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Which Ulcers are Which?

Which Ulcers are Which?. Diagnosis and evaluation of chronic ulcers. Thomas M. Bozzuto, DO, FACEP, UHM Medical Director Phoebe Wound Care and Hyperbaric Center Albany, GA Past President, American College of Hyperbaric Medicine. Course Outline. How to differentiate different types of ulcers

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Which Ulcers are Which?

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  1. Which Ulcers are Which? Diagnosis and evaluation of chronic ulcers Thomas M. Bozzuto, DO, FACEP, UHM Medical Director Phoebe Wound Care and Hyperbaric Center Albany, GA Past President, American College of Hyperbaric Medicine

  2. Course Outline • How to differentiate different types of ulcers • Tips in diagnosing • Arterial ulcers • Venous ulcers • Pressure ulcers • Dehisced surgical ulcers • Treatment suggestions • Resources

  3. The Burden of Chronic Wounds • Affect 6.5 million people • Medicare spending in 2014 was $35.3 billion • Infections = $16.7 billion • Chronic ulcers = $9.4 billion • Surgical wounds = $6.5 billion

  4. Acute wounds • Definition: • Short duration (<6 weeks) • Normal Healing Process • Normal inflammatory phase • Normal granulation • Normal tensile strength • No local / systemic compromise • No underlying etiology • Cause: • Usually trauma / surgery

  5. Chronic Wounds • Definition: • Long duration (>6 weeks) • Abnormal Healing Process • Prolonged inflammatory phase • Poor / absent granulation • Poor tensile strength / dehiscence • Local / systemic compromise (ischemia, corticosteroids) • Underlying etiology (DM; RA; SLE: etc.) • Causes: • Local • Systemic

  6. Distribution of Wound Types

  7. Top 3

  8. 5-Year Mortality Armstrong DG, Wrobel J, Robbins JM: Are diabetic-related wounds and Amputations worse than cancer? Int Wound Journal, 2009; 4(4): 286-7

  9. WOUND Systemic Illness Soft Tissue Infection Nutrition Oxygen Osteomyelitis Perfusion Pressure Systemic Healing Ability Edema Compliance

  10. The Ideal Wound Approach • From diagnosis to follow up: • Evidence based • Recognition of wound characteristics • Criteria for assessment • Labs and imaging • Wound bed preparation • Appropriate treatment • Proactive follow-up

  11. Approach • Wound etiology must be accurately identified • Clear treatment plan • Offloading DFU • Compressing VLU • Appropriate dressings

  12. Stages of wound healing • Vascular response (immediate – 5 days) • Inflammatory response (3 – 7 days) • Proliferation (3 – 25 days) • Maturation (25 days – 1 year) 100 50 0 % 0 1 2 3 4 5 6 7 … 25 … 365 Days

  13. <

  14. Metabolic Syndrome - Type 2 Diabetes

  15. Diabetic Foot Ulcers • Ulceration below the ankle – commonly on plantar surface • Associated with neuropathy, PAD or both

  16. Major Contributing Causes and Risk Factors for DFU

  17. Ulcers • Any leg ulcer, regardless of etiology may have associated arterial insufficiency • Must mitigate the trauma and treat the arterial insufficiency as well as treating the wound • Ruling out associated arterial disease in leg ulcers is critical for wound healing • Pain with elevation • Arterial disease • Pain when dangling • Venous disease

  18. Smoking • Smokers are 16 times more likely than non-smokers to have PAD • Smokers are more likely to have amputations • Smokers are more likely to have proximal amputations • Higher pack-years = more likely to have proximal amputation • Neither the amputation level nor the amputation itself was enough motivation for the patients to participate in smoking cessation. Anderson JJ, et al. A comparison of diabetic smokers and non-smokers who undergo lower extremity amputation: a retrospective review of 112 patients. Diabet Foot Ankle. 2012; 3: 10.3402/dfa.v3i0.19178

  19. Diagnostic and Laboratory Tests • Toe pressures and wave forms are considered first line • The ABI is known to be unreliable in patients with vascular stiffness and fails to detect the early phase of arteriosclerotic development. The toe vessels are less susceptible to vessel stiffness, which makes the TBI useful1 • TcpO2 or fluorescein/indocyanine green angiography may provide better information about perfusion at site of ulceration • ABI (absent of feeble pulses with ABI <.7 confirms ischemia. May be inaccurate with numbers > 1.2 because of calcification (non-compressible) • Pulse-volume recordings • Medicare does not consider palpation of pulses to be adequate vascular testing • When to consult vascular • ABI < 0.8 • TcpO2 <40 mmHg • Toe pressure < 45 mmHg • Ankle systolic pressure <50 mmHg 1. Høyer C, Sanderman J, Petersen L. The toe-brachial index in the diagnosis of peripheral arterial disease. J Vasc Surg. 58:1, July 2013

  20. Neuropathic Testing

  21. Diagnostic and Laboratory Tests • Imaging • If able to probe to bone – x-ray or MRI should be done • MRI is most accurate imaging in diagnosing osteomyelitis or soft tissue infection • If lower extremity ischemia is suspected – doppler or angiography • Tc99 bone scan in patients with kidney disease who cannot get MRI (or can use gadolinium as contrast for MRI) • Labs • CBC (leukocytosis and anemia) • Glucose (HgbA1c) • CRP & ESR • Prealbumin • Comprehensive Metabolic Panel

  22. The Ulcerated Foot and Off-Loading • The most reliable way to maintain off-loading in a patient with a diabetic plantar foot ulcer is with a device that the patient cannot interfere with, even inadvertently, because the device cannot be removed from the foot.

  23. Plantar pressures and diabetes Plantar pressures with various footwear.

  24. Efficacy of Various Treatments in Healing Ulcers TCC Percent Healed Dermagraft Apligraf Regranex “Usual Care” 20 0 12 Weeks

  25. Beware the great masquerader

  26. Venous and Arterial Leg Ulcers • Venous Leg Ulcers • Open lesion between knee and ankle that occurs in the presence of venous disease • Venous disease is the MOST COMMON cause of leg ulcers (60-80%) • Arterial Leg Ulcers • Can occur anywhere in lower extremity • Account for 5-10% of leg ulcers

  27. Primary Characteristics of Venous and Arterial Ulcers

  28. Arterial vs Venous Ulcers • Labs • CBC • CRP, ESR • Diagnostics • ABI, TCOM, Doppler • Monofilament testing • Imaging • MRA • Angiogram • Venous doppler

  29. Scope of the Problem –Venous Ulcers • Comprises 70% of LE ulcers in the U.S. • 500,000-1,000,000 people • Over 40% report first ulcer by age 50 • 13% report first ulcer by age 30 • Recurrence rate – 72% at one year • US annual healthcare expenditure $1.9-2.5 billion • Each case > $40,000 • 2 million annual workdays lost

  30. Scope of the Problem • Median duration 9 months • 20% have not healed in one year • 66% had episodes of ulceration lasting 5 years • 2-3% of total US healthcare budget

  31. Etiology • Over 50% caused by previous DVT • Sedentary lifestyle • Obesity • Women • Standing • Men who smoke

  32. Etiology • Primary cause: • Reflux through incompetent valves • Venous outflow obstruction (DVT) • Superficial reflux – 45% • Deep reflux 12% • Mixed – 43%

  33. Action of the Musculovenous Pump in Lowering Venous Pressure in the Leg

  34. Treatment • Underlying pathophysiology is failure of muscle pump • If this is corrected, 93% of all VU’s will heal at a mean of 5.3 months (requires at least 80% compliance with wear) • Physical modalities • Exercise • Compression

  35. Treatment • Key Points • Compression is the mainstay of therapy • Always precede compression with arterial evaluation of leg • 40-50 mmHg is required (30-40 is adequate) • Sustained compression is required

  36. Elastic vs. Inelastic Bandages • Inelastic Bandage • Unna’s Boot • Low resting pressure and high pressure on ambulation • Impregnated with • Zinc oxide • Calamine • Glycerin • Sorbitol • Mg silicate • Ace wrap or Coban over boot

  37. Multi-layer compression • Elastic bandages produce sustained compression with minor variations in walking • Layer one • Soft padding • Layer two • Ace bandage • Layer three • Coban

  38. Arterial Ulcers • Risk factors • Diabetes mellitus • Foot deformity and callus formation resulting in focal areas of high pressure • Poor footwear that inadequately protects against high pressure and shear • Obesity • Absence of protective sensation due to peripheral neuropathy • Limited joint mobility

  39. Arterial Ulcers • Etiology • Restrictions to blood vessels due to peripheral vascular disease • Chronic vascular insufficiency • Vasculitis (inflammatory damage of blood vessels) • Diabetes mellitus • Renal failure • High blood pressure • Arteriosclerosis (hardening of the arteries) • Atherosclerosis (thickening of the arteries, due to the buildup of fatty materials) • Trauma • Limited joint mobility • Increased age

  40. Arterial Ulcers • Treatment • Examine feet (especially between the toes) and legs daily for any unusual changes in color or the development of sores. • Quit smoking. Smoking can harden or clog the arteries, leading to improper perfusion to the extremities. • Manage blood pressure, cholesterol, triglyceride and glucose levels. • Ensure that footwear is properly fitted to avoid points of rubbing or pressure. Avoid wearing constrictive socks. • Avoid crossing legs while sitting. • Avoid sitting or standing for extended periods. • Avoid cold temperature. • Protect legs and feet from injury and infection. • Exercise as frequently as is comfortable.

  41. Pressure Ulcers • A pressure ulcer is defined as a localized injury to the skin or underlying tissue usually over a bony prominence as a result of pressure in combination with shear and/or friction

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