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- 1. Pedal Wounds and Treatment Principles Michael Gruse Jr. DPM/PGY-1
- 2. Wound Healing Wound repair requires an environment which is conducive to epithelialization, collagen formation, angiogenesis, and wound contracture Cleveland VA Medical Center
- 3. Treatment Principles Establish Etiology or Pathology of Ulcer Cleveland VA Medical Center
- 4. Treatment Principles Arterial Ulcers Cleveland VA Medical Center No flow - No go Must Establish Flow
- 8. Treatment Principles Arterial Ulcers Establish flow • Anti Platelet Medication • Pletal (cilostazol) • Plavix (clopidogrel) • Referral to Vascular Surgeon Cleveland VA Medical Center
- 9. Next Step?
- 10. Treatment Principles Prevention Do not allow Chronic Venous Insufficiency to progress to ulceration Venous Ulcers Cleveland VA Medical Center
- 13. Treatment Principles Prevent edema • Elevation • Compression • Support Hose • Intermittent Compression Pump Venous Ulcers Cleveland VA Medical Center
- 15. Treatment Principles Skin Care • Maintain moisture • Treat stasis dermatitis Venous Ulcers Cleveland VA Medical Center
- 16. Treatment Principles Venous Ulcers Cleveland VA Medical Center Trauma
- 17. Treatment Principles Prevention Neuropathic Ulcers Cleveland VA Medical Center
- 20. Treatment Principles Prevention • Good glycemic control • Daily foot inspections • "Diabetic" socks • Change shoes in middle of day • Weight distributing insoles q6months • Regular professional care Neuropathic Ulcers Cleveland VA Medical Center
- 21. Treatment Principles REMOVE EXCESSIVE PRESSURE or DISTRIBUTE PRESSURE EVENLY Neuropathic Ulcers Cleveland VA Medical Center
- 22. Treatment Principles Methods of Reducing Pressure •Total Contact Cast •Felted foam dressings •Firm but moldable insoles •Rocker bottom soles •Metatarsal bars •Non-weight bearing Neuropathic Ulcers Cleveland VA Medical Center
- 23. Treatment Principles After etiology is addressed Provide Normal Wound Care Must Understand Eiology of Wound Cleveland VA Medical Center
- 24. Treatment Principles Diagnose and Control Infection • signs and symptoms • radiographs • wound cultures and sensitivities • antibiosis Treatment of Dermal Wounds Cleveland VA Medical Center
- 25. Is it infected?
- 26. Treatment Principles Diagnose and Control Infection Signs and Symptoms • Fever • Cellulitis - Lymphangitis • Drainage • Foul odor • Palpable - tender lymph nodes Treatment of Dermal Wounds Cleveland VA Medical Center
- 27. Treatment Principles Diagnose and Control Infection Radiographs • baseline • soft tissue swelling & density • soft tissue planes • gas • bone involvement Treatment of Dermal Wounds Cleveland VA Medical Center
- 28. Treatment Principles Diagnose and Control Infection Wound cultures and Sensitivities • Curette base of wound • aerobic and anaerobic if indicated • If wound probes to bone – it is infected until proven otherwise Treatment of Dermal Wounds Cleveland VA Medical Center
- 29. Treatment Principles Diagnose and Control Infection Antibiosis • begin broad spectrum coverage • Cover MRSA if recent antibiotics or hx of MRSA • reassess after culture is returned Treatment of Dermal Wounds Cleveland VA Medical Center
- 30. Treatment Principles Debridement should be aggressive and thorough Treatment of Dermal Wounds Cleveland VA Medical Center
- 31. Treatment Principles Debridement • sharp debridement if applicable • wet to dry dressings • saline preferred • Dakin's-Betadine-Peroxide-Acetic acid ? • enzymatic debridement if ischemic • autolysis Treatment of Dermal Wounds Cleveland VA Medical Center
- 32. Treatment Principles AUTOLYSIS the body's wound fluid hydrates and lyses the wound by mobilizing the body's own enzymes Treatment of Dermal Wounds Cleveland VA Medical Center
- 33. Treatment Principles Wound Dressings A moist wound environment is physiologic and speeds epithelialization Treatment of Dermal Wounds Cleveland VA Medical Center
- 34. Treatment Principles Wound Dressings • Epithelialization occurs up to 50% faster in a moist environment than in a dry environment. • Wound fluid possesses growth factors that stimulate angiogenesis and epithelialization Treatment of Dermal Wounds Cleveland VA Medical Center
- 35. Treatment Principles Wound Dressings There is no evidence that anything stimulates granulation tissue with the possible exception of growth factors Treatment of Dermal Wounds Cleveland VA Medical Center
- 36. Treatment Principles Phases of Healing Cleveland VA Medical Center I. Inflammatory Phase Erythema, warmth, edema, pain A) Vasoconstriction B) Vasodilation C) Leukocyte migration D) Monocytes > macrophages
- 37. Treatment Principles Phases of Healing Cleveland VA Medical Center II. Proliferative Phase • Beefy red granulation tissue Macrophages Collagen synthesis Angiogenesis • Thin, silvery epithelial layer Epithelialization • Wound shrinkage Contraction
- 38. Treatment Principles Phases of Healing Cleveland VA Medical Center III. Maturation Phase Shrinkage, thinning, paling of scar Collagen remodeling Capillary regression Tensile strength increases
- 39. Treatment Principles Ask yourself the following questions Is it arterial? Is it venous? Is it neuropathic? Is it infected? Is there osteomyelitis? SUMMARY Cleveland VA Medical Center
- 40. ?