Wound Care Update Mike Lusko, DO, FACEP, UHM

Baptist Medical Center Downtown – Jacksonville Florida

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”)

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

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

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

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…

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.

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

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

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)

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.

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.

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…

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.

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

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

Venous Ulcer (mention ‘champagne bottle’ deformity)

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

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

Arterial Ulcer

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

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

Diabetic Ulcer

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

Advanced Treatment Modalities

Total Contact Cast

Predictive Patient Outcomes with Total Contact Cast

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.”

Biosynthetic Graph Materials - Dermagraph

Biosynthetic Graph Materials – Apligraf

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

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

HBO – Hyperbaric Oxygen Therapy

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

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

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…

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.

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

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

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

Questions? Thank you. THANK YOU