The Basics of Identifying And Caring For Problem

WoundsBy Lisa Hezel, RN WCC CHT

Objectives

Identify Problem Wounds Choose Appropriate Treatment Options

for Wounds Identify when it’s time to refer Learn a little about HBOT

Common Chronic Wounds

o Pressureo Diabetic / Neuropathico Arterialo Venouso Surgical

Pressure Wounds

Pressure Wounds

This staging system was developed by the NPUAP(National Pressure Ulcer Advisory Panel) and classifies only pressure ulcers based on anatomical depth of soft tissue damage.

Normal Skin

Stage 1 Appears as defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, this ulcer may appear with persistent red, blue or purple hues.

If it doesn’t become pale with pressure aka blanch, this is considered a Stage I pressure ulcer.

Stage 1

Pressure on anterior tibialis tendon from compression wrap applied incorrectly

Stage 2 Stage 2-Partial thickness skin loss involving epidermis,

dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister or shallow crater.

Pink Partial Painful No slough, eschar or undermining

Stage 2

Stage 3

Stage 3- Full thickness skin loss involving damage to, or necrosis of, subcutaneous tissue that may extend down to but not through, underlying fascia.

The ulcer presents clinically as deep crater with or without undermining of adjacent tissue.

Stage 3

Stage 4 Stage IV—Full thickness skin loss with extensive

destruction, tissue necrosis, or damage to muscle, bone or supporting structures (ie. Tendon, joint capsule) Undermining and sinus tracts may be associated w/ stage

IV ulcers

Can differentiate from stage III ulcers because it will go PAST the Fascia

Stage 4Plantar heel: past

subcutaneous level and goes to the calcaneous

bone

Sacrum, eschar, past sub-q tendon exposed

Deep Tissue InjuryPurple or very dark areas that are surrounded by profound redness, edema, or induration suggest that deep tissue damage has already occurred and additional deep tissue loss may occur.

Unstageable

The deepest level of tissue must be visible in order to stage a pressure wound.

Management of Pressure Ulcers

Offload

Nutrition

Dress

Debride

Protect

Group 1 Pressure Relief Group 1 mattress overlays preventative

Qualifications:

1. Completely Immobile

Or2.  Limited mobility

3. Any stage pressure ulcer on the trunk or pelvis.(plus 1 of the below)4. Impaired nutritional status.

5. Fecal or urinary incontinence.

6. Altered sensory perception.

7. Compromised circulatory status.

Group 2 Pressure Relief

Low Air Loss/Alternating Pressure Mattress

Aggressive pressure ulcer treatment

Qualifications:

1 large or multiple stage 3 or 4 pressure ulcer(s) on trunk or pelvis

Or

Recent flap or skin graft for pressure ulcer

Wheelchair Cushion Pressure Relief Cushion covered with Rx for Wheel Chair

Preventative Measure

ROHO

Diabetic Foot Ulcer

Diabetic Facts 7th leading cause of

death in the US 16 million (6% of

population) people in the US have diabetes

Each year: 798,000 new cases of DM diagnosed

15% of all diabetics will develop diabetic foot ulcers

14-20% patients with DFU require amputation

Wagner Staging

Wagner Classification

Grade 0 Pre-ulcerative callus, no

open lesion

Grade 1

Superficial diabetic

Foot ulcer

Grade 2Penetrates to ligament

tendon, bone, joint, fascia

NO Abscess, NO Osteo

Wagner Classification

Grade 4

Gangrene portion of Midfoot

Grade 5

Extensive Gangrene of whole

Foot. ONLY treatable with amputation

Grade 3

Deep UlcerWith Abscess/Osteo

Progression of a diabetic foot ulcer

Foot Deformities

CharcotHammer ToeCallus Formation

Assessment Corns and Calluses Nails: Thickened or Atrophic, Ingrown ,Color of

nail bed, Discharge, Fungal infections Edema: poor fitting shoes, impedes healing Pulses Color & temperature of feet HgbA1c

Goal for HgbA1c of <7

Treatment of DFU

Blood sugar control

Debride

Off Loading

Manage Bacteria

Dress

Re-Vascularize

HBOT(if criteria

met)

Lower Extremity Ulcers

Arterial

Characteristics of Arterial Insufficiency

Intermittent claudication to sharp, unrelenting pain

Diminished or absent pulses

Pallor and coolness

Loss of hair

Tight shiny skin

Thickened nails

Characteristics of Arterial Ulcer

Located in areas of pressure, tips of toes

Very painful

Deep, may involve joint

Usually circular in appearance

Wound base pale to black

Little, if any, edema

Assessment Pain

Intermittent claudication – crampy pain associated with activity

Rest Pain

Pulses

Skin appearance

Skin temperature

Edema

Hair Growth on Toes

ABI’s, Waveforms

Ankle—Brachial Index (ABI) ABI 0.9-1.30 Normal Study

ABI 0.8 - 0.9 moderate PVD

ABI 0.5 - 0.8 claudication

ABI < 0.5 critical ischemia

Always check ABI with LE ulcers

*ABI is not reliable measurement for diabetic patient

Treating Arterial Ulcers

Eliminate Cause

Pain Control

Debridement

Moist Wound Care

HBOT

Medications that May Help Arterial Ulcers

• Vasodilators & Decrease Plaque Formation

ACE Inhibitors—(Lisinopril, Captopril, etc) end in “il”

• Relaxes smooth muscle & vasodilates

Pletal (Cilostazol)

Venous Insufficiency

Venous Insufficiency Characteristic

Achy, cramping pain Pulses present Hyperpigmentation of skin Lots of edema Inverted Champagne Leg

Lipodermatosclerosis—tissues become ´woody´ in texture and the leg narrows near the ankle

Venous Ulcer Characteristics

Irregular Wound Edges Skin scaling Moderate to heavy exudate Partial to full thickness Malleolus region

Management of Venous Disease

Elimination of Edema

Compression

Elevation Debridement Moist Wound Care Skin Care--dermatitis

Non-Healing Surgical Wounds

Surgical Wound Complication

Infection Dehisence

Bug Bite Gone Bad

Treatment of Surgical Wound

Eliminate Cause

sutures

meshinfection

Heal

Debride

Moist Wound Care

Specialist

Advanced Wound Care

Wound Healing ProcessInjur

y

Hemostasis

Inflammation

Proliferation

Maturation

Acute, Healing Wound Young, healthy cells

Plenty of growth factors

Few inflammatory cytokines

Low levels of proteases

Treating Chronic Wounds Prevent & Control Infection

Treat/Eliminate Causative Factors Edema

Varicose veins

Diabetes

Heart disease

Pressure

Malnutrition

Debris/foreign body/necrotic material

First…Listen to Your Patient

Identify Problems Early and Transition to Advanced Wound Care

Good Wound Care

History Assessment Debridement Warm, moist

environment Offloading Topical Care

Advanced Wound Care Growth Factors Bioengineered

Tissue NWPT Hyperbaric Medicine Curative Surgery Cellular Tissue

Products

Holistic Care Treating the Whole patient versus treating the Hole in

the patient

In Addition to Wound Measurements…

Lab Work – CBC, HgbA1C, Albumin

Vascular Testing - Doppler, Angiography, MRA, TCPO2 measures, Arteriogram

Infection Assessment - X-ray, Bone Scan, Tissue Biopsy, MRI

Physical Assessment – Vital Signs, Pain, Weight, Psychological, Community Resources

Chronic, Non-Healing Wounds Prolonged Inflammation

Bacteria

Foreign Body

Repetitive trauma

Necrosis

Lack of growth factors

High cytokine levels & excess concentration of MMPs

Wound Dressings

Protect from contamination

Prevent trauma

Absorbs drainage

Debrides

Provides medication, moist healing environment, etc.

When picking out your dressings, remember the Cardinal Rule:

Keep Moist tissue Moist and Dry tissue Dry!

Topical Wound Management

Considerations Wound: depth, presence of slough, moist, dry, painful,

infection?

Product: conformability, antibacterial activity, pain, ease of use, fluid handling properties

Patient: activity level, continence, mental status, sensitivity to medicated dressings, fragile skin, lifestyle, compliance, caregiver

Cost: unit cost, reimbursement, availability

Clean Granular Wound Base Objectives: Protect & keep moist

Treatments: Hydrocolloid

Hydrogel

Secondary dressing

Vacuum assisted closure (VAC) device

Wet to damp saline (Temporarily)

Clean Deep Wound Crater Objective: Fill the space with uniform

contact Treatments:

Hydrogel Alginate Foam Hydrocolloid Vacuum assisted closure (VAC) device Wet to damp saline (Temporarily)

Slough or Necrotic Wound

Objective: Debride and cleanse Treatments:

Enzymatic debridement: Santyl Collagenase Autolytic debridement: hydrocolloid,

hydrogel dressings Pulse irrigation Wet to damp saline (Temporarily)

High Drainage Wound

Objectives: Absorb and contain Treatments:

Alginate

Foam

Vacuum assisted closure (VAC) device

Wet to damp saline (Temporarily)

Sinus/Tunnel/Underming

Objectives: Prevent pre-mature closure, absorb exudate

Treatments: Loose packing Impregnate gauze with hydrogel Calcium alginate if high drainage Vacuum assisted closure (VAC) device Wet to damp saline (Temporarily)

Infected Wound

Objectives: Decrease local bacterial count

Treatments: Topical antibiotic or antimicrobial Incision & Drainage Culture & Sensitivity Wet to damp saline (Temporarily)

Local Wound Care Hydrocolloid

Hydrogel

Calcium alginate

Foam

Collagenase

Antimicrobials

Growth factors

Cellular or Tissue Products (Formerly known as Biological Skin Substitutes)

Hydrocolloid Indications: Venous ulcers, pressure ulcers,

diabetic ulcers, 1st and 2nd degree burns Absorbency and film dressing

Highly absorbent gel (polyurethane) Oxygen and water vapor permeable

Adhesion and elasticity Bacterial barrier Allows for autolytic debridement Can stay in place for 72 hours

HydrocolloidsPros: Come in all shapes, sizes, and thicknesses

Cons: Must be applied correctly or will roll—choose appropriate size, thickness for location of wound

Hydrogel Indications: Mildly exuding wounds, clean

wounds, partial thickness wounds, pressure, diabetic, surgical

Absorbs 5 times own weight-- can absorb a limited amount of exudate.

Cooling soothing effect Facilitates autolytic debridement Delivered in many forms

Amorphous gel, Sheets, Strands Can stay in place for 24 hours

Hydrogels

Pros: Hydrogel pads are great for burns, can be very soothingHydrogels come in all forms

Cons: Can be difficult to find and can be costly depending on brand

Calcium Alginates Indications: Wounds with large amount of

drainage Derived from brown seaweed Absorbs up to 30 times weight

Will form a gel when comes in contact with exudate

Comes in many forms Sheets, ropes, loose fibers packs

Maintains a moist wound environment Can stay in place 24 to 72 hours

Calcium AlginatesPros: non-adhesive, moldable, absorbent, aids in providing Moist Healing environment

Cons: If wound isn’t wet enough, will stick

Specialty Absorptive

Highly absorptive fiber layers such as cellulose, cotton or rayon

Pros: Non-adherent, easy to use, absorbentCons: May be costly

Foam Indications: Highly exudative wound requiring

a non-stick surface (e.g. venous stasis) Highly absorbent (20 times weight)

Non-adherent wound contact layer, hydrocellular foam, waterproof outer layer

Can be formed Cavity, heel, sacral, trach etc.

Allows for autolytic debridement and gaseous exchange

Can be left in place for 72 to 96 hours

FoamsPros: Lots to choose from, provides moist environment, effective with hypergranulationCons: Can be expensive if exudate requires daily changes

Collagenase Santyl Indications: A wound requiring debridement of fibrinous

exudate, other necrotic material or slough

Debrides necrotic tissue without harming good tissue

Apply once daily

Not recommended for use with Silver products

Antimicrobials Indications: Infected wounds

Bacterial count greater than 10 5 --decreases wound healing rates Bacterial proteases degrade growth factors

Topical Silver products Acticoat

Silvercell

Silvasorb gel

Iodoflex/Iodosorb gel sustained release of iodine and the desloughing action is

provided by the unique cadexomer matrix

Growth FactorsIndication: Diabetic foot ulcer

Activates endothelial cells and fibroblasts

Stimulates vascular proliferation, migration, new blood vessel formation

People who use 3 or more tubes of REGRANEX® Gel may have an increased risk from cancer.

Can be very effective

Have a new “360” program to help patients obtain medication and monitor progress.

CollagenOxidized Regenerated Cellulose

(ORC)  Indicated in Stalled Wounds

ORC inactivates MMPs and Elastace

Damaged

tissue

Cytokines

Excess proteas

es

Cellular or Tissue Products (CTP)

So many, so little time

Apligraf

Dermagraf

Oasis

Graft Jacket

Primatrix

Integra

And so many more….

Compression & Collagen

VSU Day 1

Prisma

Silver Foam

3 layer Compression

4 weeksHas decreased more than half in wound

surface area

Continue same care

7 weeksResurfaced

Measured for Compression Stockings

CTP Oasis

Day of application

VSU

2 Days post AppNote the carmelization

4 weeks post initial App

2 wks s/p 2nd Oasis Application

What is this?

Stasis Dermatitis

What type of wound?

Arterial

What is the Stage?

Stage 1, 5th right sub-met head

Stage 1 pressure

When to Refer No change in size or depth for 2 weeks

Increase in size

Vascular Changes

Necrosis

Infection

Edema

Dehiscence

Foreign Body

Repetitive trauma

Wounds to Refer to Wound Center for Evaluation

Diabetic Ulcers

Pressure Ulcers

Venous Stasis Ulcers

Osteomyelitis

Vascular Insufficiency Ulcers

Delayed Radiation Injury

Burns, Bites and other complex or problem healing wounds

Hyperbarics

What Is It? Hyperbaric Oxygen Therapy (HBOT) is breathing 100%

oxygen while the entire body is pressurized to a point greater than sea level

This is usually 2 to 2.4 absolute atmospheres (the equivalent of the pressure exerted by a 33-45 foot dive into sea water)

Monoplace Chambers

Multiplace Hyperbaric Chamber

Compression of bubbles Increases Partial Pressures of Oxygen

Hyperoxygenation (O2 carried via plasma)

Vasoconstriction (Reduces Edema) Angiogenesis (Increases rate) Antimicrobial (aerobic/anaerobic)

2 Mechanisms of Action

Effects of HBOT on Wound Healing

Oxygen levels remain high in arterial blood - 2 minutes

muscle - 3 hours

subcutaneous tissues - 4 hours

At tissue PO2 of 30mm Hg: leukocytes kill bacteria

fibroblast growth begins

collagen is laid down

Typical Treatment Protocol 100% Oxygen at 2-2.5 ATA

90 Minutes

5/days a week

Re-Evaluate every 20 treatments

Up to 60 treatments depending on indication

UHMS Indications for HBOT1. Air or Gas Embolism2.    Carbon Monoxide Poisoning       Carbon Monoxide Poisoning Complicated By Cyanide Poisoning3.    Clostridial Myositis and Myonecrosis (Gas Gangrene)4.    Crush Injury, Compartment Syndrome and Other Acute

Traumatic Ischemias5.    Decompression Sickness6.    Arterial Insufficiencies:             Central Retinal Artery Occlusion            Enhancement of Healing In Selected Problem Wounds7.    Severe Anemia8.    Intracranial Abscess9.    Necrotizing Soft Tissue Infections10.  Osteomyelitis (Refractory)11.  Delayed Radiation Injury (Soft Tissue and Bony Necrosis)12.  Compromised Grafts and Flaps13.  Acute Thermal Burn Injury 14.  Idiopathic Sudden Sensorineural  Hearing

Adjunctive HBOT and Problem Wounds

HBOT is only one component of a comprehensive wound healing program

Non-healing wounds are evaluated to determine underlying conditions which might interfere with healing

More conservative measures should be tried first

What We Will Cover Today Radionecrosis

Failing Graft/Flap

Gas Gangrene

Refractory Osteomyelitis

Diabetic Foot Ulcer

Arterial Insuffiency

Radionecrosis Vascular Changes from Radiation

Edema

Medial thickening (progressively depletes the blood supply to the irradiated tissue)

Collagen deposition may also cause severe scarring and further blood vessel obliteration, resulting in tissue hypoxia and necrosis

Effects of Ionizing Radiation on the Cell Rapid cell death with heavy doses

DNA Synthesis impaired, mitosis delayed

Soft Tissue Radionecrosis

Radionecrosis from treatment for Cancer of Laranyx 05/02/02

Same neck, 07/09/02after 40 hyperbaric treatments

Failing Flap Long-term survival of skin grafts and flaps depend on

angiogenesis

When the wound bed does not have enough oxygen supplied the graft may partially fail

HBO2 can help by assisting in the preparation and salvage of skin grafts and compromised flaps

Gas gangrene infection Clostridium bacteria

High amounts of oxygen can inhibit the replication, migration, and production of endotoxin

Advantages of using HBO as adjunct to for gas gangrene: life-saving because exotoxin production is rapidly halted

limb and tissue-saving

preventing limb amputation that might otherwise be necessary.

Refractory Osteomyelitis

Augments the efficacy of certain antibiotics Aminoglycosides

Vancomycin

Quinolones and certain sulfonamides

Provides adequate oxygen for fibroblast activity—cells that provide healing in hypoxic tissue

Decreases inflammation

Diabetic Foot Ulcer Wagner Grade 3

Used in conjunction with standard wound care, offloading

Improved results compared to routine wound care

Arterial Insufficiency

Tissue Hypoperfusio

nHypoxia Infection

Arterial Insufficiency

Left Lower Extremity Ulcer, before and after 40 treatments

References http://www.npuap.org/resources/educational-and-clinical

-resources/pressure-ulcer-categorystaging-illustrations/

http://www.as.miami.edu/chemistry/2008-1-MDC/2085/Chap4_New/chap4.htm

http://www.webmd.com/diabetes/guide/glycated-hemoglobin-test-hba1c

http://sydney.edu.au/medicine/diabetes/foot/Pvdx1.html

http://www.webmd.com/dvt/d-dimer-test-for-deep-vein-thrombosis

http://rarediseases.info.nih.gov/gard/9671/lipodermatosclerosis/resources/1

References Continued http://

membership.uhms.org/default.asp?page=indications

http://aawconline.org/

http://www.wocn.org/

http://www.nawccb.org/default.asp

http://mkt.medline.com/clinical-blog/channels/clinical-solutions/understanding-the-role-of-outpatient-wound-centers/

http://www.medscape.com/viewarticle/566133_8

References Continued

http://www.bayareahyperbarics.com/files/UHMS-lay-language.pdf

http://www.surgerysupplements.com/hydrocolloid-wound-dressings-reduce-incision-healing-time/

https://woundcare-today.com/categories-pyramid/hydrogel-dressings

Thank You for Your Time!

Thank You!

Questions?