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Cutaneous Ulcers & Wound Care Management
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Definition Wound Ulcer
Breach in the continuity of skin or mucous membrane Ulcer Persistent breach in the continuity of skin or mucous membrane associated with cell death
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Anatomy
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Wounds Acute Wounds Chronic Wounds Cuts, Abrasions, Lacerations Contusions Punture Skin flaps and Bites Benbow ( 2005) Fail to pass through normal healing process Any wound > 3/12 considered a chronic wound They passes through the normal healing process readily
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How do wounds heal Haemostasis Inflammation
Proliferation or Granulation Remodelling or Maturation
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Neutrophil Immigration
Chronic wounds The wound healing cascade impairs and arrests at different stages Hemostasis CHRONIC WOUND Platelet Aggregation Neutrophil Immigration Monocyte Immigration Granulation Re-epithelialization Wound Closure Scar Formation Remodeling Minutes Hours Days Weeks Months Years Time
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Normal Healing Process
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Growth factors and wound healing
They are poly peptides, stimulate wound healing, promote chemotaxis, miotgenesis of fibroblasts and smooth muscle cells Platelet derived growth factor Insulin like growth factor epidermal growth factor fibroblast growth factor transforming growth factor 1
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Chronic wounds Normal healing process impaired
Arrest at different levels Remains at same stage without progressing to wound healing Often an underlying cause remains and undetected
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Local factors that impede wound healing
Inadequate blood supply ** Increased skin tension Poor surgical apposition Wound dehiscence Poor venous drainage ** Presence of foreign body and foreign body reactions Continued presence of micro-organisms & Infection ** Excess local mobility, such as over a joint
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systemic factors that impede wound healing
Advancing age and General immobility ** Obesity *** Smoking Malnutrition *** Deficiency of vitamins and trace elements *** Systemic malignancy and terminal illness Chemotherapy and radiotherapy Immunosuppressant drugs, corticosteroids, anticoagulants Inherited neutrophil disorders, such as leucocyte adhesion deficiency Diabetes and CRF***
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Appearance of a chronic wound
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Chronic Wounds Appearance
approach has been criticised for being too simplistic as wound healing is a continuum and wounds often contain a mixture of tissue types.
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Wound healing continuum
Wound Healing Continuum (Gray et al. 2005) have been developed. This tool incorporates intermediate colour combinations between the four key colours
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Necrosis
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sloughy
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Granulation
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Wound Infection The presence of multiplying organisms within a wound that overwhelm the host immune response with associated clinical signs and symptoms. (Kingsley 2001) Organism Density
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Wound Infection Organism Density
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Factors which influence wound infection
1. The quantity of micro-organisms 2.quality –Virulence and antibiotic resistance 3. The patients resistance to the level of bacteria in the wound( immune response) Microbial bio-burden within wounds can range from contamination, colonisation, critical colonisation and infection.
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Fecal and urinary management systems
1.Organims from surrounding skin- Regional flora- Deptheroids, Anerobes Wound Contamination Hand hygeine Wound Colonization 3.Organisms from External environment- through direct or indirectly – Pseudomonas, Multiresistant organisims etc Wound Surface Critical Colonization Wound Infection Fecal and urinary management systems 2.Organisms from GIT and GUT Gram Negatives such as E.coli, Klebsiella, Enterobacter, Anerobes Advance Wound Infection
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Clinical Signs of wound infection
Classical Signs Increased pain Copious amounts of exudate Malodour Cellulitis Pyrexia Abscess Formation
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Additional Signs Increase in size of wound Delayed wound healing
General unwellness Dark discoloured granulation tissue Increased friability Pocketing at base of wound. (Cutting and Harding 1994).
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Classification Wounds
Simple Skin Complex Deeper
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Classification Wounds
Rank & Wakefield Tidy Surgical incisions Untidy Crushing, tearing
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Classification Wounds
Open Incised Abrasion Lacerated Crush Penetrating Closed Contusion Hematoma
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Classification Wounds
Surgical Wounds Clean Clean Contaminated Contaminated Dirty
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Crush Syndrome Crushing of Muscles>Extravasation of blood>Myoglobin release Earthquakes, Industrial accidents, Air crashes Renal failure, Toxemia, Septicemia, Gas gangrene Rx- Multiple deep incisions, Mannitol, NaHCO3, Hemodialysis
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Classification Ulcers
Pathological Specific Non-Specific Neoplastic or Malignant
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Specific Ulcers Tropical ulcers Tuberculosis
Buruli ulcers- myco ulcerans Syphilis- trp pallidium Yaws- treponema pertenue Actinomycosis
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Non-Specific Ulcers Ulcers with metabolic or systemic disease
Traumatic Ulcers of Vascular origin Venous Arterial Pressure sores Neurotropic (trophic) ulcers Leprosy Diabetic neuropathies Cord lesions Ulcers with metabolic or systemic disease Diabetic ulcers Haemoglobinopathies Infective (pyogenic) Cryopathic
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Malignant Ulcers Squamous cell carcinoma Rodent Malignant melanoma
Kaposis’s sarcoma
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Wagner’s Classification
Grade 0- Preulcerative/Healed Grade 1- Superficial Grade 2- Deeper to subcutaneous Grade 3- Abscess formation Grade 4- Gangrene of part of tissue Grade 5- Gangrene of entire limb
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Characteristics of anUlcer
Edge Sloping – non specific Undermined – tuberculous/ decubitus Punched out – syphilitic/neuropathic Floor – what is seen Base – what is palpated
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Edge
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Edge
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Margin Regular Irregular Rounded, Oval
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Floor Discharge Granulation Serous Red Pale & Smooth Purulent
Pink, Punctate, Nodular – suggestive of malignancy Discharge Serous Purulent Sero-purulent Bloody Sero-sanguinous Sulpher granules
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Base On which the ulcer rests Palpated Indurated in malignancy
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Specific ulcers Tropical Ulcers
Caused by synergy of F fusiformis / Borrelia vincenti Starts as septic blisters Tropical Countries – poor hygeine, malnutrition, walking barefooted In the chronic phase the ulcer becomes non specific
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Tuberculous Bursting of Caseous LN Slightly painful
Neck, Axilla, Groin Undermined thin reddish-blue edge, Sero-sanguinous discharge & induration Enlarged LN Lupus Vulgaris- Cutaneous TB- Face & Hands Check the lungs- CXR
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Syphilitic Treponema Pallidum Hard Chancre- Ext Genitals
Punched out edges Painless, indurated base(button Like) Nipple, lip, tongue, anal canal Secondary- Mucus patches, Condylomas Tertiary – Gummatous (Subcut bones) VDRL/ biopsy
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Non Specific Ulcers Causes are many Sloping edge Phases
Acute or infective phase Transition phase Reparative or healing phase Chronic, indolent or callous phase -secondary infection, poor circulation, fB
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Traumatic Ulcers Anywhere on body
Diagnosis is based on history & sloping edge Limbs-Shin, Malleoli, Joints Chronic- Staph Eg Plaster Sores, Skin burns, Caustic ulcers
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Venous Ulcers Occurs in theMedial lower 3rd leg
Due to venous stasis- poor oxygenation/nutrition Leg oedema ,Surrounding skinPigmentation varicosities Causes Varicose veins-Perforator incompetence, Stasis DVT-Valveless Recanalisation after DVT
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Arterial Ulcers Inadequate skin circulation
Limbs- Repeated pressure/trauma Causees Atherosclerosis- Ant & lat legs, Dorsum, Heels Buerger’s disease- Painf, Claudication, Punched out ulcers Raynaud’s disease The skin is shiny, hairless & hypoaesthetic Dorsalis pedis/ post tibial pulses are absent
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Trophic Ulcers Neurologic deficit, Impaired blood supply & nutrition
Sites - trochanter Sacrum, Heel, Buttocks, Occiput Bedsores, Perforating Ulcers Causes Diabetic Neuropathy, Paraplegia, Leprosy, Spinal injury, Peripheral injury, Peripheral neuritis
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Decubitus ulcer Ischemia from prolonged pressure bw
Bed and body prominences those unaware of warning signals of discomfort eg unconscious patient, Maceration of skin from sweat, urine Poor nutritional status Reflection of nursing care
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Diabetic Ulcer Diabetic Neuropathy-Trophic Atherosclerosis-Arterial
Glucose laden tissues-Infective
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Malignant Marjolin’s ulcer SCC from chronic scar Malignant
Lips, cheeks, penis, vulva, mouth, oesophagus 40 yrs+ SCC, BCC, Melanoma
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Others Soft Chancre- Ducreys Painful, Ext genitals, with Bubo
Meleney’s Ulcer Post-op- Perforated viscus, Empyema Thoracis Strepto & Staph, Abdomen Martorell Hypertensive, Old age Post calf Bazin’s
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MANAGEMENT Wound Care Plan (WCP)
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Patient Centered – dealing with person with a chronic wound
Holistic –Total care -Not only wound itself- need to address pts other needs, diseases, and psychosocial wellbeing Wound Care Plan (WCP) Inter-diciplinary Needs Participation of multitude of disciplines
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History Mode of onset Duration Painful or painless Discharge
PMH suggestive of systemic illness DM, TB, SCD, Neuropathy, Peripheral ischaemic symptoms arterial disease – intermittent claudication Previous interventions Treatment
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The history of an ulcer Venous Varicose veins DVT/thrombophlebitis
Sclerotic changes Oedema Vasculitis History of autoimmune disease Painful Lack chronic arterial occlusive symptoms Systemic symptoms of autoimmune disease
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The history of an ulcer Neoplastic Chronicity Previous malignancy Risks Exposures UV radiation Ionising radiation
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Examination Palpation Inspection Tenderness Size & Shape Edge & margin
Base Depth Bleeding Surrounding skin Inspection Size & Shape Number Position ( anatomical site) Edge, Margin, Floor Discharge Surrounding area
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Examination Lymph Nodes Peripheral pulsations Nerves
Joints for mobilty Systemic examination
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Investigations Routine- urine &Blood : FBC, ESR, FBS,
Genotype, mantoux Renal & Liver functions wound swab
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Ulcer evaluations Specific VDRL, X-ray of part/ CXR Edge biopsy
FNAC of LN Colour Doppler Connective disease profile Angiography
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The treatment of leg ulcers
Dressings Encourage healing Moist Reduce oedema Remove pathogens Protect healing tissue Debridement Necrotic tissue Slough Foreign bodies amputation
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The treatment of ulceration
Vascularise Angioplasty Bypass Optimise cardiac circulation Eliminate venous hypertension Varicose vein surgery Venous valve replacement Sclerotherapy Venous bypass
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The treatment of ulceration
Wound closure Secondary intention SSG V.A.C. Plastic surgery flaps Systemic treatment Steroids Diet Trace elements Avoid cross contamination
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Aim of management of acute wounds
Healing without complications such as infection and disfiguring Wound care Remove FB Dry or wet to dry dressing to cover the wounds Suturing if acute Bites - Prophylaxis
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Management of Wounds Resuscitation of patient Cleaning, Dressing
Hemostasis Splint Fluids Inj TT
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Management of Wounds Incised Primary Suturing Lacerated
Excision & Primary Suturing Crushed Debridement, excision Delayed Primary Suturing Deep devitalised Debridement Secondary Suturing/ Grafting
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Treatment Treatment of cause Correction of Deficiencies
Blood transfusions Pain Mangement Debridement, Cleaning, Dressing Antibiotics Suturing, Grafts, Flaps
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A. Cleanse Debris from the Wound
Cleansing agents Flowing Water –Requesting pt to bath before dressing change Normal Saline*** Commercial Cleansers Hydrogen Peroxide Povidone iodine Hypochlorite solution Sterile vinegar solution Mechanical Cleansers –Whirl pools Salt dips Honey
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2. Possible Debridement Mechanical Autolytic Enzymatic Biological
Surgical
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Ideal dressing agent Protect from bacterial invasion
maintain optimum humidity absorb serum from wound site protect granulation tissue reduce pain
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Goals for therapy Debridement – Mechanical / surgical / biological / enzymatic Off loading foot wear . Antibiotics Appropriate wound care .
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Dressing agents No role for Hydrogen peroxide Boric acid EUSOL
Dakin solution (hypochlorite ) Iodine As they are toxic to the tissues
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Dressing agents Poly urethane films Foams and Hydrocolloids
transmit water vapour , oxygen , carbon dioxide non absorbent useful for healing wounds with minimal drainage Foams and Hydrocolloids Permeable , easy to apply , minimum re injury when removing the dressings 60-95% water content maintains the moist atmosphere
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Dressing agents Alginates Sea weed preparation absorb exudates
useful for exudative wounds Cultured keratinocytes Cells are cultured and transferred to petroleum gauze labour intense and expensive
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Management issues Nutrition-proteins , zinc , vitamin c
Pain management Change of dressings Removal of slough- hydrogels , varidase decrease the bacterial load – iodoflex Reduction of exudates- alginates Odour – iodoflex, silver , metronidazole Eczema- steroids
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Role of antibiotics Bacteria can secondarily colonize the wound and general tendency is to over treat . Not necessarily indicate infection wound bacteria may be transient and may not be detected on random swabs Fever /erythema /swelling / increased pain / leucocytosis
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Antibiotics in acute wounds
Only indicated if contaminated or evidence of infection is demonstrated Evidence of infection (local) Redness Warmth Swelling Tenderness Local Lymphadenopathy
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Antibiotics For spreading infection and or evidence of systemic infection Take blood cultures Treated with Broad Spectrum antibiotics intravenously. Topical antimicrobials - used to reduce wound bio burden (EWMA 2006).
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D. Promote Granulation and Epithelialization
Granulation enhancers Minimal Dressing changes to reduce disturbances to the granulation Avoid usage of substances which impede granulation tissues
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F. Minimize discomfort Pain relief Psychological support
Family education and create conducive environment Social support
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Chronic Wound Care: 10 Pearls for Success
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Chronic Wound Care: 10 Pearls for Success. Dr
Chronic Wound Care: 10 Pearls for Success!! Dr. Gary Sibbald, BSc, MD, MEd, FRCPC (Med), FRCPC (Derm), MACP, FAAD, MAPCA 1. For those with Diabetes for wound healing and further prevention: A - Check A1c - greater than 9% will affect wound healing. Recommended is less than 7%. B – Blood Pressure C - Cholesterol D - Diet E - Exercise F - Foot care - Check both feet at each appointment, shoes should be professionally fitted, consider chiropody. S- Smoking
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Chronic Wound Care: 10 Pearls for Success
2. For those with Venous Ulcer Disease - Compression bandaging is for treatment, stockings are for prevention. (Exudate/creams will damage the integrity of the stockings). COMPRESSION IS FOR LIFE! The right compression is the one the patient will wear
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Chronic Wound Care: 10 Pearls for Success
3. For those with any distal neuropathy - Shoes should be professionally fitted. 4. Smoking Cessation -IMPORTANT FOR ALL! - each cigarette decreases leg circulation for 30% for an hour or increase sympathetic tone for 8 hours 5. If wounds not decreased by 30% in size by week 4, unlikely to heal by week 12. Consider biopsy or a comprehensive re-assessment
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6.Query Infection? Culture using the Levine technique (Compress wound with normal saline for 10 minutes, press swab into a clean granulated area to express fluid and rotate 360 degrees 7. Treat the cause! Consider all the possible contributors to non-healing: Drugs, Occult malgnancy Systemic Disease (diabetes anemia, vascular disease), smoking, non-adherence
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Over view Definition Problem – How big is it ? Types
Pathophysiology of venous , arterial , diabetic ulcers Assessment / Evaluations Treatment options – Dressing agents , surgical options
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Chronic Ulcer Chronic ulcers results when sequel of repair is disturbed at one or more stages of inflammation proliferation , re epithelialization , remodelling common organisms colonizing the ulcers Staph aureus , Strep pyogens , Strep fecalis , E coli
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Team Surgeon Wound Care Practioner Nursing officer Physician
Physio-therapist Nutritionists Attendant
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Department of Orthopaedics General Hospital Marina, Lagos
Thank you Department of Orthopaedics General Hospital Marina, Lagos
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