Download - IT’S NOT HEALING…WHAT NOW? - ACFP
2019‐03‐11
1
IT’S NOT HEALING…WHAT NOW?AN INTRODUCTION TO THE CONCEPT OF ATYPICAL WOUNDS
Maria Lourdes M. Celis, MD, CCFP(COE), FCFP , Joanna Debosz, MD, CCFP
Emily Kwan MD, FRCPC (Geriatric Medicine)
Dr. Emily Kwan Disclosure
• Faculty: Department of Geriatric Medicine, University of Calgary
• Relationships with financial sponsors:‐ Grants/Research support: N/A
‐ Speakers Bureau/Honoraria: N/A
‐ Consulting Fees:N/A
‐ Patents:N/A
‐ Other: The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
1
2
2019‐03‐11
2
Dr. Maria Celis Disclosure
• Faculty: Department of Family Medicine, Care of the Elderly Program
• Relationships with financial sponsors:‐ Grants/Research support: N/A
‐ Speakers Bureau/Honoraria: N/A
‐ Consulting Fees:N/A
‐ Patents:N/A
‐ Other: The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
Dr. Joanna Debosz Disclosure
• Faculty: Department of Family Medicine
• Relationships with financial sponsors:‐ Grants/Research support: N/A
‐ Speakers Bureau/Honoraria: N/A
‐ Consulting Fees:N/A
‐ Patents:N/A
‐ Other: The Alberta College of Family Physicians has provided support in the form of a speaker fee and/or expenses.
3
4
2019‐03‐11
3
IT’S NOT HEALING….WHAT NOW?
OBJECTIVES:
• IDENTIFY PRESENTATION OF ATYPICAL WOUNDS
• DESCRIBE HOW DIFFERENT WOUND DRESSING SHOULD BE USED IN PRACTICE
• USE NEW KNOWLEDGE IN WOUND ASSESSMENT TO PLAN FOR MANAGING ATYPICAL WOUNDS
Plast Aesthet Res 2015;2:250-6.
5
6
2019‐03‐11
4
TYPICAL CHRONIC ULCERS
• DIABETIC NEUROPATHIC ULCERS
• ARTERIAL ULCERS
• VENOUS INSUFFICIENCY ULCERS
• PRESSURE INJURY ULCERS
• TRAUMA
• SURGICAL
https://woundcareadvisor.com/wp‐content/uploads/2017/08/diabetic‐foot‐ulcer.jpg
https://www.nursingtimes.net/pictures/420x280/9/0/9/1205909_leg_ulcer.jpg
http://www.sierravein.com/images/leg_ulcer.jpg https://encrypted‐tbn0.gstatic.com/images?q=tbn:ANd9GcSopZ‐9LiTWxeS3G9azjMCIPTFJUenvejjUfKWED40pU5LWrlO5
ATYPICAL CHRONIC ULCERS
• DEFINITION: WOUND OF UNKNOWN ETIOLOGY, CAUSED BY A DISEASE
OR CONDITION THAT DOES NOT TYPICALLY CAUSE A WOUND
• ABOUT 5% OF ALL WOUNDS
• CAUSES: MALIGNANCY, IMMUNOLOGIC, SYSTEMIC DISEASE, GENETIC
DISORDERS (SICKLE CELL), INFECTIONS (FUNGAL AND
MYCOBACTERIAL)
https://www.woundsource.com/
Acta Med Croatica. 2012 Oct;66 Suppl 1:5-
11
7
8
2019‐03‐11
5
WHAT TO CONSIDER
• ABCDE • Asymmetry• Border irregularity• Color• Diameter• Evolving size, shape or color
• HISTORY (PMX, MEDICATIONS)
• LOCATION
• RISK FACTORS
TYPICAL VS. ATYPICAL WOUNDS
9
10
2019‐03‐11
6
https://members.nursingquality.org/ndnqipressureulcertraining/Module2/OtherWoundTypes.aspx
TYPICAL OR ATYPICAL ?
https://www.dovepress.com/pyoderma‐gangrenosum‐challenges‐and‐solutions‐peer‐reviewed‐fulltext‐article‐CCID
TYPICAL OR ATYPICAL ?
11
12
2019‐03‐11
7
http://medtronicendovenous.com/content/uploads/2016/06/wound_DSC_0227_2.jpg
TYPICAL OR ATYPICAL ?
TYPICAL OR ATYPICAL ?
http://www.mohshawaii.com/most‐common‐types‐of‐skin‐cancer/basal‐cell‐carcinoma‐2/
13
14
2019‐03‐11
8
A 49 YEAR OLD WOMAN, HEALTHY • PRESENTED WITH A WOUND TO LOWER SHIN WHICH STARTED AS
A SMALL CUT FROM SHAVING
• CELLULITIS DEVELOPED, TREATED WITH ORAL AND THEN IV ANTIBIOTICS
• CELLULITIS RESOLVED BUT A MUCH LARGER ULCER, NOW VERY PAINFUL REMAINED - AT THAT POINT SHE WAS REFERRED TO WOUND CLINIC
PAST MEDICAL HISTORY• HISTORY OF FATIGUE, MUSCLE PAIN AND MALAISE, NO UNIFYING
DIAGNOSIS, SYMPTOMS PERSIST
• NO MEDICATION
FAMILY HISTORY• CROHN’S DISEASE
15
16
2019‐03‐11
9
PHYSICAL EXAMINATION
• NO CLINICAL INDICATIONS OF ARTERIAL OR VENOUS DISEASE
• CELLULITIS WAS RESOLVED
17
18
2019‐03‐11
10
• large shallow ulceration of the left lateral calf• base of the ulcer showed slough with some hemorrhage necrosis. • border of this lesion showed a classic purple‐greyish hued discoloration with evidence of incipient
epidermal necrosis• no significant undermining, no evidence of infection
INVESTIGATIONS• PUNCH BIOPSY (2 SAMPLES ARE NEEDED: HISTOLOGY AND
TISSUE CULTURE)
• ROUTINE BLOOD WORK, CRP
• SPEP
• LUPUS PROFILE
• INFLAMMATORY BOWEL DISEASE PROFILE
19
20
2019‐03‐11
11
• PYODERMA GANGRENOSUM
Skin, Biopsy:
Neutrophil‐rich dermal infiltrate
If an infectious etiology has been excluded clinically, the histologic findings may be seen in a neutrophilic dermatosis such as pyoderma gangrenosum. Clinical and pathologic correlation, including correlation with final tissue culture results, is necessary for a definitive diagnosis.
DIAGNOSIS
• URGENT REFERRAL TO DERMATOLOGY
• INITIALLY STARTED ON ORAL PREDNISONE AND INTRALESIONAL KENALOG INJECTIONS
• DESPITE THAT, ULCER CONTINUED TO ENLARGE IN SIZE AND PAIN CONTINUED TO BE SEVERE
TREATMENT
21
22
2019‐03‐11
12
14.7 cm x 10cm
23
24
2019‐03‐11
13
• IN ADDITION TO ORAL PREDNISONE, CYCLOSPORINE WAS ADDED
• ONLY WHEN CYCLOSPORINE WAS ADDED, DID THE ULCER STOP EXPANDING
TREATMENT CONTINUED
25
26
2019‐03‐11
14
• FIVE MONTHS AFTER INITIAL TRAUMA, ULCER FULLY RESOLVED
27
28
2019‐03‐11
15
PYODERMA GANGRENOSUM
• RARE CUTANEOUS ULCERATIVE DISEASE WITH DISTINCTIVE MORPHOLOGICAL PRESENTATION
• IDIOPATHIC IN 25‐50% OF PATIENTS
• CAN BE ASSOCIATED WITH INFLAMMATORY CONDITIONS SUCH AS INFLAMMATORY BOWEL DISEASE, AUTOIMMUNE CONNECTIVE TISSUE DISEASES (MOSTLY LUPUS, RHEUMATOID ARTHRITIS), MONOCLONAL GAMMOPATHIES AND OTHER HEMATOLOGIC DISORDERS
SOURCE: UPTODATE
PYODERMA GANGRENOSUM
• DEFECTS IN CELL‐MEDIATED IMMUNITY, NEUTROPHIL AND MONOCYTE FUNCTION, AND HUMORAL IMMUNITY HAVE BEEN REPORTED ‐ HOWEVER NOT CONSISTENTLY ENOUGH
• OFTEN STARTS AS MINOR TRAUMA AND CAN BE EXACERBATED BY SAME (PATHERGY)
• SKIN BIOPSY IS NECESSARY FOR DIAGNOSIS (MUST EXCLUDE INFECTION)
• TREATMENT INCLUDES SYSTEMIC CORTICOSTEROIDS AND ADDITIONAL AGENTS DEPENDING ON SEVERITY AND NUMBER OF LESIONS
29
30
2019‐03‐11
16
KC 53 YEAR OLD MAN DIABETIC
• WITH DM NEPHROPATHY, CHARCOT ARTHROPATHIC ULCER,
NEUROPATHY, LEFT FOOT ULCER HEALING
• INCREASED SWELLING OF BOTH LEGS, QUITE TENDER WITH
INDURATION, COMPRESSION INCREASED TO TWO LAYERS.
• US FOR DVT IS NEGATIVE
• GFR 15 ML/MIN, HIGH PHOSPHATE, NORMAL
CALCIUM, NOT UREMIC
• SMALL BLISTERING PAINFUL ULCERS
DEVELOPED ON INDURATED AREAS
INCREASING NUMBER IN A WEEK
• URGENT NEPHROLOGY CONSULTATION FOR
POSSIBLE CALCIPHYLAXIS.
31
32
2019‐03‐11
17
• BONE SCAN SHOWED CALCIFICATIONS ON THE
RIGHT LEG, NO BIOPSY DONE
• URGENT DAILY DIALYSIS
• DEBRIDEMENT IN THE CLINIC WITH LOCAL
WOUND DRESSINGS TO CONTROL DRAINAGE
• COMPRESSION WRAPS FOR EDEMA
CALCIFIC UREMIC ARTERIOLOPATHY
• USUALLY SEEN IN PATIENTS WITH END STAGE RENAL DISEASE
• SXS: PAINFUL ISCHEMIC NECROTIC LESIONS OCCURRING IN
AREAS WITH GREAT ADIPOSITY ( BUTTOCK, ABDOMEN, LEGS)
• PAINFUL RED TO PURPLE LIVEDOID PLAQUES RAPIDLY
PROGRESSES TO NON HEALING NECROTIC ULCERS
• DIFF DX: DM WOUND, ARTERIAL, VENOUS, PRESSURE ULCER
Source:UptoDate
33
34
2019‐03‐11
18
Diagnosis
• DX: BIOPSY- CAUTION
• RADIOGRAPHY- SOFT TISSUE, MAMMOGRAM TECHNIQUE,
SPIRAL CT, US, BONE SCAN
• LOOKING FOR ARTERIOLAR CALCIFICATIONS
• LABS: CALCIUM, PHOSPHOROUS, PTH, CREATININE
Source:UptoDate
CALCIFIC UREMIC ARTERIOLOPATHY
• TREATMENTS: NO EVIDENCE BASED GUIDELINES
• SYSTEMIC TREATMENT: DIALYSIS, PARTIAL
PARATHYROIDECTOMY
• WOUND CARE: DEBRIDEMENT, TOPICAL WOUND CARE, PAIN
MANAGEMENT
Source:UptoDate
35
36
2019‐03‐11
19
PROPERTIES OF A GOOD WOUND DRESSING
● COMFORTABLE
● CONFORMABLE
● LONGER WEAR TIME-MORE DRESSING CHANGES INCREASE THE PH OF THE
WOUND
● INSULATES
● MAINTAINS MOIST WOUND ENVIRONMENT
● BARRIER TO TRAUMA AND INFECTION
37
38
2019‐03‐11
20
GAUZES
• FIBRES OF COTTON, RAYON OR POLYESTER, PLAIN OR IMPREGNATED WITH PETROLEUM
JELLY OIL OR WATER EMULSION, GEL OR ANTI MIC
• VARIOUS SHAPES AND SIZES, CHEAP PRODUCT
• IND: LOW EXUDATE, FILL DEAD SPACE, DELIVER PRODUCT, CLEANS
• CI: NOT FOR HIGH EXUDATIVE WOUNDS
• DISADV: MACERATION, FREQUENT DRESSING CHANGES
Source: Wounds Canada
ACRYLICS /FILMS/MEMBRANES
• WATERPROOF FILM, IMPERMEABLE TO LIQUID AND BACTERIA
• MOISTURE VAPOUR TRANSMISSION RATES VARY
• ADV: EXTENDED WEAR TIME, WOUND MONITORING, SUPPORTS
AUTOLYTIC DEBRIDEMENT
• CI: MOD TO HIGH EXUD, INFECTED, DEEP CAVITIES,
• DIS: NOT FOR HIGH EXUD WOUNDS
Source: Wounds Canada
39
40
2019‐03‐11
21
CALCIUM ALGINATES
• FIBROUS ROPES OF GLUCURONIC ACID AND SODIUM CMC
• USED FOR MODERATELY TO HIGHLY EXUD WOUNDS, HEMOSTASIS,
FILLING WOUND DEAD SPACE
• ADV: CONFORMABLE, MOISTURE BALANCE
• DIS: : SECONDARY DRESSING NEEDED, MACERATION
• CI: DRY WOUND, DEEP SINUSES, HEAVY BLEEDING
Source: Wounds Canada
GELLING FIBRES
• SHEETS / STRIPS OF CMC, TURNS INTO GEL WHEN ACTIVATED
• IND: MOD TO HIGHLY EXUD WOUNDS , AUTOLYTIC DEBRIDEMENT
• CI: DRY WOUNDS, NARROW DEEP SINUSES
• ADVANTAGE: ABSORPTIVE, CONFORMABLE
• DISADVANTAGE: MACERATION, SECONDARY DRESSING
Source: Wounds Canada
41
42
2019‐03‐11
22
FOAMS
• POLYURETHANE, WITH VARIOUS MOISTURE VAPOUR
TRANSMISSION RATES
• OPTIONS: ANTIMICROBIAL, WITH BORDER, PAIN CONTROL
• ADV: CONFORMABLE, LOW TO MOD EXUDATE, WICKS EXUDATE
• DIS: MACERATION, DOES NOT REDUCE PLANTAR PRESSURE
Source: Wounds Canada
HYDROCOLLOIDS
• OCCLUSIVE SHEET DRESSING, POLYURETHANE
• MAY CONTAIN GELATIN, CMC, PECTIN
• USE: LOW LEVEL EXUDATE, AUTOLYTIC DEBRIDEMENT
• NOT USED: HIGH EXUDATING WOUNDS, INFECTED WOUNDS,
ARTERIAL WOUNDS, MAY MACERATE AND TEAR SKIN
Source: Wounds Canada
43
44
2019‐03‐11
23
CHARCOALS
• ACTIVATE CHARCOAL WITHIN A SLEEVE DRESSING
• SOME MAY HAVE SILVER
• IND: MALODOROUS WOUNDS, MILD TO MOD EXUDATE, CAVITY
WOUNDS
• CI: HIGHLY EXUDATING WOUNDS
Source: Wounds Canada
ANTIMICROBIAL AGENTS IN DRESSINGS
• SILVER
• POLYHEXAMETHYLENE BIGUANIDE
• IODINE
• GENTIAN VIOLET/METHYLENE BLUE
• HONEY
Source: Wounds Canada
45
46
2019‐03‐11
24
QUICK REVIEW OF WOUND DRESSINGS
47
48
2019‐03‐11
25
What dressing would you use
What dressing would you use
49
50
2019‐03‐11
26
PEARLS
• IF A TYPICAL CHRONIC WOUND IS NOT HEALING IN SPITE OF
BEST WOUND PRACTICES, CONSIDER ATYPICAL CAUSE
• REVIEW MEDICAL HISTORY, FAMILY HISTORY, MEDICATIONS
• BIOPSY THE WOUND
• REFER TO THE WOUND CLINIC FOR INTERDISCIPLINARY CARE
WOUND CLINIC
• Sheldon Chumir Wound Clinic - Family Physicians, Dermatologists, Vascular Surgeon, Physiotherapist, RN’s with wound certification, LPN’s
• Different Wound Care Clinics associated with Home Care across the city
• Home Care would be able to follow/care for wounds at home
• Referrals can be faxed to Central Access at 403-943-1602
• More details at www.informalberta.ca
51
52
2019‐03‐11
27
ACKNOWLEDGEMENTS
• Dr Connie Zhang
• Cyrilene Lynch-Parker
• Teaching Materials provided by Sheldon Chumir Wound Clinic
53