1. Wound Care Update
Mike Lusko, DO, FACEP, UHM

2. Baptist Medical Center Downtown – Jacksonville Florida

3. By the Numbers …
Chronic wounds affect 6.5 million Americans/year at a treatment cost of $25 billion per year
Additional $39 billion in lost wages/ year
$15.3 billion estimated expense on wound care products in 2010
(the cost of “success”)

4. 26 million Americans with Diabetes Mellitus…
The Cost of Failure
26 million Americans with Diabetes Mellitus…

5. Chronic Wound
An insult or injury that has failed to proceed through an orderly and timely repair process to produce anatomic and functional integrity”
Masoro and Austad, 2006

6. SKIN 101: Physiology (How Do Wounds Heal?)
First Day of injury- Hemostasis
- Vasoconstriction, platelet release, clot formation
First Week- Inflammation
- Vasodilation
- Neutrophils and macrophages clean the wound and produce growth factors
First Month- Proliferation
- Angiogenesis
- Collagen fiber synthesis by fibroblasts
First Year- Maturation
-Shrinking and strengthening of the scar
read

7. Wound Detectives When Things Go Wrong… We need to become -History
-Location
-Size
-Appearance of the wound’s
-edge
-bed
-periphery
“However, when things go wrong and healing stops or fails to proceed accordingly, we need to become wound detectives…

8. Size Does Matter Size Width Length Depth Tunneling Undermining
And perhaps contrary to popular belief, size DOES matter in wound care at least. Wound Measurements are important in assessing the progress of wound closure , as well as helping us communicate effectively as wound care providers.

9. TIME Is Critical!
…And we need to remember that in wound care, as in many other things, TIME is critical.

10. T = Tissue
Nonviable tissue in a wound bed is a deterrent to healing and must be removed…

11. I = Infection
IS the wound infected? First, we need to remember that low levels of bacteria in the wound may actually be beneficial to healing by stimulating proteolytic enzymes and neutrophil release.
Second, We need to distinguish between contaminated wounds (contain low #s of non replicating bacteria), colonized wounds (replicating bacteria without a host response) and infected wounds (high bacterial burden with a host response that delays healing including erythema, pain, and purulent discharge)

12. M = Moisture Balance
A clean moist wound bed is critical for epithelial cell migration across its surface. While the old adage, ‘if its wet make it dry…isn't always true, it does convey the time-honored principle of dynamic moisture balance in effective wound healing. This is especially important, as we will see, in dressing selection.

13. E = Edge of Wound
We need to look carefully at the wound edge. Hard, rolled, undermined edges are also a deterrent to epithelial cell migration across the wound bed and must be sharply excised.

14. Comprehensive PATIENT Assessment
When we assess the wound, we need to remember to assess the patient beneath the wound. As its been said, we need to see the whole patient, rather than just the hole in the patient. To this end, we need to remember the Titanic Principle…

15. TITANIC Principle Diabetes Venous Hypertension Trauma Malignancy
Peripheral Arterial Disease
Psychosocial Issues
It was the massive substructure of the ice beneath that caused the ship to founder. In the same way, if we try to heal the wound without addressing the underlying diabetes… then we are not likely to be successful.

16. Common Wounds
Lets take a moment to discuss some of the common wounds we see in the clinic, so that you can recognize and treat them appropriately

17. 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
read

18. Venous Ulcer
(mention ‘champagne bottle’ deformity)

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

20. 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
read

21. Arterial Ulcer

22. Restore Blood Flow Large vessel bypass/ endarterectomy/ profundoplasty
Endovascular procedures
Balloon angioplasty (with or without stent)
Laser ablation
Atherectomy 22

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

24. Diabetic Ulcer

25. 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.
read

26. Advanced Treatment Modalities

27. Total Contact Cast

28. Predictive Patient Outcomes with Total Contact Cast

29. 2010 Consensus Panel on Treatment
Treatment – Advanced Therapies
“The panel recognizes the prognostic value of 50% area reduction of the wound at four weeks and recommends utilization of this parameter as a clinical decision point for the use of advanced therapies in healing DFUs. Use of advanced modalities, when indicated, should be viewed as the new standard of care and these advanced modalities should not be a ‘last resort’ in the treatment of DFUs.”

30. Biosynthetic Graph Materials - Dermagraph

31. Biosynthetic Graph Materials – Apligraf

32. Human Amnion/Chorion Allograph
Why Amniotic Membrane?
Human amniotic membrane in clinical literature since 1910
In vivo studies show the barrier properties of amniotic membrane help reduce scar tissue formation
Literature shows amniotic membrane enhances would healing
Modulates inflammation
Reduces scar tissue formation
Contains essential growth factors

35. Well lets change direction for a moment and discuss HBOT as an advanced treatment modality available for us in the care of our patients.

36. HBO – Hyperbaric Oxygen Therapy

37. 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 ( ATA)
Typical treatment length is 90 mins - 2hrs

38. Chamber Description Dual-place chamber Multi-place chamber Mono-place
read .
Multi-place chamber

39. 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
We talked about the science of HBO, now I want to look at the 4 main mechanisms that benefit our patients with this therapy. For the purposes of our discussion today, lets focus on the two that are most pertinent to wound care…

40. A Case in point… Day 1: Dusky appearance Dry tendon
No signs of healing
HBO initiated
This patient stepped on a nail, developed an abscess and presented to the WHC with a large area of necrotic tissue. His wound was surgically debrided and treated with standard wound care with no improvement. The wound is dusky, the tendon is dry, and few signs of healing are noted. TCOM was completed determining tissue hypoxia and a vascular consult was obtained to rule out a corrective surgical measure. HBOT was recommended.

41. 10 Days Later… Improved granular bed Viable tendon
No evidence of infection
Read

42. 30 Days Later…
Significant depth reduction Tendon nearly covered Ready for graft
Read

43. 45 Days Later… Skin Grafted and HEALED!
Healed… This patient was saved BKA amputation and all associated financial and personal costs.

44. Questions?
Thank you.
THANK YOU