Francis Derk1, Troy Wilde2,
Tim Pham2, Mike Griffiths3
1South Texas VA Medical Center (San Antonio, United States)
2UTHSC ...
To develop a structured and detailed evidence based
wound conversion algorithm, incorporating advanced
present day wound t...
The authors conducted evidence based research
analysis using various treatment approaches, including
all available wound m...
>1.30 Poorly compressible vessels,
arterial calcification
0.90–1.30 Normal
0.60–0.89 Mild arterial obstruction
0.40–0.59 M...
In clinical practice within a large wound care center, the
algorithm has validated and has been found to be
especially use...
Wounds
Stage C
Location
GRADE 1
Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals
TWO2
Of...
Wound
Stage C
Location
GRADE 2
Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals TWO2
Off...
Wound
Stage C
Location
GRADE 3 Stage BStage A Stage D
Size
Assessment
of edema
Nutritional
Status
PMH
Biologicals
TWO2
Off...
The authors propose a holistic Wound Conversion Algorithm as a
retrograde, step-wise therapeutic intervention guide for wo...
1. Armstrong, David, and Et Al. "Quality of Life in Healing Diabetic Wounds Does the End Justify the Means?" THE JOURNAL O...
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EWMA 2013 - Ep543 - Evidence based wound conversation algorithm utilizing the University of Texas wounds and classification system

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Francis Derk1, Troy Wilde2,
Tim Pham2, Mike Griffiths3
1South Texas VA Medical Center (San Antonio, United States)
2UTHSC (San Antonio, United States)
3AOTI (Oceanside, United States)

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EWMA 2013 - Ep543 - Evidence based wound conversation algorithm utilizing the University of Texas wounds and classification system

  1. 1. Francis Derk1, Troy Wilde2, Tim Pham2, Mike Griffiths3 1South Texas VA Medical Center (San Antonio, United States) 2UTHSC (San Antonio, United States) 3AOTI (Oceanside, United States)
  2. 2. To develop a structured and detailed evidence based wound conversion algorithm, incorporating advanced present day wound therapies & utilizing the University of Texas Wound classification system as its matrix. The algorithm is evidenced based and formulates a singular or multi modal approach from simple to highly complex phases. The algorithm is intended to provide the clinician with a retrograde methodology, intended to drive the wound to healing by converting higher grade wounds to lesser grade levels and finally to full healing.
  3. 3. The authors conducted evidence based research analysis using various treatment approaches, including all available wound modalities; evidence based analysis, and numerous clinical applications with established wound protocols, single and or multi modal processes, wound treatments and outcomes. The University of Texas Wound Classification system serves as the framework, along with standardized definitions of infection, laboratory test limits, and ischemia parameters.
  4. 4. >1.30 Poorly compressible vessels, arterial calcification 0.90–1.30 Normal 0.60–0.89 Mild arterial obstruction 0.40–0.59 Moderate obstruction <0.40 Severe obstruction Classic signs: Inflammation (erythema, warmth, tenderness, ain or induration purulent secretions Presence of systemic findings of infection (fever, chills, night sweat, nausea, vomiting, malaise) Secondary signs: Non-purulent secretions, friable or discolored granulation tissue, undermining of wound edges, foul odor) Stages Stage A: No infection or ischemia Stage B: Infection present Stage C: Ischemia present Stage D: Infection and ischemia present Grading Grade 0: Epithelialized wound Grade 1: Superficial wound Grade 2: Penetrates to tendon or capsule Grade 3: Penetrates to bone or joint UTHSCA WOUND CLASSIFICATION SYSTEM ERYTHROCYTE SEDIMENTATION RATE (ESR) TEST Westergren NORMAL VALUE Child 0-10 mm/hour Adult (male) 0-15 mm/hour Adult (female 0-20 mm/hour Adult 4.5-11.0 Neutrophils Bands 3-5% (total WBC count) Segs 54-62% Lymphocytes 25-33% Monocytes 3-7% Eosinophils 1-3% Basophils 0-0.75% Leukocyte (WBC) Normal Values Ischemia, PVD and PAD: Defined by ABI/NIV studies, ultrasound, clinical wound assessment including necrosis, eschar, gangrene, lack of lower extremity and pedal pulses, findings consisting of pallor, cyanosis, lack of digital hair growth, and advanced studies including MRA and Angiography. Definitions Ankle-brachial Index (ABI) Interpretation Infected wound: per infectious disease guidelines the presence of infection is defined by ≥ 2 classic findings of inflammation or purulence
  5. 5. In clinical practice within a large wound care center, the algorithm has validated and has been found to be especially useful when treating higher grade wounds which may require surgical intervention, a multi- disciplinary team approach, wound staging, and advanced adjunctive therapies. We found that classifying a wound, determining etiology, and taking a holistic approach that progressed the wound from more severe to less severe grades resulted in better outcomes.
  6. 6. Wounds Stage C Location GRADE 1 Stage BStage A Stage D Size Assessment of edema Nutritional Status PMH Biologicals TWO2 Offloading Wound Debridement Wound Bed preparation Topicals Daily wound care Monitor decrease in size Wound Conversion to lesser grade Montior WBC, CRP, Sed Rate X-rayC&S Surgery/debridement Eliminate Infection Consider Infectious Disease consult prn Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA No Vascular Intervention Vascular intervention TWO2 Build Wound Matrix Wound Conversion Montior WBC, CRP, Sed Rate C&S X-rays Eliminate Infection Antibiosis Surgical Debridement TWO2 Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA Wound Conversion Depth Wound base Granular/Non-granular Non-Granular / FibrousGranular Conversion to Granular Wound Bed Denotes Multi-modality Therapy: prn TWO2 (2) (10, 17, 19) (10, 17, 19) (13, 19) (12, 18) (1,10, 19) (12, 18) (5, 9) (3, 5) (8) (10, 17, 19) (5, 16) (6, 19) (6, 19) (12,18) (10, 11, 13, 17, 19) (5, 9) (3,5) (8) (10, 17, 19) (12,18) (6, 19) (6, 19) Evidence Based Wound Conversion Algorithm for University of Texas Grade 1 Wounds and Classification System Infected Ischemic Infected / IschemicNo Infection or Ischemia (11,15) (11,15) TWO2 Topical Wound Oxygen
  7. 7. Wound Stage C Location GRADE 2 Stage BStage A Stage D Size Assessment of edema Nutritional Status PMH Biologicals TWO2 Offloading Wound Matrix Assessment Wound Bed preparation Topicals Monitor decrease in size and depth Wound Conversion to Grade 1 Montior WBC, CRP, Sed Rate X-raysC&S Surgery/debridement Eliminate Infection ID Consult Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA No Vascular Intervention Vascular intervention TWO2 Build Wound Matrix Wound debridement Montior WBC, CRP, Sed Rate C&S X-rays Eliminate Infection Antibiosis Surgical Intervention TWO2 Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA Depth Granular Bed Tendon / Capsule Exposure Negative Pressure Build Wound Matrix Multi-modal Therapy Cam Boot TCC MRI Serial Films Monitor Labs Monitor wound Monitor C&S Manage necrotic / escharotic tissue prn Monitor granulation tissue Consider Negative Pressure adjunct Ascertain elimination of Infection Vascular intervention or Non-intervention Continue TWO2 Wound base Granular/Non-granular Denotes Multi-modality Therapy: prn MRI Negative Pressure Monitor wound Build wound matrix TWO2 (2) (10, 11, 19) (13, 19) (10, 17, 19) (12, 18) (12, 18) (12, 18) (12, 18) (4, 19) (4, 19) (4, 19) (10, 11, 13, 17, 19) (1)(10, 11, 17, 19) (5, 9) (3, 5) (8) (10, 17, 19) (5, 16) (10, 11, 13, 17, 19) (10, 11, 13, 17, 19) (10, 17, 19) (6, 19) (6, 19) (6, 19) (10, 17, 19) (3, 5) (8) (5, 9) Infected / IschemicNo Infection or Ischemia Infected Ischemic (11,15) (11,15) TWO2 Topical Wound Oxygen Evidence Based Wound Conversion Algorithm for University of Texas Grade 2 Wounds and Classification System
  8. 8. Wound Stage C Location GRADE 3 Stage BStage A Stage D Size Assessment of edema Nutritional Status PMH Biologicals TWO2 Offloading Wound Matrix Assessment Wound Bed preparation Topicals Monitor decrease in size and depth Wound Conversion to lesser grade/lesser depth Monitor WBC, CRP, Sed Rate X-raysC&S Surgery/debridement Eliminate Infection ID Consult prn Vascular Assessment NIVs/ABIs Transcutaneous O2 Angiogram/MRA Vascular intervention TWO2 Build Wound Matrix Wound debridement Montior WBC, CRP, Sed Rate C&S X-rays Eliminate Infection Antibiosis Surgical /Vascular Intervention TWO2 NIVs/ABIs Transcutaneous O2 Angiogram/MRA Depth Granular Wound Base Negative Pressure Build Wound Matrix Multi-modal Therapy Cam Boot /TCC MRI Serial Films Monitor Labs Monitor wound Manage necrotic /escharotic tissue Monitor granulation tissue Consider Negative Pressure adjunct Limb Salvage Amputation prn Fibrous Tissue Surgery/debridement prn TWO2 Wound Conversion to lesser grade Amputation TWO2 HBO2 May not be a Candidate HBO2 May Stage for further Surgery Continue with TWO2 Wound base Granular/Non-granular Bone (2) (10, 11, 19) (10, 11, 19) (10, 17, 19) (10, 17, 19) (10, 17, 19) (12, 18) (12, 18) (12, 18) (12, 18) (10, 11, 19) (4, 19) (4, 19) (10, 17, 19) (12, 18) (13, 19) (10, 11, 17, 19) (1) (5, 9) (3, 5) (3, 5)(8) (8) (5, 9) (5, 16) (6, 10) (6, 19) (7, 14) (7, 14) (6, 19) (6, 19) (6, 19) Denotes Multi-modality Therapy: prn No Infection or Ischemia Infected Ischemic Infected / Ischemic (11,15) (11,15) TWO2 Topical Wound Oxygen Evidence Based Wound Conversion Algorithm for University of Texas Grade 3 Wounds and Classification System
  9. 9. The authors propose a holistic Wound Conversion Algorithm as a retrograde, step-wise therapeutic intervention guide for wound healing, that has been validated in daily clinical practice in a busy wound care center. The wound conversion algorithm utilizes a blended approach of evidenced based modality use, advanced wound therapies, and practical field application which have yielded positive results. Future publication encompassing clinical based outcome evidence utilizing the algorithm will be forthcoming. The authors fully expect modification of this algorithm with future advances with modalities in wound care, but propose a useful tool in wound care at the present.
  10. 10. 1. Armstrong, David, and Et Al. "Quality of Life in Healing Diabetic Wounds Does the End Justify the Means?" THE JOURNAL OF FOOT & ANKLE SURGERY (2008): 278- 82. Web. 2. Arnold, Meghan, and Adrian Barbul. "Nutrition and Wound Healing." Plastic and Reconstructive Surgery 117.7s (2006): 42-56. 3. Bernard, Louis, Ilker Uçkay, Albert Vuagnat, Mathieu Assal, Richard Stern, Peter Rohner, and Pierre Hoffmeyer. "Two Consecutive Deep Sinus Tract Cultures Predict the Pathogen of Osteomyelitis☆." International Journal of Infectious Diseases (2009): n. pag. Print. 4. Birke-Sorensen, H., M. Malmsjo, P. Rome, and Et Al. "Evidence-based Recommendations for Negative Pressure Wound Therapy: Treatment Variables (pressure Levels, Wound Filler and Contact Layer) – Steps towards an International Consensus." Journal of Plastic, Reconstructive & Aesthetic Surgery 64 (2011): S1-S16. Print. 5. Crouzet, J., and L.p Lavigne. "Diabetic Foot Infection: A Critical Review of Recent Randomized Clinical Trials on." International Journal of Infectious Diseases 15 (2011): 601-10. Print 6. Datillo, Phillip. "Critical Limb Ischemia: Endovascular Strategies for Limb Salvage." Progress in Cardiovascular Diseases 54 (2011): 47-60. Print. 7. Duzgun, A., H. Satir, O. Ozozan, B. Saylam, B. Kulah, and F. Coskun. "Effect of Hyperbaric Oxygen Therapy on Healing of Diabetic Foot Ulcers." The Journal of Foot and Ankle Surgery 47.6 (2008): 515-19. Print. 8. Elgazzar, Abdelhamid H., Hussein M. Abdel-Dayem, James D. Clark, and Harry R. Maxon. "Multimodality Imaging of Osteomyelitis." European Journal of Nuclear Medicine 22.9 (1995): 1043-063. Print. 9. Fleischer, Adam E., James S. Wrobel, Andrea Leonards, Scott Berg, Daniel P. Evans, Robert L. Baron, and David G. Armstrong. "Post-treatment Leukocytosis Predicts an Unfavorable Clinical Response in Patients with Moderate to Severe Diabetic Foot Infections." The Journal of Foot and Ankle Surgery 50.5 (2011): 541-46. Print. 10. Frykberg, Robert G. "The Science Of Advanced Wound Care: What Should You Be Using In Your Office?" Superbones West Conference. Las Vegas. 24 Oct. 2010. Lecture. 11. Goldman, Robert, and Et Al. "More than One Way to Measure a Wound: An Overview of Tools and Techniques." ADV SKIN WOUND CARE 15 (2002): 236-45. 12. Gordillo, Gayle M., Sashwati Roy, Savita Khanna, Richard Schlanger, Sorabh Khandelwal, Gary Phillips, and Chandan K. Sen. "Topical Oxygen Therapy Induces Vascular Endothelial Growth Factor Expression And Improves Closure Of Clinically Presented Chronic Wounds." Clinical and Experimental Pharmacology and Physiology 35.8 (2008): 957-64. 13. Jones, I., L. Currie, and R. Martin. "A Guide to Biological Skin Substitutes." British Journal of Plastic Surgery 55.3 (2002): 185-93. Print. 14. Kalani, Majid. "Hyperbaric Oxygen (HBO) Therapy in Treatment of Diabetic Foot Ulcers." Journal of Diabetes and Its Complications 16 (2002): 153-58. Print. 15. Lavery, Lawrence, and Et Al. "Classification of Diabetic Foot Wounds." THE JOURNAL OF FOOT AND ANKLE SURGERY 35.6 (1996): 528-31. 16. Lipsky, Benjamin, Anthony Berendt, and Et Al. "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections." Clinical Infectious Diseases 54.12 (2012): 132-73. 17. Nusbaum, Aron G. "Effective Method to Remove Wound Bacteria: Comparison of Various." Journal of Surgical Research 176 (2012): 701-07. Print. 18. Orsted HL, Poulson R, and the Advisory Group. Evidence-based practice standards for the use of topical pressurised oxygen therapy. Int Wound J 2012; doi: 10.1111/j.1742-481X.2012.00956. 19. Rogers, Lee C. “Key Concepts From The 2010 Consensus Statement On Diabetic Foot Ulcerations.” Superbones West Conference, Las Vegas, 24 Oct 2010: Lecture 20. Armstrong, David G, Lavery, Lawrence A, Harkless, Lawrence B. “Validation of a Diabetic Wound Classification System.” Diabetes Care 21 (1998): 855-859. 21. Tahir, Khan, Farooqui, Falahat, Niazi, Khusrow. “Critical Review of the Ankle Brachial Index.” Current Cardiology Reviews 2008: 101-106 References:
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