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Olympia Talk

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For more information visit www.aronowitzmd.com

For more information visit www.aronowitzmd.com

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  • V.A.C. ® ATS System - PN M8259968 T.R.A.C.™ Disposables Ambulatory or Non-ambulatory Moderately to heavy exudating wounds (>15 cc s/day) Multiple wounds V.A.C. ® System - PN M8259924 V.A.C. ® Disposables Non-ambulatory Moderately to heavy exudating wounds (>15 cc s/day) Multiple wounds V.A.C. ® Freedom™ System - PN 320000 T.R.A.C.™ Disposables Ambulatory Moderately to heavy exudating wounds (>15 cc s/day) Multiple wounds Source: V.A.C. Therapy Clinical Guidelines, A Reference Source for Clinicians, June 2003, p.8. miniV.A.C. ® System - PN M8259936 T.R.A.C.™ Disposables Ambulatory Minimally exudating wounds (<15 cc s/day) Single wound
  • Transcript

    • 1. Wound Management; A multidisciplinary approach with continuity Joel Aronowitz, MD Natalya Stepansky, PA-C Olympia Wound Care and Hyperbaric Treatment Center
    • 2. Chronic Wounds; An Age Old Problem “ Miracle of the black leg” performed by Saints Cosmas and Damian 1462 A.D.
    • 3. “ Chronic Wounds”
      • Wounds that do not heal within three months are considered chronic (Mustoe, 2005)
      • Wounds cause patients severe emotional and physical stress, a significant financial burden on patients and the whole healthcare system (Augustin and Maier, 2003)
      • Mustoe T. 2004. The American Journal of Surgery
      • Augustin M and Maier K. 2003. Dermatology and Psych
    • 4. Wounds 2007 in US: Bottom line…
      • $16+ Billion spent annually on Wound care (enough to rescue GM, Ford, Chrysler and still have coffee money!
      • 6 million Americans suffer from Chronic wounds
      • Nearly 3 million diabetic wounds
      • 2.5 million from venous stasis ulcers
      • 1.1 to 1.8 Million NEW wound cases each year
      • 82,000 LE amputations each year
      • Diabetes = 11 mil pts: 165% growth by 2050
      • Age 65+ pts = 34 mil pts: 138% growth by 2050
      • (CDC, National facts sheet 2005)
    • 5. Wounds 2006: Bottom line
      • “ Woundcare” is considered main stream medicine
      • Therefore, woundcare treatments are covered by Medicare, HMOs, W/C, and most other payers.
      • “ Wound Care Center” is the 2 nd fastest growing medical service, next to “Out-patient surgery centers”
      • WCC is now part of most hospital service portfolio, along with Cancer center, Heart center, Surgry center and ERs.
    • 6. Chronic Wound: Epidemiology in the U.S.
      • 2002 CDC Data
      • 100,000 Ulcer
      • 93,000 PAD
      • 58,000 Neuropathy
      • CDC Hospitalization Data 2002 data (www.cdc.gov)
    • 7. Hospital Discharge Rates for per 1,000 Diabetic Population
      • PAD: 3.6
      • ULCER: 6.2
      • Neuropathy 5.7
      • (Per 1000 DM pts)
      • Essentially unchanged for 20 years, despite the advance in woundcare
      • CDC Hospitalization Data 2002 data (www.cdc.gov)
    • 8. Obesity in the U.S.
      • Two Thirds of Adults in the US is either Over-weight or Obese today.
      • At this rate, The U.S. Adults are projected to be near
      • “ 100% Obese” by
      • the year 2040.
      • (Flegal et al. JAMA 2002)
    • 9. Severe Burn Wounds
      • 78yo female
      • Fell & Stuck in hot shower
      • “ Not much Pain…”
      • 3 rd degree burn, both feet and legs
      • “ Pseudo Eschar” present
      • Tx: Serial Debridement, VAC and HBO
    • 10. “ Open Tib-Fib Fracture” Wound with Chronic Osteomyelitis
      • 82yo male
      • MVA  Open Ankle Fx
      • “ 9 separate surgeries”
      • Tx:
      • Serial Debridement, Compression dressing, VAC and HBO
    • 11. Diabetic (Neuropathic) Foot Ulcers
    • 12. 5 DM patients with Gangrene & Palpable foot pulses.
      • Arteriogram  Occlusion of all three infrapopliteal arteries.
      • “ We recommend that arteriography be performed routinely if gangrene is present… irrespective of pedal pulse status.”
      • (Andros et a. Arch Surg. 1984 Nov;119(11):1260-3.)
    • 13. Chronic Sacral Pressure Ulcer -- Undermining eliminated with VAC therapy
    • 14. KO – S/P Radiation  Abscess
      • Breast CA
      • Radiation!
      • Mastectomy 
      • Breast Implant 
      • Infection
      • Abscess  I&D
      •  Gaping wound
    • 15. Hydradenitis Suppurativa of Breasts
    • 16. Post Op; debride, breast reduction
    • 17. MRSA; A Necrotizing Infection
      • 51 year old woman with local necrotizing infection of medial thigh from MRSA abscess, no risk factors.
    • 18. Necrotizing fasciitis
      • Local Features;
        • Increased Pain over an Area of Skin Changes
        • Brawny, wooden edema extending beyond area of erthyema
        • Absence of lymphangitis
      • Systemic Features;
        • High Fever
        • Tachycardia
        • Stable BP
        • Normal Mental Status
    • 19. Wound Classifications
      • Partial and Full Thickness Wound Classification
        • Superficial  Partial Thickness  Full Thickness
      • National Pressure Ulcer Advisory Panel (NPUAP)
      • Pressure Ulcer Classification
        • Stage 1 thru Stage 4, by Depth
      • Wagner Classification of DM foot ulcers (0-1)
        • Widely used, OLD and Most data available
      • UT San Antonio Classification of DM foot ulcers
        • Most Logical and comprehensive.
        • By Depth, and/or Infections, and/or Ischemia.
        • Grade 0-4 x Stage A-D (16 categories)
    • 20. Wound Staging: NPUAP classification
      • Stage 1 : 
      • Erythema ( Non-blanchable), Intact Skin
      • Stage 2 : 
      • Partial Thickness skin ulcer
    • 21. Wound Staging
      • Stage 3 :
      • Full Thickness skin loss
      • Sub-Cutaneus Layer ( Fat and Fascia)
      • Stage 4 : 
      • Bone Exposed (+ Muscle and Tendons)
      • Osteomyelitis (Bone Infections) Probable.
      • Antibiotics and/or Surgery indicated
    • 22. Chronic Wound Types
      • Surgical (Abdomen, Orthopedic)
      • Pressure (Sacrum, Heel, Troch)
      • Burn (Hands and Feet)
      • Lower Extremity Wounds
        • Venous
        • Arterial (Ischemic)
        • Pressure
        • Diabetic
    • 23. 4 Types of Lower Extremity Ulcerations
      • Venous Ulcers:
      • Caused by incompetent venous system.
      • Arterial Ulcers:
      • Caused by narrowing/blockage of leg arteries.
      • Pressure Ulcers:
      • Also called “Decubitus ulcers”
      • Caused by Pressure from bed = Local tissue ischemia
      • Diabetic Ulcers:
      • Very Difficult to Manage;
      • Neuropathy + Ischemia + Immune dysfunction
    • 24. (1) Venous Ulcer ( 2 ) Arterial Ulcer ( 3 ) Pressure Ulcer ( 4 ) DM foot Ulcer
    • 25. WOUND CARE are we up to date?
    • 26. Compression Therapy; Graduated (Stronger at the ankle)
      • Unna “boots” = Gauze with Zinc Oxide paste
      • Multi-layer Compression bandage
      • Compression Stockings (Tighter the better)
    • 27. V.A.C. ® Therapy Systems V.A.C. System ATS V.A.C. System Freedom Source: V.A.C. ® Therapy Clinical Guidelines, p.8 Slide 28, Rev 06/04 Courtesy of KCI, San Antonio, TX 06/04
    • 28. “ Vascular Surgery Consult S/P revascularization
      • BEFORE AFTER
    • 29. “ IN GOD WE TRUST… ALL OTHERS MUST SHOW DATA”
      • Evidence-Based Medicine (EBM)  
      • EBM is the GOLD STANDARD today for clinical practice and treatment guidelines --   The Oxford Centre for EBM
    • 30. Sources: Mintel Group; National Center for Health Statistics Obesity in the U.S.
    • 31. Obesity and Diabetes in the US. 1991  2001 (Mokdad et al. JAMA 2003)
    • 32. DM Statistics in the U.S.
      • Estimated 18 million DM pts today
      • Diagnosed 13 million
      • Undiagnosed 5.2 million
      • 6.3% of Americans
      • (CDC survey 2004)
    • 33. Life Shortening Effect of DM = 13 years. (Manuel et al. Diacare 2004)
    • 34. We keep up with wound care, reconstructive surgery and hyperbaric medicine… So you don’t have to…
    • 35.  
    • 36. A Comprehensive Approach
      • “ Wounds are found at the intersection of all health, illness, and aging.”
      • FOR EXAMPLE…
    • 37.  
    • 38.  
    • 39. BEFORE AFTER 3mo F/U
    • 40. Severe Burn Wounds
      • 78yo female
      • Fell & Stuck in hot shower
      • “ Not much Pain…”
      • 3 rd degree burn, both feet and legs
      • “ Pseudo Eschar” present
      • Tx: Serial Debridement, VAC and HBO
    • 41. Initial Presentation
    • 42. B/L Anterior Legs Lacerations + Burn wounds
    • 43. HBOT + Surgical Debridements
    • 44. Week 1 -- Topical Papain/Urea for escharectomy
    • 45. Week 2 – VAC Started on R foot
    • 46. Week 3 – VAC continued on R foot
    • 47. Week 4 – d/c VAC, Silver Alginate + Collagen ORC
    • 48. Week 1  1 Month Later
    • 49. First Visit 1 month Later w/ VAC+HBO
    • 50. 2 Month Later
    • 51. HEALED 3 month Later
    • 52. First Visit HEALED
    • 53. Reconstructive Surgery Complications
      • 35yo female
      • Breast Reconstruction
      •  Breast necrosis
      •  Lattisimus Free flap for reconstruction
      •  Dehiscence
      • Tx: Serial Debridement, VAC and HBO
    • 54. Left Breast Dehiscence  Treated with VAC + HBO
    • 55.  
    • 56. Upperback dehiscence  Treated with VAC + HBO
    • 57.  
    • 58.  
    • 59. BEFORE and AFTER
    • 60. Surgical Wound on DM + ESRD
      • 70yo Male
      • DM Type 2
      • Poor BG control
      • Left BKA, Toe Amp
      • On Hemodialysis
      • S/P 5 th Met head amp
      • for Osteomyelitis
    • 61. Wound VAC, HBO Started
    • 62. Followed up in my office, Once a week
    • 63. Continue to Improve in Depth & Size
    • 64.  
    • 65.  
    • 66.  
    • 67. OR: Debridement + Primary Closure
    • 68. 1 wk Post-op
    • 69. Comprehensive Wound Care at Olympia Medical Center
      • Admission diagnosis and referral
      • Accurate documentation, outcomes tracking
      • Inpatient surgical, non surgical treatment
      • Advanced reconstructive surgery
      • Outpatient follow-up in Wound Care Clinic
      • Convalescent follow-up
      • Team approach
    • 70. THANK YOU!