Wound Care'A Patient Centered Approach

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Wound Care.A Patient Centered Approach
H. Sprague Taveau IV, DO, MBA, FACOFP Senior
Medical Advisor Diversified Clinical Services
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Faculty Disclosure H. Sprague Taveau IV, DO, MBA

• It is the policy of Diversified Clinical
  Services to ensure balance, independence,
  objectivity, and scientific rigor in all of its
  individually sponsored or jointly sponsored
  educational programs.
• H. Sprague Taveau IV, DO, MBA, FACOFP is the
  Senior Medical Advisor for Diversified Clinical
  Services. He owns no stock nor does he have a
  financial interest in any products or services
  that are being presented in this program.
• REGRETABLY!!!

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• Goals Establish a universally applicable
  approach to wound patient assessment
• Objectives
• Acquire a systematic plan for wound patient
  assessment
• Know the assessment steps for wound evaluation,
  description and identification of local factors
  affecting wound healing
• Know the assessment steps for wound patient
  evaluation and identification of systemic factors
  affecting wound healing
• Know the indications for secondary testing in
  wound patient evaluation

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Wound Healing Failure
Infection
Ischemia Hypoxia
Chronic Inflammation
Cellular Failure
Recurrent Injury
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Philosophy of wound patient assessment

• Identify an ulcer/wound etiology or diagnostic
  category
• Identify the final common pathways to healing
  failure acting in this patient which enables
  setting key therapeutic goals for management
• Identify the presence of co-morbidities that
  might impact the selection of treatment options
  or other aspects of patient care.

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Step 1 Obtain a complete history of the wound

• Date of occurrence, duration
• Etiologytrauma, pressure, surgery, infection,
  etc.
• Ameliorating and exacerbating factors
• Evaluations previously completed
• Treatments previously administered
• Impact on the patient

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Step 2 Obtain a complete review of systems

• To elicit other important information about wound
  etiology
• To identify co-morbidities that might impact
  wound healing or selection of treatment
  interventions
• Define factors that might affect treatment
  options
• Define general health status, activity level

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Step 2 Obtain a complete review of systems

• All of the information obtained in Step 2 becomes
  vitally important in Step 7.

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Grading Ambulatory Status

• Grade VI Unlimited community ambulator
• Grade V Limited community ambulator
• Grade IV Unlimited household ambulator
• Grade III Limited household ambulator
• Grade II Supervised household ambulator
• Grade I Wheelchair ambulator
• Grade 0 Bedridden

Volpicelli LJ, Chambers RB, Wagner FW. J BONE
JOINT SURG 1983, 65-A599-605.
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Step 3 Determine the location of the wound

• Location can point us to specific essential
  aspects of treatment independent of the specific
  etiology

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Step 3 Determine the location of the wound

• Is the wound on the lower extremity?
• If yes, can be diabetic, neuropathic, primary
  arterial, primary venous, inflammatory,
  malignant, infectious, etc.
• Location can be an important factor in
  differential diagnosis of wound etiology

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Step 3 Determine the location of the wound

• Is the wound on the lower extremity?
• If yes, be sure to complete a full vascular
  assessment
• Arterial
• Venous
• If yes, also complete a neurosensory/muscular
  status assessment

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Step 3 Determine the location of the wound

• Is the wound on the lower extremity?
• If no, is the wound over a bony prominence in
  contact with a support surface?
• If yes, consider the most likely diagnosis is a
  pressure ulcer

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Step 5 Assess the woundMEASURE
M Measure E Exudate A Appearance (wound
bed and surrounding skin) S Suffering U
Undermining R Reevaluation E Edge
Keast DH, et al. MEASURE A proposed assessment
framework for developing best practice
recommendations for wound assessment. Wound Rep
Reg 2004 12S1-S17.
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Step 5 Assess the wound and wound patient

• Appropriate ancillary testing to assess the
  wound
• Culture
• Histopathology
• Blood work
• Diagnostic radiology
• Appropriate ancillary testing to define the
  significance and impact of co-morbidities
• ECG, CXR
• Blood work
• Consultations

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Assess for Loss of Protective Sensation
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Step 5 Assess the wound

• Define the impact of the wound on the patient
• Suffering Pain
• Severity and Complexity

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Step 6 Identify the final common pathways acting
to cause wound healing failure

• Infection
• Malperfusion/hypoxia
• Cellular failure
• Unrelieved pressure/trauma
• Pathological inflammation

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Step 7 Identify the co-morbidities impacting
wound healing and wound care

• Diabetes mellitus
• ESRD/dialysis
• Edema (as secondary etiology)
• CHF
• Chronic arterial insufficiency (as secondary
  etiology)
• Mobility impairment/CVA/cord injury
• Smoking
• COPD
• Vasculitis, Raynauds, other collagen vascular
  disease
• Wound contamination including incontinence
• Steroid therapy
• Chemotherapy
• Distant malignancy
• Malnutrition

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Step 8 Define the key therapeutic objectives

• Resolution of infection and maintenance of
  bacterial balance
• Enhancement of perfusion and oxygenation
• Resolution of edema
• Relief of pressure
• Ambulatory off loading
• Mechanical stabilization

• Enhancement of tissue growth
• Pain control
• Preservation of function
• Exudate control and wound moisture balance
• Odor control
• Patient/caregiver education
• Patient compliance

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Fundamental Questions

• Is the wound healable?
• Is the patient optimized to support healing?
• Nutrition
• Glycemic control
• Metabolic control
• Is the wound optimized to support
  healing/response to local interventions?
• How important is time?
• DFUrisk of osteomyelitis, progression
• Preserving, restoring function
• How compliant is the patient/family?
• Be cognizant of complications of technology

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Step 9 Select the most appropriate treatment
plan (CPG) for management and the specific
interventions appropriate for this patient.
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Wound Diagnosis or Type

• Diabetic ulcer
• Arterial insufficiency ulcer
• Venous leg ulcer
• Pressure ulcer
• Surgical wound/dehiscence/failing flap or graft
• Progressive soft tissue infection/osteomyelitis
• Laceration/acute traumatic injury/crush injury
• Burn

• Abrasion/skin tear
• Contact dermatitis
• Dermatological conditions/rash
• Vasculitis ulcer
• Radiation wound
• Stoma wound
• Other

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Step 10 Monitor the response to therapy and
adjust as needed

• Follow a subset of the steps used in the initial
  evaluation
• Failure to make consistent clinical progress
  should prompt a thorough re-evaluation and a
  change in the treatment plan

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Essential step 1 Adequate perfusion?
If you dont get water to the garden, the garden
wont grow!!
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Essential step 2 Non viable tissue?
Wounds wont heal in a sewer!!
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Essential step 3 Inflammation or infection?
Wounds with BUGS dont heal!!
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Essential step 4 Edema?
Wounds dont heal in a swamp!!
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Essential step 5 Wound microenvironment
conducive to healing?
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Essential step 6 Tissue growth optimized?
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Essential step 7 Offloading, pressure relief?
Wounds dont heal under pressure!!
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Essential step 8 Pain controlled?
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Essential step 9 Host factors optimized?
Wounds dont heal without building blocks!!
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Steps in the Evaluation of the Problem
WoundOverview of Assessment
Recap

• Identify the wound etiology
• Define the extent and character of the wound
• Identify the specific pathophysiology of wound
  healing failure Final common pathways
• Identify co-morbidities impacting wound healing
  or treatment options
• Develop a treatment plan addressing all of the
  above

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Goals Objectives

• Goal
• To gain an appreciation for the indications for
  treating patients with HBO.
• Objectives
• To familiarize you with emergent indications
• To familiarize you with non-emergent indications
• To familiarize you with contra-indications
• Relative
• Absolute

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Emergency/Acute Indications

• Cerebral Arterial Air or Gas Embolism
• Carbon Monoxide Poisoning
• Cyanide Poisoning
• Hydrogen Sulfide Poisoning
• Clostridial Myositis Myonecrosis
• Acute Traumatic Ischemia
• Crush Injury
• Compartment Syndrome
• Replantation Limb/Digits Etc.

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Emergency/Acute Indications

• Decompression Sickness
• Exceptional Blood Loss (Anemia)
• Intracranial Abscess
• Necrotizing Soft Tissue Infections
• Thermal Burns
• Combined Synergistic Necrotizing STI
• Compromised Skin Grafts/Flaps

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Acute Traumatic Ischemia

• 4 year old slipped and fell into a riding lawn
  mower, sustaining a mid-calf amputation of his
  leg. Leg was successfully replanted.
• Ischemic time 10 hours
• Txd aggressively with HBO

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Acute Traumatic Ischemia

• Appearance of muscle three days after
  replantation shows 100 viability as HBO
  counteracted reperfusion injury.

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Acute Traumatic Ischemia

• Three Months after Injury
• HBO _at_ 2.4 ATA x 90 minutes q8h x 6
• Then q12h x 4

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Acute Traumatic Ischemia

• The result was excellent function of the leg.
  The patient regenerated his nerves and ended up
  with a sensate foot. He was able to walk and run
  with the aid of a brace.

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Crush Injury

• Crush Injury with avulsion of palmar skin
• Appearance at time of presentation 1 hour after
  injury

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Crush Injury

• Elevation of avulsed palmar skin of crushed right
  hand

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Crush Injury

• Immediate post-op view
• Note vertical blue line through mid-palm
• Area not expected to survive

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Crush Injury

• 11 weeks post injury
• HBO _at_ 2 ATA x 90 minutes q8h x 3 then q24h x 17

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Crush Injury

• 11 weeks post injury
• Full range of motion

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Non-approved Emergent Indications

• Retinal Artery Insufficiency
• Actinomycosis

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Chronic/Elective Indications

• Problem Wounds
• Diabetic Foot Ulcers (Chronic Wagner III)
• Arteriolar Insufficiency
• Etc.
• Chronic Refractory Osteomyelitis
• Delayed Radiation Injury
• Soft Tissue
• Bony
• Meleny Ulcer (Invasive Group A Strep)

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Age associated differences in cellular
Proliferation (in vitro)
New born
Young adult
Old adult
(Buras and Buras, Harvard Medical School, MGH,
Boston)
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Decreased cellular proliferation with diabetes
(Buras and Buras, Harvard Medical School, MGH,
Boston)
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HBO Dramatically Increases Old Adult Fibroblast
Proliferation
(Buras and Buras, Harvard Medical School, MGH,
Boston)
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HBO Dramatically Increases Diabetic Fibroblast
Proliferation
(Buras and Buras, Harvard Medical School, MGH,
Boston)
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TcpO2 As A Predictor of Wound Healing in Diabetic
Foot Wounds
Initial healing success
Initial healing failure
Pecoraro, et al. Diabetes 401305-1313, 1991
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2 hours pre2 hours post
What About Smoking?
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Smoking Effects on Benefit from HBO
The avg pt with gt 10 pk/yrs who benefitted from
HBOT needed 8-14 more HBO treatments than a non
smoker for the same outcome (Otto Fife, UHM
200027(2)83-89.
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Wagner Classification Diabetic Foot Ulcers
Wagner FW. Foot Ankle 1981, 64-122

• Grade 0 Intact skin
• Grade I Superficial without penetration deeper
  layers
• Grade II Deeper reaching tendon, bone, or joint
  capsule
• Grade III Deeper with abscess, osteomyelitis, or
  tendonitis extending to those structures
• Grade IV Gangrene of some portion of the toe,
  toes, and/or forefoot
• Grade V Gangrene involving the whole foot or
  enough of the foot that no local
  procedures are possible

Grade I or II w/Infection Grade III
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Problem Wounds

• Achilles tendon rupture repair
• 4 months post-op
• Suture line breakdown 2 weeks post-op
• Multiple failed attempts at secondary closure

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Problem Wounds

• TCOMs in the periwound area demonstrated soft
  tissue hypoxia immediately adjacent to wound edges

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Problem Wounds

• 5 weeks post-HBO
• HBO _at_ 2 ATA x 90 minutes q24h x 20
• Routine wound care
• Oral antibiotics

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Problem Wounds

• Posterior view
• Excellent range of motion
• Ambulating without difficulty

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Problem Wounds

• Non-healing transmetatarsal amputation
• Suture line breakdown
• 3 mos s/p Fem/Tib bypass
• Considering BKA

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Problem Wounds

• 10 weeks post-HBO
• Complete healing
• No surgical debridement
• No revision
• No BKA
• HBO _at_ 2 ATA x 90 minutes q24h x 20

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Soft Tissue Radionecrosis

• Malignant Fibro-Histiocytoma
• Wide excision
• Radiation therapy
• 2 months post-op
• Dehiscence
• Radionecrosis
• Purulent drainage

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Soft Tissue Radionecrosis

• Close-up view
• 9 x 6.5 cm
• Stage III/IV Ulceration

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Soft Tissue Radionecrosis

• 1 week post-HBO
• 2 ATA
• 90 minutes each
• Q24h
• 20 treatments
• 5 days/week
• Routine wound care
• Oral antibiotics

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Soft Tissue Radionecrosis

• 10 days post-STSG
• Ambulating without difficulty
• No further procedures required

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Compromised Flap

• ORIF open fracture right Tibia
• Wound break down
• Exposed plate
• Flap rotated
• Skin graft to donor site
• Distal ischemia
• Impending necrosis

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Compromised Flap

• Post-HBO x 10 Treatments

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Compromised Flap

• Complete Healing
• HBO _at_ 2.4 ATA x 90 minutes q12h x 6
• Then 2 ATA x 90 minutes q24h x 14
• No further procedures necessary

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Old Absolute Contraindications

• Known Malignancies
• Increased Vascularity
• Implanted Pacemakers
• Manufacturing Defects

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Absolute Contraindications

• Untreated Pneumothorax
• Optic Neuritis
• Pregnancy
• Retrolentil fibroplasia
• Early closure of PDA

Weigh risk/benefit ratio
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Chemotherapy and HBO Risks

• Oxygen Toxicity (Pulmonary CNS)
• Alkylating Agents
• Plant Alakaloids
• Anthracyclines
• Antineoplastic/Cytotoxic Agents
• Anti-tumor Antibiotics
• Cyto-skeletal disrupters (Taxanes)
• Epipodophyllotoxins
• Epothilones
• Peptide Antibiotics
• Platinum Based Agents
• Topoisomerase II Inhibitors

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Chemotherapy and HBO Risks
Since there are no RCTs and very few case reports
regarding chemotherapeutic agents and HBO, we can
only extrapolate from information in the
literature as it pertains to mechanism of action.
In our opinion, patients undergoing
chemotherapy with the aforementioned agents
should not be treated with HBO for at least 6
weeks or 6 half lives (whichever is longer) after
their last dose of that agent.
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Chemotherapy and HBO Risks

• Probably Safe
• Monoclonal antibodies
• Nucleotide analogs and precursor analogs
• Retinoids

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Medication and HBO Risks

• Oxygen Toxicity (Pulmonary)
• Amiodarone

IV gt than Oral.Irreversible
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Relative Contraindications

• Upper Respiratory Infections
• Chronic Sinusitis
• Emphysema w/CO2 Retention
• High Fevers
• History of Seizure Disorder

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Relative Contraindications (Continued)

• History of Surgery for Otosclerosis
• PE tubes
• Viral Infections
• Get worse
• Congenital Spherocytosis
• Hemolysis in presence of increased paO2
• History of Optic Neuritis
• May be associated with blindness

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Complications Side Effects

• Barotrauma of the Ear
• PE tubes
• CNS Oxygen Toxicity
• Pulmonary Oxygen Toxicity
• Visual Refractive Changes

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Complications Side Effects (Continued)

• Numb Fingers
• Dental Problems
• Occult abcess
• Claustrophobia

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Sepsis

• 79 Mortality Untreated
• 65 Mortality Treated
• 90 minutes BID _at_ 2.5 ATA
• Reduction in splenic bacterial CFUs

Buras, J.A. et al
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UTA Hermann Memorial Multiplace
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Perry Sigma 40
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Perry Sigma 34
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Seachrist 3600E
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Seachrist 3200
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Brooks AFB Research Chamber
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Home Grown HBO Can
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Wound Care.A Patient Centered Approach
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