4 categories are largely a division of convenience: Treatment algorithms, reimbursement, research/literature, and statistical data are organized accordingly.
3er Curso Latino Americano de Cicatrización Avanzada en Heridas (II)
3 ER CURSO LATINO AMERICANO DECICATRIZACIÓN AVANZADA EN HERIDAS
WOUND DIAGNOSIS ANDTREATMENT BY ETIOLOGYARTERIAL, VENOUS, NEUROPATHIC/DIABETIC Tammy Luttrell MSPT, PhD, CWS , FACCWS Profesora Adjunto Colorado Univerisity, Anschutz Medical Campus National Jewish Health
WOUND HEALING PHASES• Acute wounds heal by predictable and timely course of events • Hemostasis • Inflammation • Proliferation • Granulation • Epithelialization • Remodeling
CHRONIC WOUNDS“those wounds that fail to progress through a normal, orderly, and timely sequence of repair or wounds that pass through the repair process without restoring anatomic and functional results” Lazarus, GS, et al. (1994) Definitions and guidelines for assessment for wounds and evaluation of healing. Arch of Derm. 130, 489-493.
CHRONIC WOUNDS• Characteristics • Necrotic tissue • Bioburden • Chronic inflammation • Impaired hemodynamics • Senescent fibroblasts and keratinocytes • Chronic wound fluid with growth inhibiting proteases • Overgrowth of epithelium with lack of underlying connective tissue => rolled edges
DIAGNOSING WOUNDS• By tissue involvement (to determine local care) • Superficial • Partial thickness • Full thickness• By etiology (to determine systemic care) • Arterial • Venous insufficiency • Neuropathic • Pressure • Atypical
ARTERIAL WOUNDS• Caused by ischemia• Usually located at the peripheral extremities• Caused by macro- or microvascular disease • Macro – obstruction of the larger named arteries by PVD, embolus, thrombus, trauma • Micro – disease of the small unnamed arterioles and capillaries, usually with diabetes or small emboli after some type of vascular surgery
PERIPHERAL VASCULAR DISEASE• Arteriosclerosis • abnormal thickening and hardening of the artery walls • Smooth muscle cells and collagen fibers migrate into the inner arterial wall and cause it to harden• Atherosclerosis • Arteriosclerosis in which fat and fibrin deposit on the inner walls of the arteries • Begins with a fatty streak and then becomes a fibrous plaque
ARTERIOSCLEROSISTHICKENING OF THE ARTERIAL WALLS
ATHEROSCLEROSISCHOLESTEROL/FAT DEPOSITS – SITE OF MICROINFLAMMATION
PVD – CRITICAL PHASES1. Collateral circulation insufficient for metabolic needs => shunting of blood to muscles where there is less resistance => delayed healing of traumatic wounds2. Claudication - pain with activity – most effectively treated with exercise a. thigh and buttock claudication = aortoiliac or iliac involvement b. calf claudication = femoral or popliteal involvement3. Rest pain – requires revascularization surgery • May have “dependent leg syndrome” • May be accompanied by signs of ischemia at distal digits
MICROVASCULAR DISEASE• Occlusion of the small arteries too small to be named (<0.5mm)• Most frequently seen in patients with diabetes• Cannot be treated with vascular surgery• May result in non-healing wounds even after revascularization
ARTERIAL WOUNDS• Evaluation • Pulses • Capillary refill time • Rubor of dependency • Skin appearance – shiny, thin, pale, NO hair growth • Condition of nails and hair • Location – distal toes or fingers • Edges – even, punched out appearance • Tissue – dry, necrotic, little or no granulation
ARTERIAL SCREENING• Pulses • Grading • Upper extremity • 0 = no pulse • Brachial • 1+ = barely felt • Radial • 2+ = diminished • Ulnar • 3+ = normal • 4+ = bounding • Lower extremity (indicative of • Femoral aneurysm) • Popliteal • Dorsalis pedis Doppler signal is NOT • Posterior tibialis equal to a palpable pulse!!!
ARTERIAL SCREENING• Rubor of dependency • Elevate the lower extremity 45 , note slight blanching of plant surface • Place in dependent position, redness or rubor that takes 30 secs or more to occur • Indicative of arterial disease, usually advanced
ARTERIAL SCREENING• Capillary refill • Detects microvascular disease • Press the end of any toe for 2-3 seconds and observe for blanching • Normal refill is less than 3 seconds
BUERGER DISEASE• Also known as thromboangiitis obliterans• Disease of macrovascular circulation• Occurs in feet and/or hands• More common in men, especially heavy smokers• Pathology • Inflammation of the peripheral arteries with thrombi and vasospasm
BUERGER DISEASE• Symptoms • Pain and tenderness • Redness • Cyanotic skin • Thin shiny skin • Thick malformed nails • Gangrene or ulcers (advanced cases) Age may assist in diagnosis – usually younger than typical patient with arterial wounds. Arterial wounds in younger patients indicative of some other pathology.
INVASIVE TESTS FOR PVD• Arteriogram • Radiographs of vascular system after injection of radiopaque dye • Used to determine specific site of lesion prior to by-pass surgery
NON-INVASIVE TESTS FOR MACROVASCULAR DISEASE• Ankle-brachial index• Doppler arterial waveforms• Ultrasound duplex scanning • Ultrasound • Doppler• Color flow doppler scanning• Great toe pressure• Plethysmography (measures volume)• Segmental blood pressure recordings• Exercise stress test
ABI ---ANKLE BRACHIAL INDEX (ABPI-ANKLE BRACHIAL PRESSURE INDEX)• Where PLeg is the systolic blood pressure of dorsalis pedis or posterior tibial arteries and• PArm is the highest of the left and right arm brachial systolic blood pressure
ANKLE-BRACHIAL INDEX• Ratio of ankle systolic pressure to brachial systolic pressure• Indicates the severity of PVD• Interpretations • 1.0– 1.2 – normal • 0.8-1.0 – minimal peripheral arterial disease. Compression for edema control is safe to use. • 0.5-0.8 – moderate peripheral arterial disease, often accompanied by intermittent claudication. Referral to a vascular specialist is advised. Compression therapy is contraindicated if <0.6; modified compression is indicated if 0.6-0.8. • <0.5 – severe ischemia with resting pain. Compression therapy is always contraindicated. • <0.2 – tissue death will occur.
Presión máxima tobillo Indice Presión en el tobillo-brazo = derechoPresión máxima brazo derecho derecho brazo (mm Hg) e izquierdo Presión máxima tobillo 92 mm Hg Obstrucción = = 0.56= moderada Presión braquial 164 mm Hg máximaPresión en la arteria Interpretación del índicetibial posterior y calculadopedia del tobillo Por encima de 0.90 – normalderecho e izquierdo 0.71 – 0.90 – obstrucción leve 0.41 – 0.70 – obstrucción moderada 0.00 – 0.40 – obstrucción severa N Engl J Med 355; august 3, 2006
ANKLE-BRACHIAL INDEX• ABI > 1.3 is not reliable • Frequently seen in diabetics • Caused by calcification of the arteries resulting in artificially high systolic pressure • Great toe pressure and toe/brachial index used instead of ABI • Normal > 55 mmHg pressure • Normal TBI – 0.8-0.99 • < 30 mmHg – pt will need revascularization
PREVENTION OF ARTERIAL WOUNDS• No smoking• Control blood sugars• Control hypertension, hyperlipidemia, hypercholesterolemia• Provide proper foot care (Goodman, p454)• Exercise (Goodman, p 455)
Cuidado Pre-Operatorio No haga desbridamiento. Mantenga el área seca; proteja los dedos con algodón o gaza estéril entre ellos. Use una cuna para los piés Descargue los talones con almohadas Eschar management – Dry and intact, paint with Betadine, use of dry topical silver. Eschar is the “barrier” substitute. Do not debride Keep area dry; protect toes with cotton or sterile gauze between toes Use foot cradle Off-load heels with pillows
Cuidado Pre-Operatorio No haga desbridamiento. Mantenga el área seca; proteja los dedos con algodón o gaza estéril entre ellos. Use una cuna para los piés Descargue los talones con almohadas Disminuya elevación de la extremidad Eleve la cabecera de la cama 5-7 grados Mantenga la extremidad caliente Evite ejercicio en exceso
TRATAMIENTO DESPUÉS DE CIRUGÍA Desbride la herida con tejido necrótico cuando haya tejido de granulación visible en sus bordes. (D. Armstrong) Provea un medio ambiente húmedo con el apósito avanzado apropiado. Proteja los piés con almohadas debajo de las pantorrillas.• Debride wound of necrotic tissue when granulation tissue is visible at the edges (D. Armstrong)• Provide moist wound environment with the appropriate advanced dressing• Protect foot with pillows under calves
TRATAMIENTO DESPUÉS DE CIRUGÍA Descargue la herida con ortóticos, zapatos especiales, dispositivos. Controle el edema post-operatorio para prevenir dehiscencia de sutura. Cubra la incisión con gaza estéril seca Aplique vendaje de corta elasticidad en forma de espiral• Off-load wound with orthotic, special shoes, assistive device• Control post-op edema to prevent incisional dehiscence • Cover incision with dry sterile gauze • Apply short stretch elastic bandage in spiral wrap
GIVE AND TAKE OF ARTERIAL WOUNDS• GIVE • Blood supply • Protection• TAKE • Any cause of trauma • Necrotic tissue if signs of infection are present
VENOUS WOUNDS• Relate to ≈70% of LE wounds• 500,000-1,000,000 in US• 40% occur before the age of 50• Recurrence rate is as high as 72%• Estimated cost of care $40,000/case
VENOUS SYSTEM• Superficial veins • Great saphenous • Small saphenous• Deep veins • Femoral • popliteal• Perforator veins• Lymphatic system
CHRONIC VENOUS INSUFFICIENCY• Causes • Reflux as a result of incompetent valves in the perforator, superficial, or deep veins • Obstruction – e.g. chronic deep vein thrombosis • Lack of venous pump activation during the gait cycle • Dorsiflexion – calf muscles compress deep veins with up to 250 mmHg pressure • Plantarflexion – deep vein pressure falls and allows blood to flow from superficial veins to deep veins, through perforators • Does not occur with ankle hypomobility or gastrocsoleus weakness/paralysis• Results in venous hypertension and excessive moisture in the interstitial tissue• Prevents adequate oxygen and nutrients from reaching the skin
VENOUS PUMPJames, R et.al.: Incompetent venous valves: ultrasound imaging and exo-stent repairPhlebolymphology N°56
PATHOPHYSIOLOGICAL CHANGES• Vessel dilatation and elongation• Increased collagen deposition in both vein walls and skin• Plasma protein leaks into interstitial space with resulting fibrin cuff around arterioles• Increased leukocytes with decreased immune function• Increased inflammatory cells resulting in tissue remodeling and dermal fibrosis
RISK FACTORS• Hx of DVT (37%)• Hx of hip/knee/calf surgery• Ankle hypomobility/fusion• Employment involving prolonged standing• Morbid obesity• Pregnancy• Congestive heart failureSystemic disorders will cause bilateral edema; extremity dysfunctions will cause unilateral edema.
PROGRESSION OF VENOUS DISEASE• Heavy, aching feeling in legs• Telegentsia or reticular veins• Varicose veins• Edema without ulceration• Skin changes without ulceration• Skin changes with ulceration
COMMON SKIN CHANGES – CRITICAL IN DIAGNOSING CVI• Hyperpigmentation (hemosiderin)• Lipodermatosclerosis• Dilated long saphenous vein• Atrophie blanche• Unlateral or bilateral edema• Dermatitis• Thickened skin• Cellulitis
WHERE ARE VENOUS WOUNDS LOCATED?In the gaiter area
VENOUS WOUND EVALUATION• Girth of arch, malleoulus, calf• Type and amount of drainage• Edges (uneven) and location (gaiter, above the ankle)• Pulse exam/ABI in case of absent pulses, severe pain, failure to heal with standard care• Other components of any wound evaluation
VASCULAR TESTS - SCREENING• Approximation of central venous pressure • Screens for cardiac incompetence as cause of edema• Jugular distention • Indicates right ventricular failure• Valve competency with Doppler• Percussion test for saphenous vein competency• Homan’s sign – not reliable• Ankle-brachial index – r/o arterial component
VASCULAR TESTS/VALVE COMPETENCY• Place probe over distended vein• Compress vein 10-15 cm proximally • Audible sound (reflux) means valves between compression and probe are incompetent• Compress vein distal to probe • NO audible sounds indicates venous obstruction
TREATMENT - PREVENTION• Compression hosiery• Elevation (higher than heart)• Exercise to activate venous pump• Avoid prolonged sitting or standing• Avoid crossing the legs• Skin lubrication
COMPRESSION HOSE• Class I • 20-30 mmHg pressure • Used for venous disease with skin changes• Class II • 30-40 mmHg pressure • Used for history of ulceration or severe skin changes• Class III • 40-50 mmHg pressure • Used for lymphedema, pts who reulcerate with Class II, pts who work standing (e.g. dentists)• Class IV • > 60 mmHg pressure TED hose used for DVT prophylaxis are NOT sufficient for treatment of Chronic Venous Ulcers I!!!
LAPLACE EQUATION• P = (TN x 4630) / CW • P = pressure in mmHg • T = bandage tension (in kgf) • N = number of layers applied • C = circumference of the limb (in cm) • W = bandage width(in cm) The pressure gradient between the ankle and calf makes the compression effective in managing the edema.
INTERMITTENT COMPRESSION THERAPY• Used as adjunct for wounds that do not respond to other compression methods or for maintenance in severe lymphedema• Applies compression in sequence, distal to proximal• Pressure must be less than the diastolic BP (usually ≈50 mmHg)• Recommend 1-2 hours daily or bid, depending on severity
GIVE AND TAKE OF VENOUS WOUNDS• GIVE • Protection • Compression • Exercise• TAKE • Edema • Bacteria • Devitalized tissue
DIABETIC / NEUROPATHIC WOUNDS• Occur on the foot, usually plantar surface or toes• Caused by mechanical forces or minor trauma• Occur in patients with diabetes, PVD, or Hansen’s disease because of peripheral neuropathies
INCIDENCE IN DIABETICS• 18.2 million people in US have DM (6.3% of the total population)• In certain ethnic groups, % is as high as 14.5%• 15% of people with DM will have neuropathic ulcer• 14-24% of those with ulcer will have amputation
NEUROPATHIES• Motor – muscle weakness => changes in the shape of the foot => high peak pressures during weight bearing activities • Caused by damage to large nerve fibers• Sensory – diminished sensation => lack of protective sensation • Caused by damage to small nerve fibers• Autonomic – decreases sweat and oil production => dry, inelastic skin • Caused by damage to the large nerve fibers and the sympathetic ganglion
COMMON FOOT DEFORMITIES• Pes aquinas – short Achilles tendon• Hallux limitus/rigidus• Hallux valgus• Hammer toes• Cock-up deformity• Varus deformities of toes• Tailors bunion on 5th metatarsal head• Charcot foot – collapse of arch
NEUROPATHIC WOUND CLASSIFICATIONWagner scale• 0 – at risk due to skin and foot changes• 1 – full thickness skin loss, no infection• 2 – subcutaneous tissue loss, infection• 3 – deep ulceration, infection, osteomyelitis or abscess• 4 – partial foot gangrene or necrosis• 5 – full foot gangrene
WAGNER GRADE 0AT RISK DUE TO SKIN AND FOOT CHANGES
EVALUATION• Risk factors • Recent trauma, diet, footwear, poor foot hygiene, medications, comobidities• Subjective history• Skin inspection • Dry skin with fissures • Calluses • Discoloration in dermal layer (RBCs from deep injury) • Lack of toe and dorsal hair• Heel inspection• Toe inspection • Nail condition • Interdigital spaces• Foot deformities• Shoe assessment
EVALUATION• Sensory assessment• Vibration test• Pressure assessment with Semmes-Weinstein monofilaments• Skin temperature - 3 discrepancy is significant• Reflexes• Musculoskeletal assessment, especially ROM • Dorsiflexion - 10 • Hallux extension – 50-60
PREDICTORS OF COMPLICATIONS• Semmes-weinstein monofilaments • 3.61 (0.4g) = normal • 5.07 (10g) = loss of protective sensation • 6.10 (100g) = total loss of sensation• Vibration • 128 Hz tuning fork • Measures only yes/no response • Test end of great toe, medial malleolus, tibial tuberosity• Reflexes • Diminished due to large motor nerve involvement • Predictable pattern (LE>UE, distal>prox, symmetrical pattern)
NON-INVASIVE VASCULAR ASSESSMENT• Pulses• Capillary refill time• Ankle brachial index • May be unreliable in diabetic if >1.3• Great toe pressure • Normal is 60-90% of the brachial pressure • Normal TBI is 0.8-0.99• Exercise stress test• Transcutaneous oxygen tension• Color flow Doppler imaging
TREATMENT - PREVENTION• Patient education • Blood glucose control • Properly fitting shoes • Nail and callus care • Skin care • Diabetic or molded shoes if foot deformities are severe
PROPER FOOT CARE• Properly fitting shoes• Daily foot inspection • Check for red spots, blisters, calluses • Use mirror or family member if necessary• Proper foot care • Never walk barefoot • Avoid soaking and hot surfaces • Lubricate skin well • Do not use adhesives on skin • Wear thick white cotton socks • Cut nails straight across
TREATMENT OF WOUNDS• Treat infection (systemic vs topical)• Revascularize if needed• Control blood sugars• Debride wound• Provide moist wound environment• OFF-LOAD • Pressure redistribution • Special shoes, total contact casting, assistive devices