Primary Care Approach to Wound Management Kevin Taffe, MD, PhD

Objectives Evaluate and diagnose wounds that are commonly seen in primary care Provide basic wound management in the office setting Properly triage and refer patients with wounds to the appropriate provider(s)

Evaluation of wounds

Goals of evaluation

Goals of evaluation (cont’d)

Overview of evaluation “I need a Wound Center referral for a sore on my backside” Chief complaint History History of trauma, pressure, therapies, etc. Physical

Description of wound: general approach

Description of wound: Size

Tunneling and Undermining

Examination of Wound Bed

Wound Drainage

Wound Edges Raised edge- pressure, trauma, malignancy Rolled- stagnation, chronicity (epitherlial cells can’t migrate at wound edges) Contraction- healthy, re-epithelialization taking place

Periwound Skin: Primary Dermatologic Lesions Pyoderma gangrenosum

Periwound Skin: Infection Periwound inflammation Periwound infection Rubor Calor Dolor Rubor Calor Dolor

Wound Location

Other exam findings

Assessment of Wounds: History

Assessment of Wounds: History HPI: Location, quality, severity, duration, timing, exacerbating/ relieving factors, associated symptoms. Ask about dressings and other treatments.

History: Risk factor assessment

Basic Wound Care Managment

Treat the underlying cause

Treat contributing factors

Dressing basics Remove dead tissue Reduce bacterial burden Support/ create moist wound environment Protect wound bed

Dressings: Debridement

Types of debridement

Reduce bacterial burden

Reduce bacterial burden

Treat infection

Maintain or create a moist wound environment

Maintain or create a moist wound environment

Protect wound bed

Wound triage and referral

Triage

Triage

Triage

Triage

Triage

Dermatology referral Squamous cell carcinoma of the foot (raised, lobulated, ulcerated)

Rheumatology referral Can see ulcerations in rheumatologic disease such as RA (incl Felty’s syndrome); usually long standing but in one series this was first manifestation in 3/366 patients (Shanmugam, Victoria K et al. “Lower extremity ulcers in rheumatoid arthritis: features and response to immunosuppression.” Clinical rheumatology vol. 30,6 (2011): 849-53.)

Key take-home points A detailed history is essential for the diagnosis and treatment of wounds. The examination of wounds should include a description of all wound characteristics, location, and important supplemental exam findings. Treatment should be focused on managing the underlying cause, contributing factors, and goal-directed dressing selection. Chronic wounds do not require urgent referral; consider urgent referral to a Wound Center, ER, dermatologist, or rheumatologist in select cases.