What is a chronic wound? - New Home

American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Wound Care Practice What is the ultimate
Updates goal of a wound care

specialist ?

To get skin coverage of open wounds
and have it stay there.

 The function of the skin is to protect the
delicate internal environment from the
harsh external environment

 The tissues below the skin are moist!!

Brian F. McCrary D.O., M.P.H. ,
Lackland AFB, TX

Learning Objectives What is a chronic
wound?
Discuss common misconceptions regarding chronic
wounds Definition - Any wound that fails to go
Understand the basic principles of good wound care through the normal phases of healing
Discuss factors that are beneficial and detrimental to (inflammation, proliferation, maturation)
wound healing Multiple causes
Provide examples of treatment for venous stasis Unrelated to a specific time of healing/
disease lack of healing
Discuss new concepts in chronic wound care that are Can be in any location
cost effective, efficient and medico-legally
appropriate

Chronic Wound Mgmt is Chronic Wound Management
one of the few specialties is a Misnomer
where treatment is started
aggressively without a No one can heal a “chronic wound”,
diagnosis; where the that’s why they are chronic.
workup is secondary to the
treatment and where failure A chronic wound specialist identifies
is met with more treatment why the wound failed to heal and
corrects it. The goal is to turn a
chronic wound back into an acute
wound to allow it to heal.

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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Wound etiologies What is B.A.D. Wound
Care??
Arterial
Venous Betadine, Bacitracin, Bactroban, Boric
Diabetic Acid
Traumatic Acetic Acid, Air, Antibiotics (including
Surgical Silvadene)
Autoimmune Dakin’s Solution, Dry Therapies, Dyes
Pressure (Scarlet Red, Gentian Violet)
Mixed Whirlpools, Water Spray

Keys to good wound What is the big concern?
care
Loss of the protective barrier
Keep the wound base moist encourages the loss of fluids, nutrients,
Keep the skin dry allows exposure to toxic external
Pack open spaces substances and forces
Offloading
Adequate nutrition Infection ?
Adequate blood flow in and out

Here is the usual scenario: Lets get back to basics

“Dr. McCrary, Your patient Mrs. The definition of infection is…
Decubitis’ wound has a lot of
drainage and a foul odor. I took a  Redness
culture (swab). Should I call the  Increased temp
surgeon to put in a PICC line and  Swelling
what antibiotic do you want to  Tenderness, and…
start?”  Infectious agent must be present

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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

You have to have all What about the foul odor
of these!!! and the drainage??

Infection is basically inflammation They are not necessarily a part of the
(think sprained ankle) with documented spectrum of infection !!!
presence of bacteria overwhelming the

body’s normal response

Still don’t believe it ? How about the other
side of the argument?
The next time you step on a rusty nail-
If you really feel that foul odor and drainage
 Swelling, pain, fevers, but,… are always definitive for infection then…
 No odor/no drainage The next time you get a bad head cold with
 The puncture wound heals and so… drainage and foul breath then…
Culture the drainage (MRSA, VRE, ?)
NO INFECTION !!! Start Gorillacillin via central line

Definition of infection Wound swabs are out !!!

Red, hot, swollen, tender, and presence Accuracy is less than 30%
of bacteria U.S. Department of Health and Human
Services
So how do you document the presence AHCPR guidelines
of bacteria in a wound? 1994- out of date

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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Problems with this text If you are concerned about
the wound, you must
Much has changed since 1994 diagnose the wound
Much of the information is anecdotal,
not research based Wound swabs only measure what is
Recent literature considers “quantitative on the wound, not infecting the wound
swabs” as supportive, if other definitive Deep tissue (punch or needle) biopsy
signs and symptoms are present. Deep aspiration
Quantitative swabs?
- Problem is that many facilities cannot do
quantitative cultures

The wound is red, feels hot, Not Yet!!!
there is identifiable swelling,
and the patient reports pain A systemic infection should be
in the area. The “good” identified.
culture demonstrates a How about a lab test?
pathologic bacteria. Do you  CBC -
order the IV antibiotics now ?
- WBC must be elevated
 CRP, ESR, Chem, LFT

The wound is red, feels hot, Not Yet!!!
there is identifiable swelling,
and the patient reports pain in A patient with a systemic disease
the area. The “good” culture should have systemic signs such as …
demonstrates a pathologic  Malaise
bacteria. The WBC is 13,000  Fevers
with a left shift. Do you order  Nausea
the IV antibiotics now ?

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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

The wound is red, feels hot, Not Yet!!!
there is identifiable swelling,
and the patient reports pain You need to rule out other sources
in the area. The “good” of infection (urosepsis, pneumonia),
culture demonstrates a carcinomatosis, autoimmune
pathologic bacteria. The diseases, etc.
WBC is 13,000 with a left
shift. He feels nauseated and
weak with a 102o F temp.
Now do you order the IV
antibiotics?

The wound is red, feels hot, there is Yes, now you have
identifiable swelling, and the patient sufficient evidence…
reports pain in the area. The “good”
culture demonstrates a pathologic
bacteria. The WBC is 13,000 with a
left shift. She feels nauseated and
weak with a 102o F temperature.
Work up fails to identify other
etiologies other than the wound. Do
you order the IV antibiotics now ?

The question to ask is- Costs

How many of those patients Lab costs
that you treated for a wound Swabs, cultures, lab tech time,
infection were truly infected? pathologist review
Nursing time:

- To obtain swab, paperwork, calling doctor,
faxing results

Antibiotic related costs, isolation costs
Physician time

L-5

American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Risks from Antibiotics The top 5 statements you make
when the lawyer has you on the
Subjecting patient to unneeded antibiotics
Superinfection/bacterial resistance stand…
Antibiotic colitis
Risk of central lines 1. We’ve always done it that way.
Sepsis 2. That clinic/nursing home always does that
Bleeding
Pneumothorax sort of thing.
Deafness and other side effects 3. The insurance company never told me it
Liver/kidney damage
was wrong and always paid for it and the
subsequent care.
4. What do you mean, “18 years out of date?”
5. Where do you want the check sent?

Common misconception MAKE SURE THAT GOOD
WOUND CARE IS….
The reason the wound won’t heal is GOOD MEDICAL CARE
because it’s infected
Leads to “scorched earth” wound care -- Treat the WHOLE PATIENT!

- If I can kill the infection, the wound should (Blood sugars, nutrition, renal dx, anemia,
heal !!! edema, etc.)

When does Old Faithful lead Betadine
you down the Wrong Path?
Not sterile, in fact some bacteria, fungi
B.A.D. Wound Care: and viruses thrive in it.
 Betadine, Bacitracin, Bactroban, Boric Acid It merely reduces the bacterial count
 Acetic Acid, Air, Antibiotics (including temporarily
Inhibits white cells from moving into the
Silvadene) wound, decreases collagen synthesis
 Dakin’s Solution, Dry therapies, Dyes and inhibits epithelialization

(Gentian Violet, Scarlet Red)
 Whirlpools, water spray

Because we’ve always done it that way

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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Whirlpool Additionally, whirlpools
cause adjacent tissue
What do 8th graders know that you don’t ? maceration, making it more
susceptible to breakdown.

-Can also spread bacteria
to other areas and from
person to person

SILVADENE

Topical antibiotics

Have been shown to promote
superinfection by killing the
native flora

Neosporin: Significant potential
for local allergic reaction

Rule #1 What’s another name for Dakin’s solution?

Never put anything in an clean, CLOROX !!!
open wound that you would not

put in your own eye!!

L-7

American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Acetic Acid Hydrogen Peroxide

Detrimental to healing Why do patients like it
tissues by damaging the so much?
granulation tissue

Changes Ph of the wound
bed; no cell migration

Rule #2 Wet to dry dressings
Dry is a four letter word
How many of you believe that there is
What is one of the most common intelligent life in saline or gauze?
reasons for admissions to the hospital? It basically sticks to some tissue and then
Dehydration ... also known as dry!! pulls it out but…
Why is it unacceptable for whole bodies
to be dry, but OK for small parts to be - It leaves dry tissue behind…
dry?
Dry is not beneficial to wounds A very inexact debridement- and painful!!
Labor intensive if done correctly
Out of date for 20 years

Debridement Debridement

Mechanical Removal of devitalized tissue
Surgical Medium for infection
Enzymatic Remove potentially infected tissue
Autolytic Obtain appropriate deep cultures
Healthy bleeding tissue introduces
beneficial platelets and growth factors
Allows for thorough investigation of the
wound

L-8

American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Gauze Support Surfaces

Okay for rough debridement and No such thing as pressure relief!!!
protective outer layer of dressing
Gets absorbed into wounds and Pressure reduction
removes vital tissues on removal, often Clinitron vs Egg crates
has to be cut out…don’t use directly on Movement is the key!!
wounds Chair cushions
Use Telfa or Adaptic layer under gauze Mattress overlays
Pressure reducing boots
Total contact casts

Is there adequate blood flow to Is there adequate blood
the wound? flow from the wound?

ARTERIAL DISEASE Venous Stasis Ulcers

Palpate the pulse Skin discoloration
Segmental pressures Hemosiderin deposition
Doppler examination Stasis dermatitis
Waveforms Lipodermatosclerosis
A.B.I. Loss of hair below the knee
TcPO2 Shiny skin over the tibia
Can you examine the microvascular circulation?

Stasis Dermatitis Diabetes:

Red, swollen legs with no fever, multifactoral risks
no CBC changes, no easily
identifiable etiology and a history Increased risk of infection
of the same. Neuropathy (loss of protective sensation)
Vascular effects
Multiple hospitalizations and Macrovascular (trifurcation disease- below
courses of antibiotics the knee )
Microvascular (affects medial layer to
What makes you think of and prevent vasodilatation)
treat it as cellulitis? Charcot’s joints, arch collapse
↓ Humeral response (decreased NO)

L-9

American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Dressings: Rule #3

The choice of a dressing is Is the wound healing because of
multifactorial what I’m doing or in spite of what

Wound type I’m doing?
Amount of and type of drainage
Wound location
Type of treatment needed
Debridement vs healing vs protection

Systemic Factors Local Factors

COMORBIDITIES BIO-BURDEN
STRESS- PSYCHOSOCIAL OR PHYSICAL TISSUE PERFUSION
(ENVIRONMENTAL) MACRO/MICRO CIRCULATION
PAIN ESCHAR & DESICCATION
OBESITY FOREIGN BODIES/SUTURES
MALNUTRITION NECROTIC TISSUE AND DEBRIS
IMMUNE STATUS
AGE

What’s new in wound The Many Faces of
care? Venous Insufficiency

Theories Treatments Venous insufficiency comes in many
 NO shapes and sizes
 MMP’s  Hyperbarics
 VEGF  Dermagraft/Graft Management is essentially the same in
Diagnostics all cases:
 Digital Pressures jacket/Integra
 TcPO2  Platelet rich plasma  support the veins with compression
 Laser Doppler  Apligraft  support the skin with moisture
Therapies  Oasis  decrease edema with compression and
 Electrical Stim
 Normothermia, UV, Pulsed Pharmacotherapy diuretic use

Diathermy  Pletal
 Neg Pressure (VAC)  Trental
 Cornytherapy  Biogun (superoxide
 Manuka honey
radical anions)
 Other medications

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American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Venous Ulcer with Traumatic Wound
Stasis Dermatitis Becomes a Venous Ulcer

Edematous leg •Prominent
with opening varicose veins
of a surgical •LE edema
wound— •Islands of
granulation
Cellulitis? tissue with
copious fibrin

Venous Ulcer and Chronic The End of the Road with
Venous Congestion Chronic Edema-

•Woody edema Elephantiasis Nostras
•Stasis Dermatitis
•Shallow ulcer with •Large heaped
overhanging borders plaques
•Granulation tissue at •Grossly thickened
base along with fibrin skin with
cobblestone
appearance
•Gross LE edema

Garden Variety LE Edema Hemosiderin Deposition
with Stasis Dermatitis
•This skin is more
•LE edema with likely to breakdown
stasis change •Increased likelihood
•Evidence of of skin sensitivity to
healed outbreaks topical products
common •Wounds develop
•Fungal super- quickly and are slow
infections are to heal
common

L-11

American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

Prolog to Management Management of Venous
of Venous Stasis Stasis…Two Simple Steps

Wraps, dressings and topicals are of Decrease Edema
limited value relative to aggressive
medical management  Medical Management
 Compression
In other words, if a pt’s CHF or cellulitis
aren’t treated, a wrap or topical therapy  Unna’s Wraps
can only be so effective  Profores/ 2 & 3 layered dressings
 Circaids/Tribute/Reid/MedAssist
 Compression stockings

Wound Care for open wounds

Medical Management of Management of Venous
Venous Disease Disease

Maximize BP and diuretic use Treat early disease with TEDS/JOBES
Evaluate for CHF, renal and liver stockings
disease and treat aggressively
Treat infection Graduate to compression stockings (Start
Assess arterial circulation – ABIs are a with 20-30mmHg and increase compression
great way to start strength as needed)

Keep skin moist with Vasoline and
occasionally mix with Triamcinolone 0.1% to
decrease inflammation

Treat fungal infections

Management of Venous Management of Venous
Disease Disease

When pts have breakouts or ulcers develop, Some pts will require chronic Unna
switch to moist compression dressings (Unna Boot/Profore therapy
Boots) or Profores Others will achieve adequate control
with compression stockings
Dressings should be changed weekly Some will require a combination/
alternation of therapeutic strategies
Recommend F/U in approx 3-4 days after
initial application to ensure tolerance or
dressings haven’t slipped

L-12

American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

One of biggest A Quick Re-Cap
complaints-
Keep it clean, keep it moist and remove
Putting on the Stockings!! barriers to healing
Use topical enzymatic debriding
Rarely covered by insurer ointments to reduce fibrin and slough
Manage infection
Enhance nutrition
Encourage regular follow-up

SAMPLE CASE REPORTS The Role of Hyperbarics

Hyperbarics and Wound Care HBOT and Wound Care

Enhancement of tissue oxygenation: Use of HBOT is approved for use with:
crucial to collagen production Chronic wounds
Enhancement of immune system Salvage of flaps and grafts
function and response For wounds where periwound
Stimulation of angiogenesis oxygenation is below that needed for
Stimulation of growth factors collagen production (<30mmHg in Non-
Down-regulation of inflammatory diabetics and <40mmHg in diabetics).
cytokines These values are assessed by TcPO2

L-13

American Osteopathic College of Occupational and Preventive Medicine
2012 Mid-Year Educational Conference
St. Petersburg, Florida

HBOT and Wound Care HBOT and Wound Care

Necrotizing infections HBOT CAN help with
Compartment Syndrome MICROVASCULAR compromise e.g.,
Soft Tissue Radiation Injury the diabetic foot ulcer
Refractory Osteomyelitis HBOT CAN NOT help much with
Gas Gangrene MACROVASCULAR disease…for large
Thermal Burns vessel disease see the surgeons and
crank up the statins and BP meds

Final Reflections Final Reflections

Assess etiology Treat confounding variables (TREAT
THE WHOLE PATIENT)
 Pressure
 Venous  Infection
 Arterial  Malnutrition
 Underlying skin disease or cancer  Diabetes
 Circulation
 Smoking
 Poor hygiene or use of home remedies
 Minimize pressure sources

Final Reflections Basic Wound Care
Principles
If wounds are secondary to venous
stasis – apply compression dressings CONVERT A CHRONIC WOUND TO AN
If wounds are secondary to arterial ACUTE WOUND
insufficiency – consider vascular KEEP WOUND HAPPY --
surgery evaluation for macrovascular
disease and HBO for microvascular  MOIST, CLEAN WOUND BED
disease  HEALTHY, DRY SKIN
 CHANGE DRESSING NO MORE THAN NEEDED

CONTROL “FACTORS”
MONITOR REGULARLY

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