Lower Extremity Wound Evaluation and Treatment Boni-Jo Silbernagel, DPM Describe effective lower extremity wound evaluation and treatment. Discuss changes in theories of treatment in wound care and implications to current wound practice. Discuss effective lower extremity wound management strategies in primary care setting. Describe effective lower extremity wound evaluation and treatment.
Evaluating An Ulcer Location Size Color Drainage Odor Tracking Surrounding Tissue Integrity of Underlying Tissue Location Trauma Vascular Venous Diabetic Pressure Location/Trauma
Location/Vascular Location/Venous Location/Diabetic Ulcer
Location/Pressure Size Color
Drainage Odor Tracking
Surrounding Tissue Integrity of Underlying Tissue So, what is good wound care?
Where we ve been Traditional theories : Wounds should be kept dry so that a scab can form Wounds should be exposed to air and sunlight as much as possible Wounds should be covered with dry dressings Evolution of wound care dressings 1948: Experiments with occlusive dressings of a new plastic by JP Bull Properties of a nylon derivative film Water vapor permeability made it suitable for wound dressings Also noted that the presence of a variety of organisms was reduced or disappeared Evolution of wound care dressings 1963 (Hinman): Effects of air exposure and occlusion of experimental human skin wounds Used a sterile polyethylene film in artificially made wounds on health adult male volunteers Wounds were either occluded or allowed to heal open to air Results: Wounds healing under moist conditions healed 50% faster than wounds open to air Winters, CD Nature 1962
There s more? Gauze dressings present no bacterial barrier Lawrence/1994: 64 layers of dry gauze allowed bacterial penetration Hutchison/1989,1993: Moistened gauze presents less barrier Hutchison/1990: Review of 3047 wounds showed the following infection rate: 2.6% for those dressed with moisture-retentive dressings 7.1% for those dressed with gauze Ovington, L Hanging Wet to Dry Out to Dry. Home HelathCare Nurse. 2001; 19(8), 477-483 Where we re going Traditional dressings: Gauze, lint and fiber products Hydrocolloids Modern Moist Wound Dressings: Foams Films Alginates/Hydrofibers Collagen Bi-layered Human Skin Substitute Hydrogels Topical Antimicrobials Silicone Look how far we ve come!!! Wound Management Moisture Balance Complete debridement of devitalized/necrotic tissue Restore bacterial balance Treatment of edema/lymphedema and optimize cellular function Schultze, Falanga, et al Wound Rep Reg 2003, 11(Suppl) 1-28
Importance of Debridement Removal of callus and necrotic tissue Decreasing the bacterial burden Removal of phenotypically altered cells: the cellular burden Effect of Edema & Chronic Wound Fluid Normal anti-streptococcal properties of skin is inactivated Inhibits mitogenic activity and DNA synthesis Cytokine environment is more proinflammatory Protease activity is higher Growth Factor levels are decreased Schultze, Falanga, et al Wound Rep Reg 2003: 11 (Suppl) 1-28 Compression Therapy & Circulation ABI Bandage Pressure (mmhg) > 0.8 4-Layer 35-40 0.7 2-3 Layer 17-25 0.6 2-3 Layer 17-25 < 0.5 Medically Supervised
How should we select dressings? Autolytic Fillers Primary Hydrating Non-adhesive Absorbing Enzymatic Active Secondary Wound Classification: Black/Yellow/Red Concept Black Yellow Red Black Wounds (eschar) Eschar is a thick, leatherlike crust of necrotic tissue Often covers an underlying chronic process such as moist necrotic tissue Usually black but may vary in color
Goal: Debridement When is debridement contraindicated? Patients who are at increased risk of bleeding Dry stable ischemic wounds or dry gangrene Vascular compromise Hypertonic saline gel Benefits 20% sodium chloride gel solution Softens and debrides eschar Draws drainage and debris from wound Facilitates natural debridement Cost effective Indications Dry necrotic tissue Contraindications Discomfort Hypertonic saline gel
Yellow Wounds Goal: Debride, Absorb, Cleanse Sodium Chloride Impregnated Gauze Benefits: Absorbs exudate, bacteria, and necrotic material (slough) Stimulates the cleansing of wounds Cost effective Indications: Heavily draining, sloughy wounds Contraindications Dry or granulating wounds 7/25 Pressure Ulcer
8/14 (2 weeks) Necrotic Tissue Absent Red Wounds: Granulation Red and granular in appearance Fragile tissue Requires a moist, warm environment a dry cell is a dead cell Foams Indications: Superficial and full thickness wounds Skin grafts, donor sites, burns, skin tears Under compression for LE ulcers Contraindications: Dry wounds
Foams Benefits: Provide a moist environment High absorbency Conformable, may be cut to size Thermal insulation No residue MVTR No adherence to wound bed Hydrogels Indications: Dry wounds Wounds with slough wounds Wounds with eschar Over tissues and tendons to prevent drying Contraindications: High exudate wounds Hydrogels Benefits: Promote a moist environment Donate moisture to dry wounds Aid in autolytic debridement (rehydrate/soften necrotic tissue)
Silver Antimicrobial efficacy is achieved through the (+) silver ion only Silver ions are released by placing a silver substance in a fluid Effective when in contact with wound fluid Consider: Kill rate AND sustained release rate Delivery methods: foams, gels, alginates, hydrofibers, creams (SSD - approved for burns, only) How does silver work? 1. Cell wall rupture 2. Prevents eating and breathing 3. Disturbs replication
Case Studies
A Bit More Complex
Taking It A Bit Further
D. O B.???? Healing with Standard Care Diabetic Neuropathic Ulcers 24% heal in 12 weeks 31% heal in 20 weeks Venous Leg Ulcers <40% heal in 12 weeks 50% heal in 24 weeks So we need more than Standard of Care When to Use Advance Wound Treatment Healing rates at 4 weeks predict overall healing rates <50% in 4 weeks for DFU <40% in 4 weeks for VLU Rapid identification of wounds unlikely to heal with conventional care will allow for earlier interventions with advanced wound therapy Sheehan,et al Diabetes Care 2003: 26(6)1879-1882 DeRand, et al J Invest Derm 2002: 119(6) 1420-1425
Simple Steps to Success Begin With Standard Wound Care Critically Evaluate the effectiveness of the treatment (4wks 50% healed) Move to Advanced Wound Therapy