ACTIVITY DISCLAIMER DISCLOSURE. Brian Rayala, MD, FAAFP. Learning Objectives. Audience Engagement System Step 1 Step 2 Step 3

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1 ACTIVITY DISCLAIMER Wound Care Management: The Art and Science of Wound Healing Brian Rayala, MD, FAAFP The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. Please note that medical information is constantly changing; the information contained in this activity was accurate at the time of publication. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations. The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP. DISCLOSURE It is the policy of the AAFP that all individuals in a position to control content disclose any relationships with commercial interests upon nomination/invitation of participation. Disclosure documents are reviewed for potential conflict of interest (COI), and if identified, conflicts are resolved prior to confirmation of participation. Only those participants who had no conflict of interest or who agreed to an identified resolution process prior to their participation were involved in this CME activity. All individuals in a position to control content for this session have indicated they have no relevant financial relationships to disclose. The content of my material/presentation in this CME activity will not include discussion of unapproved or investigational uses of products or devices. Brian Rayala, MD, FAAFP Residency faculty/director of Procedural Training, Department of Family Medicine, University of North Carolina (UNC) School of Medicine, Chapel Hill; Staff physician, UNC Hospitals Wound Healing and Podiatry Center, Chapel Hill Dr. Rayala has received multiple awards for excellence in teaching and clinical care, including the 2017 UNC Distinguished Teaching Award for Post-Baccalaureate Instruction, the 2014 and 2016 UNC Family Medicine Residency Teaching Award, and the 2015 UNC Health Care and Faculty Physicians Award for Carolina Care Excellence. In addition, he has been named among the Best Doctors in America since He has special training and interest in dermatology, wound medicine, and medical procedures. Learning Objectives 1. Use evidence-based recommendations for systematic wound evaluation and documentation. Audience Engagement System Step 1 Step 2 Step 3 2. Apply best practices for basic and advanced laceration repair techniques. 3. Develop collaborative care plans with patients with chronic or complex wounds, and ulcer prevention strategy adherence. 4. Coordinate care with multidisciplinary teams, utilizing a patient-centered care approach, for the care and management of patients with chronic, complex wounds. 1

2 AES Poll Question How many patients with wounds do you see or manage per week? A. 0 B. 1-5 C D. >10 Presentation Topics Systematic wound evaluation Management of acute and chronic wounds Engaging the patient and the health care team to manage chronic wounds Presentation Topic #1: Systematic Wound Evaluation Learning objective: Use evidence-based recommendations for systematic wound evaluation and documentation. Systematic Wound Evaluation Acute vs. Chronic Wound No universally accepted definition Chronic wound/ulcer Several weeks (>6-12 wks) Several months (>3mos) to years Wound healing determinants Age, perfusion, infection, wound microenvironment, nutrition, comorbidities Systematic Wound Evaluation 1. Biol Cell. 2005;97: Systematic Wound Evaluation Obtain a problem-focused history Detailed wound history Goal: identification of risk factors Perform physical exam Problem-pertinent general exam Detailed wound assessment Wound-pertinent workup 2

3 Systematic Wound Evaluation: Problem-Focused History Demographics: age, gender, race PMH: comorbidities (DM, HTN, CAD, etc.), nutritional deficiencies, neuromuscular & gait disorder, dermatologic conditions Medications Allergies Exposures SH: smoking, living situation, ability for self-care (ADLs), social support, health coverage Systematic Wound Evaluation: Wound History History of Present Ulcer Location Duration Associated symptoms: pain, drainage, redness, pruritus, numbness Evaluation hx: imaging, vascular, culture, biopsy Treatment hx: prior dressings, topical and systemic tx, debridement, other surgical tx Prior wounds: evaluation, treatment Systematic Wound Evaluation: Physical Exam Vitals: including BMI, pain level Cardiovascular: cardiac exam, pulses, capillary refill Neurologic: gait/posture, strength, sensation Musculoskeletal and Extremities: deformities, LE edema, varicosities, digits, nails AES Poll Question Which positive finding provides the highest likelihood of diabetic foot osteomyelitis? A. Ulcer size >2cm 2 B. Probe-to-bone test C. ESR>70 Systematic Wound Evaluation: Detailed Wound Assessment Location Wound stage or classification Measurement (size, depth) Wound bed Wound exudate Wound edge or margin Periwound (surrounding skin) Infection Pain Etiology Wound Stage or Classification Superficial Epidermis Epidermis Partial thickness Dermis Epidermis Dermis Full thickness Adipose tissue Fascia, muscle, bone 2. EPUAP and NPUAP. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel;

4 Measurement Ruler-based methods (cm) Head to toe Greatest length & width Wound tracing Other advanced methods Practice Pearls: 4 Suspect diabetic foot osteomyelitis if: Area > 2cm 2 (+LR/-LR 7.2/0.48) Depth > 3mm Over bony prominence Visible bone Non-healing Measurement Depth Use moistened cotton-tip applicator to measure depth Then compare against a ruler (cm) If wound overlies bony prominence, perform probe-tobone testing using metal probe Practice Pearls: 5 Probe-to-bone testing: Positive test (ie, touching hard or gritty bone): increases likelihood of osteo in a high-risk pt Negative test: decreases likelihood of osteo in a low-risk pt Sn/Sp: 87%/91% +LR/-LR: 6.4/ Clin Infect Dis. 2012;54: Diabetes Care. 2007; 30: Wound Bed Granulation tissue Pink/red, moist New blood vessels, collagen, fibroblasts, inflammatory cells Necrotic tissue Eschar: thick, leathery, black Slough: yellow Fibrin: yellow, firmly adherent Wound Bed Epithelialization Epithelial cells migrate across wound surface Ground glass to pink Clean but non-granulating Hypergranulation Buildup/raising up of tissues Inhibits epithelialization Exudate Amount Minimal (or no exudate) Light (scant or small) Moderate (medium) Heavy (large or copious) Type or color Serous Sanguinous Serosanguinous Purulent (thick, opaque) yellow, green, white, or tan Edges Healthy Indistinct Attached Unhealthy Tunneling or tracking Detached 4

5 Edges Detailed Wound Assessment Unhealthy Location Wound stage or classification Measurement Undermining Hyperkeratotic, fibrotic Wound edge or margin Wound exudate Wound bed Periwound (surrounding skin) Infection Pain Presentation Topic #2: Management of Acute & Chronic Wounds Learning objectives: Apply best practices for basic and advanced laceration repair techniques. AES Poll Question Which finding, when absent, provides the highest likelihood that diabetic foot osteomyelitis is not present? A. Ulcer size >2cm 2 B. Probe-to-bone test C. MRI findings suggestive of osteomyelitis Management of Acute and Chronic Wounds: Diagnostic Tests Culture 5 : Do NOT swab undebrided ulcers or wound exudate! Instead, perform curettage from base of debrided ulcer or perform deep tissue biopsy If no other choice other than to swab exudate, perform Levine technique Pathologic evaluation: Punch or incisional bx of ulcer edge Bone biopsy GOLD STANDARD for dx of osteo 5. J Diabetes Complications. 2012;26: Management of Acute and Chronic Wounds: Diagnostic Tests Imaging 6 : X-ray: 1 st line imaging; may not show changes for 2 wks Low sensitivity (28-75%), but high specificity for uncomplicated osteo Limitations: neuroarthropathy or trauma can mimic osteo MRI: most accurate imaging for diabetic foot osteo Sn/Sp 90%/80% +LR/-LR 3.8/0.14 Limitations: Charcot neuroarthropathy Triple-phase 99m Tc MDP bone scan: Sn/Sp 90%/46% Limitations: neuroarthropathy, fracture, soft tissue infection, OA WBC scan: Sn 86%, Sp better than triple-phase bone scan Limitations: soft tissue infection 6. BMJ. 2009;339:b

6 Management of Acute and Chronic Wounds: Imaging Algorithm Management of Acute and Chronic Wounds: Diagnostic Tests Labs: ESR >70mm/h (+LR 11.0) 7 CBC: poor sensitivity Blood cx: if with severe symptoms D-dimer: to rule out VTE A1c Vascular evaluation: ABI, arterial Doppler, venous Doppler, venous reflux studies CTA, MRA, angiography, venography 6. BMJ. 2009;339:b JAMA. 2008;299: Management of Chronic Wounds: Wound Debridement Primary determinants of choice of debridement: Wound bed: debride if >25% necrotic tissue 8 Wound edge: debride if edge is Hyperkeratotic / fibrotic Marginated / detached Undermined Has tracking / tunneling 8. SOLUTIONS wound care algorithm. Princeton (NJ): ConvaTec; 2008 Management of Chronic Wounds: Dressing & Topical Therapy Primary determinants of choice of dressing: Wound bed Presence of necrotic tissue e.g., hydrogel and silver sulfadiazine (SSD) are options for dry eschar Type of granulation tissue e.g., sodium chloride impregnated gauze is good for hypergranulating wounds Wound exudate Dry to moist wounds hydrogel Moderate to heavy exudate alginate, Hydrofiber, and foam dressings Do NOT use wet-to-dry or gauze dressings (higher pain, lower pt satisfaction, longer nursing time) 9 9. Cochrane Database Syst Rev. 2004;(2):CD Management of Acute Wounds: Skin Closure Methods for Acute Wounds Sutures Staples Adhesive tapes Tissue adhesives (e.g., cyanoacrylate) Cochrane review found tissue adhesives have higher dehiscence rates compared to sutures 10 At times, adhesives may be quicker to apply AES Poll Question Do you practice in a Wound Care Center? A. Yes B. No 10. Cochrane Database Syst Rev. 2014;(11):CD

7 Presentation Topic #3: Engaging the patient and health care team Learning objectives: Develop collaborative care plans with patients with chronic or complex wounds, and ulcer prevention strategy adherence. Coordinate care with multidisciplinary teams, utilizing a patient-centered care approach, for the care and management of patients with chronic, complex wounds. Presentation Topic #3: Engaging the Patient Collaborative Care Plan Diabetic Ulcer and Amputation Prevention Primary and secondary prevention: Patient education interventions improve foot care knowledge and behavior in the short term, but NOT rates of amputation or ulceration. (SOR A) 11,12 Venous Leg Ulcer Prevention Insufficient evidence that pt education increases compliance with compression therapy. (SOR A) Cochrane Database Syst Rev. 2014;(12):CD Diabetologia Nov;51(11): Cochrane Database Syst Rev. 2016;(3):CD Presentation Topic #3: Engaging the Health Care Team Patient-centered Team-based Approach Multidisciplinary foot care team For inpatient care of pts w/ diabetic foot infections (SOR C) 14 Primary care, surgery, podiatry, ID, endocrine, nursing, nutrition, rehab, social work, care manager Primary care experts in care coordination Need for a care pathway for managing each pt (SOR C) 15,16 Approach must be centered on the patient 14. BMJ. 2011;342:d Vasc Surg. 2010;52(3 suppl):3s 16S. 16. Endocrine. 2010;38(1): Practice Recommendations Perform a systematic wound evaluation at each wound visit; be particularly attentive to wound measurement, wound bed, edge and exudate as these determine need for debridement and choice of wound dressings. (SOR B) Avoid swabbing undebrided ulcers or wound exudate. Tissue culture is the gold standard but may not be possible to perform. (SOR C) For acute wounds, use sutures and staples for high-tension wounds. For low-tension areas, tapes and tissue adhesives are good alternatives. (SOR A) Practice Recommendations Questions Among diabetics, collaborative care plans that focus on pt education improve knowledge and behavior in the short-term, but NOT rates of ulceration or amputation (SOR A). For VLU, compliance to compression therapy remains challenging and the role of pt education to address this remains unclear (SOR A). Weak evidence supports the establishment of multidisciplinary foot care teams that utilize care pathways for inpatient management of DFI (SOR C). The primary care physician carries the important role of coordinating care among different specialties and of advocating for patients and their holistic treatment (SOR C). 7

8 Contact Information Brian Z. Rayala, MD, FAAFP References 1. Biol Cell Mar;97(3): EPUAP and NPUAP. Prevention and treatment of pressure ulcers: quick reference guide. Washington DC: National Pressure Ulcer Advisory Panel; Clin Infect Dis Jun;54(12):e Diabetes Care Feb;30(2): J Diabetes Complications May-Jun;26(3): BMJ Dec 4;339:b JAMA Feb 20;299(7): SOLUTIONS wound care algorithm. Princeton (NJ): ConvaTec; Cochrane Database Syst Rev. 2004;(2):CD Cochrane Database Syst Rev. 2014;(11):CD Cochrane Database Syst Rev. 2014;(12):CD Diabetologia Nov;51(11): Cochrane Database Syst Rev. 2016;(3):CD BMJ Mar 23;342:d J Vasc Surg Sep;52(3 Suppl):3S-16S. 16. Endocrine Aug;38(1):