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CHRONIC WOUNDS

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Very few good studies; none for most treatments. Treatment modalities for pressure ulcers are considered devices: only safety, ... – PowerPoint PPT presentation

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Title: CHRONIC WOUNDS


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
LOCATION CAUSE APPEARS
PU DU Bony Prom Callus Pressure Neuropathy/trauma Crater Borders distinct
VU AU Calf/ankle Distal points Venous Stasis Inadequate arterial flow Irregular Gangrene
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
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8
Pressure Ulcers
  • Visible evidence of pathological interruption of
    blood flow to dermal tissues
  • Chief cause sustained pressure
  • Most commonly over sacrum, hip

9
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10
Pressure UlcersWhat Works
  • Must relieve pressure or it wont heal.
  • Must use moist dressing or it wont heal.

11
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12
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

13
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14
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.

15
Treatments Proven NOT to Work
  • Ultrasound
  • Lasers
  • Arginine
  • Dry dressings
  • Paraffin
  • Zinc paste
  • Antacid
  • Gold leaf
  • Aluminum foil
  • Topical insulin

16
Treatments with No Data
  • Magnet therapy
  • Honey/ Sugar
  • Skin equivalents

17
Treatments With Very Flawed Data
  • Vitamin C
  • Patients serum mixed with proprietary gel
  • Vacuum therapy
  • Electrical stimulation
  • Topical Phenytoin
  • Cytokine growth factors

18
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19
Other Effective Treatments
  • Sheng-ji-san (SJS)
  • Whirlpool
  • Any kind of pressure relieving bed
  • Debridement of necrotic tissue surgical
    (required if infected), autolytic, enzymatic

20
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.

21
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22
Pressure Ulcer Guidelines
  • Address nutrition
  • Promote granulation tissue
  • Promote epithelialization
  • Prevent contamination

23
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.

24
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).

25
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.

26
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27
Diagnosis of Venous Ulcers
  • Location on the calf
  • Bronzing (lipodermatosclerosis)
  • Exclusion of arterial insufficiency by bounding
    DP pulses, or ABI gt 0.8
  • Tend to be slow-healing (90 heal by one year),
    irregular, and associated with edema and sloughing

28
Treatment of VUWhat Works
  • Must compress the calf, or it wont heal
  • However, arterial insufficiency is an absolute
    contraindication to compression therapy
  • Must carefully assess for arterial flow

29
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

30
Infection in VU
  • All VUs are colonized
  • No evidence that colonization impairs healing,
    though may interfere with a graft
  • Dont culture VUs!

31
Recognition of Infectionin VUs
  • Fever
  • Increased pain
  • Increased skin erythema
  • Lymphangitis
  • Ulcer rapidly becomes larger
  • If infected, treat with systemic ABs

32
VU Treatments
  • Hydrocolloid dressing
  • Cadexomer iodine topically
  • Trental (anticytokine) and compression
  • Artificial skin
  • Skin graft
  • TGF-B2

33
Ineffective VU Treatments (RCTs)
  • Antibiotics, including Bactroban
  • Elase
  • Zinc
  • Stanozolol
  • Ifetroban
  • Silver sulfadiazine

34
Secondary Preventionin VUs
  • 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)

35
Treatment Guidelines--VU
  • Use moist wound dressings
  • Use a compression bandage system
  • Dont use ABs/antiseptics unless infected
  • Use grafting/artificial skin only if all other
    treatments have failedvery expensive, and high
    recurrence rate

36
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

37
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38
Neuropathy in DU
  • Use monofilament for 5 seconds or less, to avoid
    triggering propioceptors
  • Also assess temperature sensationmay use reflex
    hammer
  • Can test pinprick and 2-point discrimination

39
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

40
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41
Treatment of DUWhat 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

42
Pressure Reduction Off DU
  • Orthopedic shoes drop recurrence rate from 83
    to 17
  • Sandals
  • Splints
  • Crutches/wheelchairs
  • Total contact casting

43
Total Contact Casting
  • Worsens the ulcer if not applied perfectly
  • Need to find a consultant for this task on whom
    you can rely

44
Other PossiblyHelpful Treatments
  • Moist dressings (clearly better than dry)
  • Hyperbaric O2
  • Dermagraft (cultured skinhuman)
  • Platelet-derived growth factor
  • Antibiotics (ineffective if uncomplicated)
  • Questionable effectiveness U/S, electrical
    stimulation

45
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46
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

47
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

48
Arterial Ulcers--AU
  • Tend to occur on distal areas
  • Diminished/absent pulses
  • Punched-out appearance, or gangrene
  • Requires either salvage revascularization, or
    amputationusually the latter

49
Diagnosis ABI
  • ABI LE systolic BP/Brachial art syst BP
  • ABI lt 0.7 abnormal lt 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 lt 0.4 severe

50
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51
Medical Treatment of AU
  • Control DM and HTN
  • Moderate exercise
  • Smoking cessation
  • Dry dressings (dry gangrene preferable)
  • ? Pletal, gingko biloba

52
What Works AU
  • Amputation/revascularization/hospice if ABI lt 0.4
  • Do not compress if ABI lt 0.7
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