systemic AB’s

  25. VU Treatments • Hydrocolloid dressing • Cadexomer iodine topically • Trental (anticytokine) and compression • Artificial skin • Skin graft • TGF-B2

  26. Ineffective VU Treatments (RCT’s) • Antibiotics, including Bactroban • Elase • Zinc • Stanozolol • Ifetroban • Silver sulfadiazine

  27. Secondary Preventionin VU’s • Recurrence in ~57% • Reflux in deep veins in 50 to 71% • Prior DVT causes 95% of DV reflux • Venous support hose may reduce recurrence rate (unpublished data)

  28. Treatment Guidelines--VU • Use moist wound dressings • Use a compression bandage system • Don’t use AB’s/antiseptics unless infected • Use grafting/artificial skin only if all other treatments have failed—very expensive, and high recurrence rate

  29. Diabetic Ulcers • Chronic ulcer in a diabetic patient, not primarily due to other causes • Extrinsic causes: smoking, friction, burn • Intrinsic causes: neuropathy, macrovascular and microvascular disease, immune dysfunction, deformity, reopened previous ulcer

  30. Neuropathy in DU • Use monofilament for 5 seconds or less, to avoid triggering propioceptors • Also assess temperature sensation—may use reflex hammer • Can test pinprick and 2-point discrimination

  31. Co-Morbidity in DU • Peripheral vascular disease occurs in 11% of diabetic patients • Peripheral neuropathy occurs in 42% of diabetic patients • PVD is associated with delayed ulcer healing and increased rates of amputation

  32. Treatment of DU:What Works • Must surgically debride ulcer to allow healing: the wound edges are dead • Weekly debridement down to healthy bleeding tissue gives best results • Must keep pressure off the ulcers to allow healing

  33. Pressure Reduction Off DU • Orthopedic shoes: drop recurrence rate from 83% to 17% • Sandals • Splints • Crutches/wheelchairs • Total contact casting

  34. Total Contact Casting • Worsens the ulcer if not applied perfectly • Need to find a consultant for this task on whom you can rely

  35. Other PossiblyHelpful Treatments • Moist dressings (clearly better than dry) • Hyperbaric O2 • Dermagraft (cultured skin—human) • Platelet-derived growth factor • Antibiotics (ineffective if uncomplicated) • Questionable effectiveness: U/S, electrical stimulation

  36. Pathogens in DU Infections • Mild severity: tend to be Staph and Strep • Moderate severity (i.e. non-limb threatening): Staph, Strep, and gram neg • Severe/limb-threatening: usually 5 to 6 organisms, including Staph, Strep, E. coli, Enterobacter, Bacteroides, Proteus, Pseudomonas, and MRSA

  37. Dx of Osteomyelitis in DU • Pearl: A steel probe contacting bone, especially if consistency of bone is crumbly, has PPV 89% and NPV 56% • MRI best imaging modality; serial films also of some benefit • Bone scan non-specific • Bone biopsy gold standard • Effective treatment: amputation

  38. Arterial Ulcers--AU • Tend to occur on distal areas • Diminished/absent pulses • Punched-out appearance, or gangrene • Requires either salvage revascularization, or amputation—usually the latter

  39. Diagnosis: ABI • ABI= LE systolic BP/Brachial art syst BP • ABI < 0.7 abnormal; < 0.4 unlikely to heal • Can perform in FMC • Values: 0.9-1.30 normal; 0.7-0.89 mild; 0.4-0.69 moderate; < 0.4 severe

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