Chronic Wounds

What is the etiology of pressure ulcers?

Pressure (especially at bony prominences for those who are immobile/ bedridden) Friction Shear Moisture (Often causes sacral pressure ulcers for those who are incontinent) Aging Skin

What are the effects of a vacuum assisted closure/ negative pressure wound therapy on a patient's wound?

Reduces edema, bacterial load, necrotic tissue, and wound fluid. Increases blood flow, granulation, fibroblasts and WBCs, growth factors, and angiogenesis.

What is the etiology of a diabetic ulcer?

*A triad of ischemia, neuropathy, and infection*. There is a pO2 of <20 mmHg There are high foot pressures (revealed by a callus) due to motor neuropathy changes, and poorly fitting shoes can cause ischemia and ulceration.

When should electrical stimulation for wound healing NOT be used?

--Malignancy --Osteomyelitis --Metal near the wound --Electrode placement over electrical implant (i.e. pacemaker)

How can a patient be educated to care for their diabetic ulcer?

--Moisturize their feet --Check feet twice a day --Use clean, seamless cotton socks --Wear properly fitting shoes with a large toe box --Diabetes control

In what ways can you identify the extent of a diabetic ulcer?

--Use the Wagner Scale or University of Texas Diabetic Foot Ulcer Classification System --Assess for neuropathy via semmes weinstein filaments --Assess for ischemia via color, pulses, and capillary refill.

What two things can be done to treat a diabetic ulcer?

1) *Offload and decrease pressure* on the impacted area (felted foam, total contact casting, diabetic footwear, assistive devices) 2) *Wound care* via debridement (callous removal) and increased blood flow (walking / staying active)

What are the positive effects of treatment with ultrasound?

1) Accelerates inflammatory phase 2) Stimulates rate of healing 3) Improves mechanical properties of scar 4) Increased blood flow 5) Angiogenesis 6) Increased collagen synthesis

Describe 4 up and coming methods for wound care.

1) Amniotic Membrane as primary dressing for deep partial thickness burns 2) High frequency diagnostic ultrasound 3) Platelet derived growth factors 4) Stem cells / tissue engineering

If a patient has a pressure ulcer, what should you do to care for it?

1) Clean it- use low pressure irrigation with normal saline with a pulsatile lavage. Pat wound margins dry to avoid maceration of periwound skin. 2) Debride it- can use selective debridement with scalpel, mechanical debridement for large amounts of necrotic tissue (wet to dry gauze), autolytic debridement, surgical debridement, etc. 3) Dress it- use moist wound dressing and fill cavities.

Name 4 benefits of electrical stimulation for wound healing.

1) Increased rate of healing 2) Increased wound strength 3) Decreased bacterial load 4) Decreased pain

What kinds of wounds can electrical stimulation be used for?

1) Stage 3 and 4 pressure ulcers 2) Neuropathic ulcers 3) Venous insufficiency ulcers 4) Arterial ulcers

What are localized areas of tissue necrosis that develop when soft tissue is compressed between bony prominence and external surface over time? How common are these?

A Pressure Ulcer Seen in... 3-14% of patients in acute care settings 15-25% of patients in long term care settings

What proportion of diabetic patients develop ulcers?

15%

What can be done to prevent the onset of a pressure ulcer?

2 hour turning schedule Pillows, foam wedges, socks Special protection for hard surfaces on a bed or wheelchair. Pressure mapping Addressing underlying medication conditions Dietary consult Bridging Wound Care

What factors could put a patient at risk for developing a pressure ulcer?

A low staff to patient ratio Malnutrition Incontinence Impaired sensation (SCI, stroke) Impaired cognition / consciousness Frail institutionalized elderly Immobility/Inactivity Involuntary weight loss Dehydration

Describe the components of a vacuum assisted closure / negative pressure wound therapy.

A vacuum is applied to a wound with semipermeable sponge (i.e. hydrofera blue) and semipermeable film. Negative pressure from the external vacuum is applied through a tube going directly into the wound.

What is a chronic wound? Name 4 examples.

A wound whose progress is arrested or prolonged due to underlying conditions. Pressure ulcers, venous ulcers, arterial ulcers, and neuropathic / diabetic ulcers.

Infrared light therapy for increased circulation is a wound intervention known as _________.

Anodyne

What can put a patient at risk for developing an arterial ulcer?

Being a male Smoking Being over the age of 50 Diabetes Hypertension

Which wounds are ultrasound most commonly used for?

Chronic leg ulcers

How (generally) are pressure ulcers classified?

Classified by five stages of depth using the "Stages of Pressure Wounds" from the "National Pressure Ulcer Advisory Panel"

What kinds of wounds benefit from vacuum assisted closure / negative pressure wound therapy?

Deep wounds Skin grafts/Partial thickness burns Dehisced Wounds (often surgical- open abdominal surgery or infected sternotomy wounds) Neuropathic wounds Traumatic wounds Pressure Ulcers

What can be done to manage and care for a venous ulcer?

Elevate the legs Compress the legs with an elastic 4-layer wrap or other compression bandages/garments, OR use an intermittent compression pump. Use occlusive dressings to prevent trauma to granulation and decrease the risk of infection/pain. Use calcium alginate to absorb large amounts of exudate Can also use semipermeable foam to absorb slightly less exudate.

Where might you find arterial ulcers, and what do they typically look like? What would a patient's symptoms be like?

Found at the anterior lower leg, dorsum of the foot, and distal ends of toes. Typically have irregular shape but sharp edges with a clearly defined margin. Have a pale yellow base with purulent exudate. The skin around the wound is dry and cracked. It is also cold to the touch distal from the ulcer. There is a weak or absent pulse Patients complain of pain with elevation and exertion.

Under what conditions would you not debride a pressure ulcer? Why?

If the patient has a stable heel ulcer that does not change or heal, and has hard eschar that covers it up. Opening it up would create an avenue for infection.

When should ultrasound not be used in wound treatment?

Malignancy Over pregnant uterus Over gonads Irradiated tissue Vascular Abnormalities (DVT) Cardiac area Eyes Over spinal cord post laminectomy

How can hyperbaric oxygen treatment help in wound healing?

Increases tissue partial pressure of oxygen and increased oxygen transport through the blood.

What is the major cause of arterial ulcers? Name two conditions where this would be a problem.

Ischemia Peripheral Arterial Disease (arteriosclerosis obliterans) Buerger's Disease (thromboangiitis obliterans)

If you were to see a venous ulcer, what would it probably look like? How would the patient present?

Located over medial malleolus or just superior to it. Irregularly shaped with shaggy borders. Substantial amount of drainage A clean, healthy wound would have granulation tissue Fascia and Deep structures would not be involved- very superficial. Pain when standing and dependent. Edema and Pigmentation Alopecia Eczema of the periwound skin.

What factors can help you determine the etiology of a patient's wound?

Location Depth Color Exudate Symptoms (Pain) Comorbidities / Risk Factors

When should you not use vacuum assisted closure / negative pressure wound therapy?

Malignancy in Wound Untreated osteomyelitis Exposed vessels and organs Necrotic Tissue with eschar Unexplored fistulae (abnormal passage) Bleeding Wounds

What can help with the management of an arterial ulcer?

Moderate walking to the point of discomfort helps improve blood flow to the legs Be cautious and avoid bumps and scratches at the legs and feet. Electrical Stimulation Vascular Reperfusion Surgery Wound Care- debridement (avoid viable tissues!) and hydrocolloid dressings (in absence of infection)

What measures are included in the Braden Scale to assess the risk for pressure ulcer development?

Moisture Mobility Nutrition Activity Friction/Shear Sensory Perception

In what scenarios can hyperbaric oxygen treatment be used?

Neuropathic ulcers Osteomyelitis Gas gangrene Arterial Insufficiency

Describe the presentation of a diabetic ulcer.

Seen at the plantar surface of the foot, often at the MTPs . They are typically deep and infected. The limb is cool and shows signs of color changes (ischemia/infection). Skin is shiny and atrophic. A posterior tibial and dorsalis pedis pulse may be absent. Touch, pressure, and proprioception are lost.

What would you use to predict who is at risk for pressure ulcer development?

The Braden Scale

Describe the process of ultrasonic wound debridement, including its effects on the wound.

Use celleration MIST, an ultrasound generated mist at 25-40 kHz. Results in selective debridement, decreased bacterial load, cleansing of deep tunneling undermining, decreased need for pain medications, and faster healing rates.

What is the etiology behind lower extremity venous ulcers?

Valve Dysfunction Thrombosis

How are outcomes measured for a patient who has an arterial ulcer?

Walking Impairment Questionnaire SF-36 (health outcomes)

When should hyperbaric oxygen treatment NOT be used?

When a patient has an untreated pneumothorax