CHRONIC WOUNDS

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CHRONIC WOUNDS

• Based on a presentation by
• Dr. David Thomas
• at the AMDA Convention

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Four Kinds of Chronic Wounds

• Pressure Ulcer (PU)
• Diabetic Ulcer (DU)
• Venous Ulcer (VU)
• Arterial Ulcer (AU)

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Chronic Ulcer Types

• Etiology is different
• Treatment is different
• Outcome is different
• Gestalt is different

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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
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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

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Pain in Chronic Ulcers

• DU no or diminished pain, sensation
• VU little pain, intact sensation
• PU intermittent pain
• AU constant pain

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Pressure Ulcers

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

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Pressure UlcersWhat Works

• Must relieve pressure or it wont heal.
• Must use moist dressing or it wont heal.

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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

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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.

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Treatments Proven NOT to Work

• Ultrasound
• Lasers
• Arginine
• Dry dressings
• Paraffin

• Zinc paste
• Antacid
• Gold leaf
• Aluminum foil
• Topical insulin

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Treatments with No Data

• Magnet therapy
• Honey/ Sugar
• Skin equivalents

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Treatments With Very Flawed Data

• Vitamin C
• Patients serum mixed with proprietary gel
• Vacuum therapy
• Electrical stimulation
• Topical Phenytoin
• Cytokine growth factors

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Other Effective Treatments

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

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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.

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Pressure Ulcer Guidelines

• Address nutrition
• Promote granulation tissue
• Promote epithelialization
• Prevent contamination

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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.

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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).

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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.

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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

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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

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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

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Infection in VU

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

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Recognition of Infectionin VUs

• Fever
• Increased pain
• Increased skin erythema
• Lymphangitis
• Ulcer rapidly becomes larger
• If infected, treat with systemic ABs

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VU Treatments

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

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Ineffective VU Treatments (RCTs)

• Antibiotics, including Bactroban
• Elase
• Zinc
• Stanozolol
• Ifetroban
• Silver sulfadiazine

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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)

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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

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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

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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

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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

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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

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Pressure Reduction Off DU

• Orthopedic shoes drop recurrence rate from 83
  to 17
• Sandals
• Splints
• Crutches/wheelchairs
• Total contact casting

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Total Contact Casting

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

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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

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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

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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

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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

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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

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Medical Treatment of AU

• Control DM and HTN
• Moderate exercise
• Smoking cessation
• Dry dressings (dry gangrene preferable)
• ? Pletal, gingko biloba

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What Works AU

• Amputation/revascularization/hospice if ABI lt 0.4
• Do not compress if ABI lt 0.7