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Olympia Talk


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Olympia Talk

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