Wound Care for Internists - PowerPoint Presentation

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Wound Care for Internists

Robert Plemmons, MD, FACP, CWS

Division Director, Wound Care/Hyperbaric MedicineSlide2

AN OLD JOKE

WHAT’S THE BEST WAY TO HIDE A WOUND FROM AN INTERNIST?Slide3

AN OLD JOKE

WHAT’S THE BEST WAY TO HIDE A WOUND FROM AN INTERNIST?

PUT A BANDAGE OVER IT!Slide4

OVERVIEW

WHAT DOES A WOUND CARE SPECIALIST DO?

WHY SHOULD YOU LEARN ABOUT WOUNDS?

VOCABULARY OF WOUND CARE

RISK FACTORS FOR POOR WOUND HEALING

“READING” WOUNDS FOR INFECTION

ASSESSING WOUND SEVERITY AND PROGNOSIS

ASSESSING OTHER COMPLICATING FACTORS

HOW TO EXAMINE A WOUND

HOW TO CULTURE A WOUND

WOUND CULTURES AND THE SPECTRUM OF INFECTION

VENOUS ULCERS

DIABETIC FOOT ULCERS

PRESSURE ULCERS

ARTERIAL ULCERS

ATYPICAL ULCERS

BASIC WOUND CARE PRINCIPLES

BIOFILM

HYPERBARIC OXYGEN

WOUND CARE PEARLSSlide5

What does a wound care specialist do?

Evaluates and treats chronic, complex, or complicated wounds

Assesses vascular status and treats/refers as appropriate

Evaluates and treats underlying comorbidities

Selects appropriate basic and advanced treatment modalities

Treats skin/soft tissue infections

Performs debridement on wounds as indicated

Manages edema/lymphedema

Performs skin biopsies (rule out underlying CA, vasculitis, pyoderma, etc.)

Uses hyperbaric oxygen therapy for selected problem woundsSlide6
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Why should you learn about wounds?

NEED TO DIFFERENTIATE INFECTED FROM NONINFECTED WOUNDS

NEED TO UNDERSTAND HOW TO EVALUATE SEVERITY/PROGNOSIS OF WOUNDS

NEED TO UNDERSTAND INTERPRETATION OF WOUND CULTURES

NEED TO UNDERSTAND BASIC DRESSINGS

NEED TO KNOW WHEN A WOUND IS AN INDICATOR OF A BIGGER UNDERLYING PROBLEM

NEED TO UNDERSTAND WOUND-RELATED CONDITIONS ENCOUNTERED IN PRIMARY CARE (e.g. VENOUS INSUFFICIENCY)Slide8

Vocabulary of wound care

Partial thickness: no exposed subcutaneous tissue

Full thickness: exposed subcutaneous fat (also fascia, muscle, etc.)

Eschar: devitalized skin (“

tache

noire”, literally black spot)

Desiccation/maceration: excessive dryness/moisture

Dead space: a cavity in a wound

Undermining: presence of a space between skin and fat

Granulation tissue: new connective/vascular tissue

Slough: heterogeneous yellow material deposited on wound surface

Biofilm: a community of microbes attached to the wound surface

NPWT: negative pressure wound therapy, i.e. Wound VACSlide9
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Risk factors for poor wound healing

Nicotine use (including smokeless and vapor) HUGE impact

Uncontrolled diabetes

Obesity

Advanced age

Uncontrolled edema

Previous radiation at surgical site

Severe anemia

Cancer chemotherapy, steroids

Chronic hypoxemiaSlide12

“Reading” wounds for infection

Easy when you have cellulitis, pus, odor

Increased drainage (may be thin/serous or purulent)

Dark, discolored granulation tissue

Thickened, edematous edges

Increased pain

Failure to heal (biofilm)

Spectrum from benign colonization to critical colonization to infection/invasionSlide13

Assessing wound severity and prognosis

Size (larger correlates with worse prognosis)

Chronicity (present more than a few months, worse prognosis)

Infection/biofilm

Undermining/tunneling

Poor perfusion

Fibrosis/scar

Multiple comorbiditiesSlide14

Assessing other complicating factors

Presence of necrotic tissue

Presence of underlying foreign body (VAC foam, suture knot, mesh, gauze)

Presence of underlying prosthetic material (metal, plastic, PTFE)

Presence of underlying/undiagnosed condition (DM, RA, CA, etc.)

Patient contribution (meth-associated, factitious, picking, etc.)Slide15
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How to examine a wound

Location is major clue to etiology (e.g. ulcers over pressure points)

Peri-wound skin (inflammation, maceration, signs of PVD)

Drainage (try to express fluid/pus)

Probe for tunnels/abscess pockets with cotton tip end of swab

Probe for bone with swab stick (metal probe even better)

Inspect depths of wound for foreign bodies, bone, etc.Slide17
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How to culture a wound

Irrigate wound with saline

Debride the wound if indicated (moist gauze okay)

Obtain specimen from cleanest, deepest portion of wound

Avoid touching the walls of a sinus tract, if possible

Try to touch any exposed bone, metal, etc. in the wound bed with swab tip

Tissue preferable to swab if availableSlide19

Understanding wound cultures

Semi-quantitative: 1+, 2+, 3+, 4+ (number of quadrants on agar)

More of the bug, more likely significant; serial isolation a clue

Skin flora (coagulase-negative Staph, Corynebacterium, “

diphtheroids

”) can USUALLY be ignored, but NOT when foreign body present

Correlate with Gram stain: lots of WBCs?, lots of bugs?

Just because something grows doesn’t mean it requires systemic antibiotics. Local antiseptics (Betadine, Dakin’s, etc.) may work.

Staph aureus/MRSA and Pseudomonas associated with biofilm

Beta-hemolytic Strep (especially Group A) high-riskSlide20

Biofilm and chronic wounds

Biofilms are complex microbial communities

Organisms secrete a matrix that attaches the biofilm to a surface

Matrix protects microbes from immune system and antibiotics

Likely that almost all chronic wounds have some degree of biofilm

Some bacteria “planktonic” (active), others quiescent

Physical removal (debridement) important to remove biofilm

Povidone iodine especially active against biofilmSlide21
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Antiseptics for wound care

Silver

Dakin’s solution (dilute bleach)

Povidone iodine

Chlorhexidine

Methylene blue/gentian violet

Acetic acid

NOT hydrogen peroxide (neutralized by tissue catalases)Slide23

Dressings, basic and advanced

Gauze: no longer used as primary dressing for long-term care

Foam +/- silver: good general dressing for shallow wounds

Hydrofibers

/alginate +/- silver: good for drainage, dead space

Super-

absorbant

dressings: good for “weeping” wounds

Cadexomer

iodine: excellent with infection/biofilm

Wicking surfaces: transfer moisture from one face to the other

Occlusive dressings: good for clean, superficial wounds

Many versions of most of these; find favorite of each type. Slide24

Biologics and skin substitutes

Tissue matrix products: numerous

“Synthetic” skin

Cadaveric skin

Human tissue growth factors

CollagenaseSlide25

NPWT: negative pressure wound therapy

Wound VAC and others

Foam attached to a suction pump

Removes exudate, bacteria, slough

Decreases edema, increases blood flow to wound

Activates WBCs and fibroblasts

Promotes wound contractionSlide26

Negative pressure wound therapy Slide27

NPWT: VAC tips and tricks

Vary the strength of the vacuum (-125 versus -150 mm Hg)

Give patients VAC-

ations

from the device (1-2 weeks)

Use the NPWT in conjunction with collagenase, biologics, and instilled antiseptics/

irrigants

Tiny, disposable, mechanical devices now availableSlide28

Debridement techniques and tips

If the tissue looks dead, remove it (IF underlying perfusion adequate)

Removal of slough decreases bioburden (bacteria, biofilm)

Serial debridement of chronic wounds is associated with healing

Collect cultures AFTER debridement and irrigation

No bleeding, no healing (evaluate for revascularization)

Look for stigmata of tissue ischemia BEFORE debridingSlide29

Venous insufficiency ulcers

Typically located on lower leg/ankle/foot (gaiter distribution)

Associated with venous hypertension/reflux (cause edema, inflammation)

Study with detailed venous study (not routine duplex scan)

May have concurrent arterial disease

Frequently colonized with

S. aureus

and/or

Pseudomonas

Primary treatment modality is compression

Adjunctive medical therapy with pentoxifylline

Adjunctive surgical treatment with radiofrequency ablationSlide30
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Arterial insufficiency ulcers (PVD)

Typically located on feet (tips of toes)

Punched out “cookie cutter” ulcers with eschar, pale beds

Painful, associated with claudication, rest pain

Often associated with tobacco use (may not heal without quitting)

Study initially with noninvasive studies (ABIs/PVRs), then angiogram

Primary treatment is revascularization

Adjunctive medical therapy with

cilostazol

, aspirin

Goal of wound care is prevention of infection until revascularization Slide32
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Diabetic neuropathic foot ulcers

Often combination of neuropathy and PVD

Usually located over pressure points

Watch for foreign bodies (x-rays may show pins, staples, tacks, etc.)

MRI to evaluate for

osteo

, abscess, septic arthritis

Primary treatment is offloading (shoes/boots okay, cast best)

Underlying infection likely when deep (probe to bone)

Charcot foot (acute can mimic cellulitis, gout)

Revascularization often indicatedSlide35
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Decubitus (pressure) ulcers

Located over bony prominences

Ischemic breakdown due to unrelieved pressure

Exacerbating factors: incontinence, malnutrition

Range from red, intact skin to exposed muscle/bone

Primary treatment is pressure relief (specialized surfaces)

Adjunctive medical treatment: antibiotics, nutrition

Adjunctive surgical treatment: debridement, colostomy, flapSlide37

Pressure points over bony prominencesSlide38
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Atypical ulcers

Autoimmune/

vasculitic

ulcers (RA, ANCA+, antiphospholipid, BP)

SCCA, BCCA,

Marjolin

ulcer

Pyoderma gangrenosum (including

peristomal

)

Calciphylaxis

(PAIN!): ESRD, Coumadin

Drug-induced: hydroxyurea (ankle)

Skin biopsies and serologies may be necessary to make the dxSlide40
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Hyperbaric oxygen therapy: indications

Soft tissue radiation necrosis (skin, bladder, GI, etc.)

Osteoradionecrosis: often involving the mandible and chronic infection

Diabetic lower extremity ulcer with deep infection, e.g.

osteo

, abscess, septic arthritis (Wagner Grade 3)

Diabetic lower extremity ulcer with dry gangrene (Wagner Grade 4)

Chronic refractory osteomyelitis (failing antibiotics and surgery)

Actinomycosis

refractory to antibiotics and surgery

Gas gangrene (

clostridial

myositis and

myonecrosis)Necrotizing soft tissue infections (necrotizing fasciitis, Fournier’s)Slide42
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Basic wound care principles

Dry gauze never hurt anybody in the short term, but most wounds heal faster and hurt less if kept moist

Keep dry gangrene dry (more infection if kept moist)

It’s okay to put Betadine (povidone iodine) on wounds

Hydrogen peroxide is useless as an antiseptic

Tap water is as safe as sterile saline for cleaning an open wound

Edema is a major contributor to poor healing of leg/foot woundsSlide44

Wound Care Pearls:

Skin won’t grow over yellow or black tissue. Needs more than basic wound care!

Check noninvasive arterial studies for all chronic leg wounds.

Never underestimate the power of tobacco to prevent wound healing.

Don’t forget the possibility that the patient may be doing something that keeps the wound from healing.