Choice of therapy Choice of consultation Prognostication as long as healing ICEBERG principle

Choice of therapy Choice of consultation Prognostication as long as healing ICEBERG principle www.phwiki.com

Choice of therapy Choice of consultation Prognostication as long as healing ICEBERG principle

Moses, Chris, Mid-Day Disc Jockey has reference to this Academic Journal, PHwiki organized this Journal CHAMP Chronic Wounds Miriam B. Rodin, MD, PhD, CMD University of Chicago Learning objectives Per as long as m a competent bedside physical examination as long as discovery in addition to diagnosis of wounds Incorporate knowledge of pathophysiology in addition to wound healing into diagnostic in addition to therapeutic assessments Appreciate the magnitude of the cost in addition to care burden of chronic wounds Incorporate evidence-based knowledge as long as primary prevention in addition to clinical management of wounds Assess Learner’s Outcome Attitudinal Believes that chronic wound care is an internal medicine competency Behavioral Per as long as ms wound evaluation at bedside on teaching rounds Puts wound care in the problem list in addition to management plan Assists team to as long as mulate an effective plan of care, including prognosis as long as healing Cognitive Recognizes inappropriate, harmful or ineffective wound management

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Outline Scope of the problem Pathophysiology Differential diagnosis Management Prevention Geropardy: Name That Wound Most pressure ulcers (PU) begin in acute care hospitals. Estimates of the scope of the problem flawed by methodological barriers Incomplete ascertainment Confusion of incidence in addition to prevalence Incomparable study designs Local institutional/population variability CMS guidelines define PU a reportable hospital patient safety event; quality indicator. Incidence 2.7% – 29.5% Prevalence 4% – 69% per bed-day or 3.5% – 29.5% per patient per bed-day High risk patients: Quadriplegics Neurosurgery Orthopedic post-op hips up to 66% Critical care MICU/CCU/SICU 33% – 41% Prolonged anaesthesia time Debilitated AND age > 70

Scope of the Problem Chronic wound care products: a $14B industry. Ischemic in addition to diabetic leg ulcers are the leading indication as long as revascularization in addition to amputation. Litigation against nursing homes: 1 Falls 2 Pressure ulcers. Largest settlements as long as PU (FL $92m, TX $300m) in addition to recently, hospitals. Human cost easier to appreciate Pain Amputation Disablement Social costs (disfigurement, odors, institutionalization) Risk management Outline Scope of the problem Pathophysiology Differential diagnosis Management Prevention Geropardy: Name That Wound

Site of the injury Capillary closing pressure 32 mm/Hg Venule closing pressure 6mm/Hg Common pathway Tissue ischemia in addition to cell death due to Extrinsic pressure >>Pressure (Decubitus) Ulcer Capillary closing pressure <30mm/Hg x 15 min Stasis >> Ulceration or Dermatitis Obstructed outflow (venous insufficiency) Obstructed clearance of extracellar fluid in addition to debris (lymphatic insufficiency, sclerosis) Arterial occlusive disease Tissue hypoxia Acute TE in small or terminal arterioles gangrene Chronic PAD medium in addition to large vessels ischemic ulcers. The cause of the injury explains the chronicity of the injury Increased duration of extrinsic pressure: Debilitated patients do not spontaneously adjust position: neuropathy, sedation, restraints, weakness Loss of dermal collagen in addition to fat support of microcirculation Inflammation Poor drainage inhibits clearance of bacteria, pro-inflammatory factors, necrotic tissue Tissue hypoxia Poor perfusion in addition to anemia limit delivery of

Outline Scope of the problem Pathophysiology Differential diagnosis Management Prevention Geropardy: Name That Wound Differential diagnosis directs Choice of therapy Choice of consultation Prognostication as long as healing Pressure Ulcer The usual pressure points: sacrum, trochanters, heels, coccyx Can develop on ANY part of the body: nostrils from nasal cannula, DHT; scalp from immobilization on ventilator In joint spaces of contracted limbs Where body parts “kiss” (knees, buttocks)

PRESSURE ULCERS: Hypoxia induced cell death releases cytosolic factors into the microcirculation Provokes circulating macrophages to the wound, produce PMN chemotactic, proflammatory substances, collagenases in addition to proteases. Tissue bound macrophages do not produce tissue growth factors in the presence of these substances. Fibroblasts will not migrate into the wound bed; cell differentiation in addition to proliferation will not occur PRESSURE ULCER THERAPY Relieve pressure Remove necrotic tissue Protect clean wound base Be alert as long as secondary infection Bedside Approach Trigger: Pressure points Risk factors Immobility ICU Post-op Pressure ulcer Stage it: Inspect Palpate Debride UNLESS IT IS A DRY HEEL Probe as long as depth in addition to tunneling

Staging Stage 0 red, blanching “post ischemic hyperemia” Stage 1 red, non-blanching, indurated Dark-skinned patients: no erythema, blue or purple discoloration in addition to boggy feel on palpation Apoptotic cells are lysing, releasing chemotactic signals into interstitium, attracting macrophages. Macrophages release collagenases, proteases in addition to additional inflammatory intermediates (TNF, IL-2, IL-6). Keratinized layer intact. Intradermal edema. Staging cont’d Stage 2 Cell lysis extends into the dermis, a shallow crater appears. “Partial thickness.” Dermal thickness varies over body surface, decreases with advancing age, photoaging FULL THICKNESS WOUNDS: Stage 3 Injury extends into the subdermal tissue Stage 4 Injury extends into muscle, bone, internal structures (scrotum, rectum, visible tendons) Unstageable: Depth of wound cannot be determined in addition to is presumably 3 or 4: Eschar, heels A decubitus ulcer in an elderly patient is seen on the left. The ulcer is covered by fibrino-purulent exudate. The picture on the right shows the same wound after it has healed. Note the puckering scar

Stage 3 sacral PU with residual eschar, slough in addition to secondary necrotic tissue Stage 2 Sacral Pressure Ulcer Heel Unstageable, probable 4 ICEBERG principle Pressure is distributed in a roughly upright cone, exp in addition to ing outward in addition to down through the subdermal tissues: Eschar indicates Stage 3 or higher Subcutaneous wound is larger than the visible area of eschar

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Outline Scope of the problem Pathophysiology Differential diagnosis Management Prevention Geropardy: Name That Wound Management of pressure ulcers Explore open wound manually or with probe to determine extent of undermining in addition to tunneling Closed wound must be visually inspected daily as long as progression Eschar: leathery black or brown covering is NOT a scab MUST be opened sharply scored in addition to excised. Failure to do so will result in rapid wound extension, anaerobic seeding in addition to sepsis. Except hard, dry eschar on heel A pressure ulcer is not an infection. Foul, smelly gray in addition to yellow gunk is what macrophages make while they are cleaning up dead tissue. It is NOT a sign of infection. Signs of infection: Exp in addition to ing red, warm, indurated halo around wound Visible bone with disrupted periosteal membrane Exposed bone with surrounding granulation that will not cover the bone after 10-14 days Deep tissue biopsy is confirmatory. Assume skin flora, staph species as long as empiric treatment. NEVER swab a wound as long as culture.

Non-healing PU Should improve within 14 d. If not: Heavy “purulent” exudate: gm+ colonization: absorbent dressing Clean no exudate: gram-neg colonization: silvadene, other Ag+ impregnated dressing Recurrent necrosis: consider pressure ischemia: air fluidized bed (Level 3 device). Visible bone: Periosteum disrupted: bone bx as long as culture Terminal ulcer: multiple non-healing ulcers of various ages: (pre-death marker, “Kennedy ulcer.” Medicare approved hospice diagnosis Decubitus Do’s Stage 0 1 2 3 4 Relieve pressure x x x x x Avoid friction x x x x x Inspect daily x x x x x Occlusive dressings1 x Sharp debridement2 x x Enzymatic debrider3 x x Moist gauze/gel packing x x Absorbent dressings4 x x “Wet-to-dry” 5 1. e.g. Hydrocolloid occlusive dressing 2. Remove eschar, soft debris 3. Removes adherent slough: yellow, brown, black material, e.g. collagenases enzymatic debriders 4. Removes non-adherent exudate, e.g. Ca.alginate, Aquacel 5. Not recommended. Common Decubitus Errors Staging errors: Occlusive dressing on a 3, 4 or closed unstageable: creates anaerobic environment, prevents daily inspection. Overly aggressive debridement: Sharply debride hard, dry eschar OR fluid-filled blister on a heel Recurrent trauma to a healing wound: e.g. wet-to-dry Use of –cidal agents on granulation tissue: Topical iodine, Dakin’s, peroxide on any clean wound. Overuse of antibiotics: Creates multiply resistant organisms Encouraged by inappropriate swab wound cultures Systemic antibiotics without evidence of systemic infection (cellulitis, osteo, bacteremia)

AHCPR Clinical Guideline Pressure Ulcer Treatment A level recommendations: Minimize bacterial colonization with recommended cleaning in addition to debridement Consider a 2 wk trial of topical triple Abx or Silvadene as long as a clean non-healing wound or one that continues to produce think exudate. Systemic Abx only as long as cellulitis, sepsis, osteomyelitis Assess daily as long as recurrent PU B level recommendations: Prevent malnutrition Avoid –cidal topical agents (povidone, betadine, Dakin’s, peroxide) Irrigation with NS 4-15 psi as long as cleaning Continuously moist dressing no demonstrated difference among many competing products in addition to just NS in addition to fluff gauze. NO wet-to-dry on clean wounds. Consider nursing labor time needed as long as dressing plan Trial of low voltage electro stimulant therapy as long as refractory wounds AHCPR PU Guidelines Cont’d. C level recommendations: Initial st in addition to ardized assessment, weekly reassessment Reassess management if no healing of a clean wound within 2-4 weeks Complete H&P Q 3 mo nutritional assessment, if p.o. intake is inadequate, consider TF Vitamin in addition to mineral supplements if deficiency confirmed or suspected. Assess in addition to manage pain Psychosocial (caregiver availability) Set treatment goals Positioning schedules, devices, Air-fluidized bed if Stage 3 or 4 non-healing Debride, sharp or chemical as appropriate Moist dressings Whirlpool Loose packing of all wound cavities No evidence as long as miscellaneous topical or systemic agents, hyperbaric, UV, IR, zinc, Vit C or US. Quantitative soft in addition to bone biopsy culture as long as non-healing wounds Observe clean body substance precautions, not sterile

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