Fundamentals of Chronic Wound Care

1. Fundamentals of Chronic Wound Care Mike Lusko, DO, FACEP, UHM

2. SKIN 101: Physiology(How DoWounds Heal?) FirstDayof injury- Hemostasis - Vasoconstriction, platelet release, clot formation FirstWeek- Inflammation - Vasodilation - Neutrophils and macrophages clean the wound and produce growth factors FirstMonth- Proliferation -Angiogenesis - Collagen fiber synthesis by fibroblasts First Year- Maturation -Shrinking and strengthening of the scar

3. When Things Go Wrong… Wound Detectives We need to become -History -Location -Size -Appearance of the wound’s -edge -bed -periphery

4. SizeDoesMatter Size • Width • Length • Depth • Tunneling • Undermining

5. TIME Is Critical!

6. Take TIME to Assess the Wound Tissue viability Infection Moisture content Edge evaluation

7. T = Tissue

8. I = Infection

9. M = Moisture Balance

10. E = Edge of Wound

11. Comprehensive PATIENTAssessment

12. TITANIC Principle • Diabetes • Venous Hypertension • Trauma • Malignancy • Peripheral Arterial Disease • Psychosocial Issues

13. Let’s Look Beneath the Wound… When did the wound occur? Who has taken care of the wound? What treatment has been successfully used in the past? What studies have been performed (i.e., arteriogram)?

14. Common Wounds

15. 1. Venous Ulcer • Location: midcalf to heel (Gaitor area) • Appearance: shallow, irregular, exudate is common, painful • Origin: Venous valve incompetence • Venous hypertension • Extravascular blood loss/edema • RBCs  hemosiderin staining • WBCs  enzyme-mediated tissue destruction

16. Venous Ulcer

17. Treatment • Compression Therapy • Multilayer • short stretch • Debridement • Trental / Doxycycline • Closure • Skin graft • Skin substitutes (Apligraf/ Dermagraft) • Endo-venous closure (laser ablation: VNUS)

18. 2. Arterial Ulcer • Location: distal lower extremity • Appearance: distinct margin (cookie cutter), with central necrosis in setting of PAD: • Cool extremity • Diminished /absent pulses • Shiny skin /hair loss

19. Arterial Ulcer

20. Restore Blood Flow • Large vessel bypass/ endarterectomy/ profundoplasty • Endovascular procedures • Balloon angioplasty (with or without stent) • Laser ablation • Atherectomy

21. 3. Diabetic Ulcer Location: plantar aspect of the foot beneath a bony prominence. Appearance: ill-defined borders, prominent callus, and palpable pulses.

22. Diabetic Ulcer

23. 4. Pressure Ulcer • Location: beneath a bony prominence (heel, sacrum). • Appearance: irregular in size and depth. • Origin:Prolonged contact with inappropriately padded surface  focal ischemic necrosis. • Worsened by • friction / moisture • malnutrition • co- morbidities.

24. Pressure Ulcer Staged according to DEPTH of injury…

25. PU: Management Principles • Pressure avoidance • Frequent repositioning • Avoid bed rest • Pressure reducing surface • Nutrition: ensure proper intake and monitor • Continence and moisture control (when possible) • Wound care • Debridement • Dressing selection • Infection surveillance / control

27. HBO – Hyperbaric Oxygen Therapy

28. What is HBO? Breathing 100% Oxygen at increased atmospheric pressure The patient is enclosed in a clear, acrylic chamber Pressure within the chamber is gradually increased (2.0-2.5 ATA) Typical treatment length is 90 mins - 2hrs

29. Chamber Description Mono-place Dual-place chamber Multi-place chamber

30. The Four Mechanisms of HBO 1. Mechanical 2. Oxygen delivery 3. Antimicrobial effect 4. Poison Antidote Alters the size of gas bubbles Supplies O2 to ischemic tissues/ cell signaler Bacteriostatic/ cidal Reverse effects of CO and Cyanide through gas exchange

31. A Case in point… Day 1: Dusky appearance Drytendon Nosigns ofhealing HBO initiated

32. 10 Days Later… Improved granular bed Viabletendon No evidence ofinfection

33. 30 Days Later… Significantdepth reduction Tendonnearlycovered Ready for graft

34. 45 Days Later… Skin Grafted and HEALED!

35. THANK YOU Questions?